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COVID-19 and MS: Global Vaccination Recommendations

The International Multiple Sclerosis Federation (MSIF) updated the global recommendations for people with multiple sclerosis on how to deal with COVID-19.

Please note that this article is the latest information at the time of publication onJanuary 15, 2021 reproduces. Therefore disregarded any in the meantime changed circumstances.

The recommendations on COVID-19 and multiple sclerosis published by the International Multiple Sclerosis Federation in spring 2020 with the collaboration of internationally recognized experts and representatives from various MS societies were updated on January 15, 2021. For Austria, Ms. Univ. Prof. Dr. Barbara Kornek worked on the new version. The current update now also includes information on the COVID-19 mRNA vaccines from Pfizer-BioNTech and Moderna.

>> Global COVID-19 advice for people with MS (PDF, English)

“The global COVID-19 pandemic required increased collaboration within the MS movement. I am proud to see how the global community has come together to collect high quality data and generate timely, practical and evidence-based advice. "
Brenda Banwell, Chair of the MSIF's International Medical and Scientific Board

Extract from the recommendations

Current evidence shows that people diagnosed with MS are generally no more likely to develop COVID-19, become seriously ill, or die as a result of the infection than the general population. However, the following groups of people with MS are more prone to a severe course of COVID-19:

  • People with progressive MS
  • People with MS over the age of 60
  • Men with MS
  • Black and possibly South Asian people with MS
  • People with a higher degree of disability (e.g. an EDSS score of 6 or higher)
  • People with MS and obesity, diabetes, or diseases of the heart or lungs
  • People taking certain disease-modifying therapies for their MS (see below)

All people with MS are advised to follow World Health Organization guidelines to reduce the risk of infection with COVID-19. People in the higher risk groups should pay particular attention to these measures.

The International Multiple Sclerosis Federation makes the following recommendations

  • Keep a distance of at least 1.5 meters between yourself and others to reduce the risk of infection when coughing, sneezing or speaking. This is particularly important indoors, but also applies to outdoors.
    (National and international guidelines for physical distancing vary between at least 1 meter and 2 meters. Please bring the national guidelines and keep in mind that these are minimum distances and longer distances are advantageous.)
  • Make mask wearing a normal part of interacting with other people and ensure that you use mouth and nose protection properly.
  • Avoid visiting crowded places, especially indoors. If this is not possible, wear a mask, keep your distance and reduce personal social contacts.
  • Wash your hands frequently with soap and water or an alcohol-based disinfectant (70% alcohol is considered most effective).
  • Avoid touching your eyes, nose, and mouth unless your hands are clean.
  • When coughing and sneezing, cover your mouth and nose with a bent elbow or handkerchief.
  • Frequently clean and disinfect surfaces, especially those that are regularly touched.
  • Talk to your doctor about optimal care plans, if necessary through video consultations or personal visits. Visits to clinics and hospitals should not be avoided if recommended based on your current health needs.
  • Stay active and try to participate in activities that are good for your mental health and wellbeing. Physical exercise and social activities that can take place outside and with social distance are recommended.
  • Get the influenza vaccine and encourage your family to do the same.
  • Caregivers and family members who live with or regularly visit a person with MS in one of the higher risk groups should also follow these recommendations to reduce the chances of contracting COVID-19 in the household.

MSIF Recommendations on Disease-Modifying Therapies

Many disease-modifying therapies (DMTs) for MS work by suppressing or modifying the immune system. Some MS medications can increase the chances of developing complications if you are infected with COVID-19. However, this risk must be balanced with the risk of discontinuation or delay in treatment.

The International Multiple Sclerosis Federation recommends people with MS who are currently receiving disease-modifying therapies to continue their treatment - unless advised to consult their treating physician.

People who develop symptoms of COVID-19 or who test positive for the infection should discuss their MS therapies with their treating physician or other healthcare professional who is familiar with their care.

Before people with MS start a new disease-modifying therapy or change an existing disease-modifying therapy, they should discuss with their treating physician which therapy is best for their individual circumstances. This decision should take into account the following information:

  • Course and activity of MS disease
  • Risks and benefits commonly associated with different treatment options
  • Additional risks related to COVID-19, such as
    - the presence of other factors for a more severe case of COVID-19 such as age, obesity, existing pulmonary or cardiovascular disease, progressive MS, ethnicity at higher risk, etc. (as noted above)
    - the current and expected future COVID-19 risk in the region
    - Passed infection with COVID-19
    - Availability and access to a COVID-19 vaccine

Indications of the influence of disease-modifying therapies on the severity of COVID-19

Interferons and glatiramer acetate are unlikely to adversely affect the severity of COVID-19. There is some preliminary evidence that interferons may reduce the need for hospitalization due to COVID-19.

The available data suggest that people with MS who take dimethyl fumarate, teriflunomide, fingolimod, siponimod, and natalizumab are not at increased risk of more serious COVID-19 symptoms.

There is evidence that therapies for CD20 - ocrelizumab and rituximab - may be associated with an increased likelihood of a more severe form of COVID-19. However, these therapies should continue to be considered as an option for treating MS during the pandemic. People with MS who are receiving these therapies (or ofatumumab and ubituximab, which work in the same way) should be extra vigilant about the advice above to reduce the risk of infection.

