Table 1.
Recommended vaccines in MS patients receiving disease-modifying drugs.
| Vaccine | Type | Schedule | Indications | |
|---|---|---|---|---|
| General MS population | Special MS sub-populations | |||
| Seasonal influenza | Inactivated. Fractioned or subunits |
Single IM/SC dose every year | Annually, especially in case of present/future IS and/or significant disability |
 During any trimester Annually for all From 6 months of age, in case of present/future IS |
| Pneumoccocal: 13-PCV 23-PPV 20-PCV |
Inactivated | 13-PCV and 23-PPV (at least 2 months apart)Or single-dose 20-PCV |
In case of present/future immunosuppression and/or significant disability a |
PCV13 as age-appropriate and PPSV23 2 months apart, in case of present/future IS |
| Tetanus-Diphtheria (dT) Tetanus-Diphtheria—pertussis (dTap) |
Inactivated; tetanus and diphtheria toxoids |
3 IM doses (0,1, 6 months) in naïve patients Single IM booster dose in first vaccinated |
Same indications as in the general population b |
dTap during the end of the second or the third trimester. Repeat during each pregnancy
c
|
| Measles, mumps, rubella (MMR) | Live attenuated | 2 IM/SC doses given 4 weeks apart | Recommended in seronegative patients Complete 4 weeks before immunosuppression d |
 In seronegative, vaccinate in the post-partum period before initiating DMT. |
| Varicella | Live attenuated | 2 IM/SC doses given 4 weeks apart | Recommended in VZV seronegative patients. Complete 4 weeks before immunosuppression d |
In seronegative, vaccinate in the post-partum period before initiating DMT. |
| Human papillomavirus | Inactivated (recombinant) |
3 IM doses at months 0, 2, and 6 | Consider in women and men with MS who will receive treatment with ALZ, S1 P modulators, CLAD or anti-CD20 drugs, independently of their age e |
Ensure complete immunization in all girls and boys
b
|
| Herpes zoster | Inactivated (recombinant) f |
2 IM doses separated by 2–6 months | Consider in patients aged over 18 years g if treatment with CLAD, ALZ, S1 P modulator, NTZ, and anti-CD20 drugs |
Especially indicated in those receiving immunosuppressive therapies From 18 years of age |
| Hepatitis B virus | Inactivated (recombinant) |
Regular vaccines 3 IM doses at months 0,1,6 Enhanced immunity vaccines h 4 IM doses (0,1,2,6-12 months) for high load (40mcg) or adjuvanted (AS03) 2 IM doses (0,1 months) for adjuvanted (CpG 1018) |
Consider in high-risk i seronegative patients, especially if treatment with anti-CD20 therapies |
Ensure complete immunization in all girls and boys
b
|
| COVID-19 vaccine | mRNA Adenoviral vector Inactivated (recombinant adyuvanted) |
Primovaccination with one or two-dose scheme
j
Additional booster doses k |
Recommended for all MS patients |
During any trimester mRNA vaccines, from 6 months of age, in case of present/future IS |
Patients under 18 years of age. Patients of 60 years and older
13-valent pneumococcal conjugate vaccine (13-PCV, Prevenar 13®); 20-valent pneumococcal conjugate vaccine (20-PCV, Appenxnar®) Pneumococcal polysaccharide vaccine (PPSV23, Pnaumovax®). Use following general recommendations for immunosuppression. Age and/or comorbidities should also be considered in the indication of pneumococcal vaccination following guidelines applicable in each country. For children: routine vaccination with PCV13 as age-appropriate and in children of at least 2 years of age administer PPSV23 2 months apart.
Following national immunization schedules.
Unless national recommendations state otherwise.
Always avoid in MS patients who are already receiving the following immunosuppressive therapies (sphingosine-1-phosphate (S1 P) modulators, anti-CD20 monoclonal antibodies and before immune restoration for cladribine and alemtuzumab). Ideally avoid in MS patients who are already receiving the following immunosuppressive therapies (natalizumab, DMF and teriflunomide without lymphopenia). In these patients and in very exceptional cases, such as high risk of infection, vaccination with live attenuated vaccines could be considered if the potential risk of acquiring the infection is superior to the risk of developing vaccine-related infections.
There can be limitations and variations regarding upper age limit depending on the country and the Summary of product characteristics.
A live, attenuated herpes zoster vaccine (Zostavax®) is also available, but not recommended for patients who are receiving immunosuppressants.
With a background of chickenpox disease or live-attenuated varicella vaccination (otherwise consider varicella immunization).
Enhanced Immunity Vaccines include High load (HBVaxpro® 40mcg) or adjuvanted (AS03-Fendrix®, CpG 1018-Heplisav®). Consider If onset of immunosuppressants in the following 6 months or in patients already immunosuppressed.
Risk of sexual exposure, patients on dialysis, parenteral drug users, healthcare workers with occupational risk, and patients with specific comorbidities (HIV or HCV infection, chronic liver or kidney disease, solid organ transplant/hemopoietic stem cell transplantation recipients and/or people receiving blood products.
EMA authorized COVID-19 vaccines: Comirnaty (0, 28 days), Spikevax (0, 28 days) Valneva (0,28 days), Nuvaxoid (0,21 days), Vaxzevria (0, 28 days), Jcovden (single-dose), VidPrevtyn Beta (single booster after mRNA) Available at: https://www.ema.europa.eu/en/human-regulatory/overview/public-health-threats/coronavirus-disease-covid-19/treatments-vaccines/vaccines-covid-19/covid-19-vaccines-authorised#originally-authorised-covid-19-vaccines-section.
Follow most updated local/country guidance on COVID-19 vaccination for high-risk patients.
IS: immunosuppression; 13-PCV: 13-valent conjugate vaccine; 20-PCV: 20-valent conjugate vaccine; 23PPV: 23-valent polysaccharide vaccine; MS: multiple sclerosis; mRNA: messenger ribonucleic acid; S1 P: selective Sphingosin-1-phosphate-receptor-1 CLAD: cladribine; ALZ: alemtuzumab; DMF: dimethyl fumarate; TER: teriflunomide; NTZ: natalizumab; VZV: varicella-zoster virus.