Vaccine-preventable Infections andImmunization in Multiple Sclerosis: Practice Guideline Update

American Academy of Neurology (AAN) has released guidelines titled Vaccine-preventable Infections and Immunization in Multiple Sclerosis in September 2019 and reaffirmed October 22, 2022. Replaces "Immunization and Multiple Sclerosis: A Summary of Published Evidence and Recommendations" (December 2002). Endorsed by the Consortium of Multiple Sclerosis Centers and by the Multiple Sclerosis Association of America.

The purpose of the current update is to systematically evaluate and incorporate new evidence, vaccines, and disease-modifying therapies (DMTs). Immunization against a disease may be achieved by natural infection or by vaccination against specific agents. In this guideline update, the guideline panel uses the terms "immunization" and "vaccination" interchangeably to refer to immunity developed in response to vaccines.

Following are its major recommendations:

1. Clinicians should discuss with their patients the evidence from the systematic review regarding immunization in MS.

2. Clinicians should explore patients' opinions, preferences, and questions regarding immunizations at clinical visits to be able to effectively address the optimal immunization strategy for each patient, in keeping with the patient's MS status, values, and preferences. (Level B)

3. Clinicians should recommend that patients with MS follow all local vaccine standards (e.g., from the US Centers for Disease Control and Prevention (CDC), World Health Organization (WHO), and local regulatory bodies) unless there is a specific contraindication (e.g., active treatment with immunosuppressive or immunomodulating [ISIM] agents). (Level B)

4. Clinicians should weigh local risks of vaccine-preventable diseases when counseling individuals with MS regarding vaccination. (Level B)

5. Clinicians should recommend that patients with MS receive the influenza vaccination annually, unless there is a specific contraindication (e.g., prior severe reaction). (Level B)

6. Clinicians should counsel patients with MS about infection risks associated with specific ISIM medications and treatment-specific vaccination guidance according to the prescribing instructions for ISIM medications when one of these treatments is being considered for use. (Level B)

7. Physicians should assess or reassess vaccination status of patients with MS before prescribing ISIM therapy and should vaccinate patients with MS, according to local regulatory standards and guided by treatment-specific infectious risks, at least four to six weeks before initiating ISIM therapy as advised by specific prescribing information. (Level B)

8. Clinicians may discuss the advantage of vaccination with patients as soon as possible after MS diagnosis, regardless of initial therapeutic plans, to prevent future delays in initiation of ISIM therapies. (Level C)

9. Clinicians must screen for certain infections (e.g., hepatitis, tuberculosis, VZV) according to prescribing information before initiating the specific ISIM medication planned for use (Level A) and should treat patients testing positive for latent infections (e.g. hepatitis, tuberculosis) before MS treatment according to individual ISIM prescribing information (Level B).

10. In high-risk populations or in countries with high burden (in the case of tuberculosis), clinicians must screen for latent infections (e.g., hepatitis, tuberculosis) before starting MS treatment with ISIM medications even when not specifically mentioned in prescribing information (Level A) and should consult infectious disease or other specialists (e.g., liver specialists) regarding treating patients who screen positive for latent infection before treating them with ISIM medications (Level B).

11. Clinicians should recommend against using live attenuated vaccines in people with MS who currently receive ISIM therapies or have recently discontinued these therapies. (Level B).

12. When the risk of infection is high, clinicians may recommend using live attenuated vaccines if killed vaccines are unavailable for people with MS who are currently receiving ISIM therapies. (Level C).

13. Clinicians should delay vaccination of people with MS who are experiencing a relapse until clinical resolution or until the relapse is no longer active (e.g., the relapse is no longer progressive but may be associated with residual disability), often many weeks after relapse onset. (Level B).

Reference:

Mauricio F. Farez, Jorge Correale, Melissa J. Armstrong, Alexander Rae-Grant, David Gloss, Diane Donley, Yolanda Holler-Managan, Norman J. Kachuck, Douglas Jeffery, Maureen Beilman, Gary Gronseth, David Michelson, Erin Lee, Julie Cox, Tom Getchius, James Sejvar, Pushpa Narayanaswami Neurology Sep 2019, 93 (13) 584-594; DOI: 10.1212/WNL.0000000000008157