Further data on the use of alemtuzumab and cladribine during the COVID-19 pandemic are needed to assess their safety. People with MS currently receiving these therapies and living in an area with a COVID-19 outbreak should discuss their current lymphocyte counts with their treating doctor. (Lymphocytes are a type of white blood cell that helps protect the body from infection. If their numbers are considered low, people should isolate themselves as much as possible to reduce their risk.)

Recommendations for delaying the second or subsequent dosing of alemtuzumab, cladribine, ocrelizumab and rituximab due to the COVID-19 outbreak vary from country to country. People who are taking these drugs and need to receive the next dose should ask their doctor treating them about the risks and benefits of postponing treatment.

It is strongly recommended not to discontinue treatment without the advice of the attending physician!

Medical advice in case of relapses and other health problems

People with MS should still seek medical advice if they experience any health changes that may indicate a flare-up or some other underlying problem like infection. This can be done using alternatives to in-person clinic visits (e.g. telephone or video consultations) if the option is available. In many cases, it is possible to treat relapses at home.

The use of steroids to treat relapse should be carefully considered and only used in severe relapse. There is evidence that taking high-dose steroids in the month before contracting COVID-19 increases the risk of a more severe infection that requires a hospital visit. Whenever possible, the decision should be made by a neurologist who is experienced in the management of MS. People receiving steroid treatment for a flare-up should be extra vigilant and consider self-isolating for at least a month to reduce their risk of COVID-19.

People with MS should continue to participate in rehabilitation and stay as active as possible during the pandemic. This can be done through online sessions - if available - or in clinics if the facilities take security measures to limit the spread of COVID-19. People with mental health concerns should seek advice.

Flu shot

The flu vaccine is safe and recommended for people with MS. People with MS in countries starting the flu season are advised to get the seasonal flu vaccine, if it is available.

SARS-CoV-2 vaccine

Not enough information is currently available to comment on how the various SARS-CoV-2 vaccines under development would interact with MS or with disease-modifying therapies for MS. Notes will be included in an updated version of the MSIF statement as it becomes available.

Advice for children or pregnant women with MS

There are currently no specific recommendations for pregnant women with MS. There is general information about COVID-19 and pregnancy from the World Health Organization, but no specific advice for children with MS. These groups of people should follow the advice given above for people with MS.

COVID-19 mRNA vaccines (Pfizer-BioNTech and Moderna) and MS

The guidelines currently only apply to the mRNA vaccines (Pfizer-BioNTech and Moderna) as these have been assessed by clinical and scientific experts.

The mRNA vaccines use part of the genetic code of the coronavirus to trigger a response from the human immune system, which in turn triggers a response in the vaccinated person that produces antibodies and T cell cells to fight the virus. All data on these mRNA COVID-19 vaccines come from clinical trials that have been carefully and thoroughly reviewed and approved by regulatory agencies.

We do not know how many of the participants in the clinical trials with mRNA vaccines were affected by multiple sclerosis. Thus, there are still no data on the safety and efficacy of mRNA COVID-19 vaccines specifically for people with MS. The guidelines are therefore based on data from the general population in the vaccine clinical trials and on previous experience of vaccinating people with MS.

People with multiple sclerosis should get vaccinated

Science has shown that the COVID-19 mRNA vaccines (Pfizer-BioNTech and Moderna) are safe and effective. As with other medical decisions, the decision about a vaccine is best made jointly between the treating neurologist and the person affected by MS. People with MS should get the mRNA vaccine (Pfizer-BioNTech or Moderna) as soon as it becomes available. The risks of COVID-19 disease outweigh any potential risks of the vaccine. In addition, household members and close contacts of people with MS should receive an mRNA vaccine (Pfizer-BioNTech or Moderna), if available. This can reduce the effects of the virus. Pfizer-BioNTech and Moderna's COVID-19 vaccines must be given in two doses. Vaccination is recommended even if people with MS have already had SARS-COV-2 infection.

People with progressive multiple sclerosis, the elderly and those with a higher degree of physical disability, diseases such as diabetes, high blood pressure, obesity and heart and lung diseases as well as black and possibly South Asian people with MS are among the groups at the highest risk of having COVID-19 a hospital stay becomes necessary.

mRNA vaccines are safe for people with multiple sclerosis

mRNA vaccines (Pfizer-BioNTech and Moderna) do not contain live virus and do not cause COVID-19 disease. The mRNA vaccines (Pfizer-BioNTech and Moderna) are also unlikely to trigger an MS flare-up or make chronic MS symptoms worse. The risk of developing COVID-19 far outweighs the risk of a possibly vaccination-induced MS flare-up. The mRNA vaccines (Pfizer-BioNTech and Moderna) can cause side effects such as fever or fatigue. Fever can temporarily worsen MS symptoms. After the fever subsides, MS symptoms should return to pre-vaccination levels. Important: Even if people with MS experience side effects after the first vaccination, the second dose should be given.

COVID-19 mRNA vaccines are compatible with MS drugs

Disease-modifying therapy (DMT) should be continued unless the neurologist advises discontinuation or delay. Indeed, suddenly stopping some disease-modifying therapies can cause MS to deteriorate rapidly. Based on data from previous studies with other vaccines and disease-modifying therapies, it is considered safe to receive the mRNA vaccines (Pfizer-BioNTech or Moderna) even with disease-modifying therapy. Some disease-modifying therapies can make the vaccine less effective, but still offer some protection. For people with MS who are treated with ofatumumab, alemtuzumab, cladribine, ocrelizumab, or rituximab, the timing of vaccination may need to be coordinated with the timing of therapy. The treating neurologist determines the ideal point in time.