ClinicSpeak: flu jabs

Do you have an annual flu jab? If not, it is time to consider it. #ClinicSpeak #MSBlog #MSResearch

“The systematic review below looks at whether or not MSers on DMTs respond to flu vaccinations or not. Why is this important? Flu is a common infection and if we can prevent MSers getting flu we will help improve their disease course. Infections are a known trigger of MS relapses. About a third of relapses occur within the at-risk period after and infection; this is typically defined as up to 6 weeks after an infection. Therefore if we prevent you getting seasonal flu we will reduce your chances having an infection-triggered relapse. The good news is that most DMTs allow you to mount an appropriate antibody response to the flu vaccine. The exceptions in this study below being treated with mitoxantrone or glatiramer acetate. Mitoxantrone makes sense as this is a powerful immunosuppressive drug, but why glatiramer acetate (GA)? I think GA has been fingered because the analysis is based on a single small study. I think the latter is likely to be a false positive result. A second larger study is needed to answer the question about whether or not GA blunts your immune response to the flu vaccine. As the current flu-vaccine in the UK is an inactivated component vaccine we recommend it to all our MSers each year. Even partial immunity to the new circulating flu strains is better than no immunity. There have been several studies showing that the inactivated flu vaccine is safe in MSers and is not associated with triggering relapses or MRI activity.”

“Do you have an annual flu vaccination?”

Pellegrino et al. Efficacy of vaccination against influenza in patients with multiple sclerosis: The role of concomitant therapies. Vaccine. 2014 Jul. pii: S0264-410X(14)00869-X.

Background: MS is a chronic progressive demyelinating disease affecting over 2.1 million MSers worldwide. MSers are exposed to an increased risk of infection from communicable diseases, which may lead to severe disease relapses. Studies have analysed the issue of vaccination of MSers. These studies, however, deal mostly with safety-related issues documenting that most vaccines have been proven to be safe in MSers and that vaccination is not associated with an increased risk of relapses. By contrast, evidence on the efficacy is comparatively scant and not yet systematised in a comprehensive picture. This aspect is however important, as both MS and its treatment alter the immune responses, a situation that may be associated with a reduced vaccine efficacy. We have now reviewed the literature and assessed the effects of the therapy for MS on vaccine efficacy; we focused on the vaccine against influenza as for the other vaccines the information is still too scant. The majority of drugs appear not associated with a reduced response to vaccination against influenza, with the notable exception of mitoxantrone and glatiramer acetate. For a few drugs, among which natalizumab, information is not sufficiently clear and additional studies are needed to draw a definite conclusion. These results highlight the importance to evaluate the efficacy of vaccination in MSers treated with immunosuppressant drugs.

About the author

Prof G

Professor of Neurology, Barts & The London. MS & Preventive Neurology thinker, blogger, runner, vegetable gardener, husband, father, cook and wine & food lover.


  • Prof G.
    What about alemtuzumab? Can I have vaccine the same year I got infusion (say after 9 months), the year after?

    • Re: "What about alemtuzumab?"

      The preliminary evidence suggests that once your immune system has reconstituted, or rebooted, that it is capable of responding to both live and inactivated vaccines. I would however wait for 3-4 months after the last infusion and make sure your lymphocyte counts are not too low before having a live vaccine.

  • You repeatedly say that infections trigger relapse. How does this work with prescribing drugs like Fingolimod that increase infection risk?

    • Re: "..infections trigger relapse. How does this work with prescribing drugs like Fingolimod that increase infection risk?"

      Although immunosuppressive therapies increase your chances of getting infections they inhibit the way the immune system triggers relapses. So in theory infection on DMTs should not trigger relapses. However, this would need to be looked at in the trial. I assume Novartis has enough data from their trials to see if relapses were more common in the 6 weeks after an infection in both the placebo and fingolimod treated arms of their studies. I will ask them this question.

  • I've been discussing infections triggering relapses on an MS forum. It seems many MS patients are not aware infections can trigger relapses. One reply was that they thought a doctor would say infections would not trigger relapses, just flare up's of symptoms. Another patient agreed with this reply. This I think could be a concern, especially with CIS patients or MS patients not on DMT's?

    • Dear Prof G. This does concern me that if many MSers are not aware infections can trigger relapses, then they are vulnerable to a relapse if they are CIS or an MSer not on a DMT. I have not been informed to be vigilent about about infections, get them sorted as quick as possible – with antibiotics if required and know the importance to take enough rest during an infection so the body is able to recover. It may seem obvious to those already in the know. I had to work it out for myself through personal experience of an infection triggering a relapse, it was my first MS symptom the relapse. Then I did some websearches and then raised it with my MS nurse that infections trigger relapses. Should this be something neurologists and MS nurses are discussing with patients? CIS patients may not have access to seeing an MS nurse. I am a RRMS patient due to begin my first DMT end of October. Many thanks.

By Prof G



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