BartsMS COVID-19 vaccine advice – update

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The advice I posted on 29 Dec is already outdated. Meantime NHS England decided to introduce the 3 month gap between 1st & 2nd dose of any of the vaccines currently available in the West, and only a couple of days ago did the latest mRNA vaccine (Moderna) receive the green light from the MHRA. We have therefore updated our advice – here it is:

COVID-vaccines-DMT-BartsMS-guidance_20200109

@KlausSchmierer

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21 comments

  • Thanks for this Prof K. Do you think other neurologists will adopt this? I ask as u had my latest ocrelizumab on 5th having been offered the vaccine on 4th. Having discussed this with my MS nurse and given the changes to the vaccine dosing schedule I declined the vaccine at this time.
    When I attended for my infusion, I was asked whether I’d had my vaccination as they wouldn’t have infused if I’d had it within 6 weeks.
    I understand from my Trust that there is some flexibility on the vaccine dosing schedule on clinical grounds.
    Within any further advice from my neurologist my plan had been to follow the blog and watch for any further advice on the MS Society website. To allow for the 6 weeks needed before my next infusion, I had been planning to wait at least 3 months before having my first vaccination.

    • I believe that other neurologists may adopt this others may not, we had to weigh up local circumstances, and work around dosing of the drugs and the knowledge of the vaccine and government advice and no doubt this will be reviewed and changed as new data emerges, vaccine supplies change, data on oxford vacine emerges. For ocrelizumab the drugs label says to wait 2-4 weeks so not sure where the 6 weeks if you only get one dose but that would allow two doses and three weeks for BBioentech. With an ideal world it could give time. We know that some people are having second dose 3 weeks after first. Also the UK view of dosig to 12 week cycle appeared which we were not expecting. We will have to monitor but we thank you for sharing your experience and thoughts. At the moment the oxford vaccine is not classed as a live vaccine although it clearly is not dead but it cannot make an active infection. Some reading form othercountries and they have a different view.

        • Cannot talk for the whole country (Switzerland), but my neuro suggests infusion of Ocrevus 10 days after second dose of the vaccine (Biontec; second dose after 3 or 4 weeks). Idea is that due to data full immunization is reached one week after second shot. So, why wait longer?

          • From my reading there were very few participants in the BNT162b2 study on immunosuppression, including B cell depleting therapy. We know from other vaccines that the immunisation response is blunted by B cell therapy. We felt leaving a slightly longer gap for the vaccine response to build is not a bad thing, particularly given the effect of ocrelizumab on B cell depletion outlasts the regular 6 month interval. So there is no harm delaying your ocrelizumab by another week (probably months). We recently discussed the risk-benefit balance of ocrelizumab here: https://www.msard-journal.com/article/S2211-0348(20)30355-2/fulltext

          • Thanks a lot docs. Your allways very helpful.
            I don’t see any ideal moment for vaccination then considering your advice. Except maybe month 4 – 5 after last Ocrevus infusion. Am I right?
            And why should the Corona vaccine rather be blunted after 10 days than after 6 weeks?

          • Boa, this is virtually an evidence-free zone. Apart from the VELOCE study that waited for 12 weeks after the first course of ocrelizumab (Day 1 and day 15 half-dose infusions), there is no reliable data. Please note that most people in the VELOCE study made an immune response.

          • Ocrevus causes the most problems with regard the UK dosing schedule (less so if have a short vaccination course) and the 6 monthly dosing by waiting late you maximize the chance that the remaining B cells repond. Ocrelizumab depletes within day 1 at that point your antibody response to a vaccine may be blunted in some people it may be 6-15months for the B cells to return and during that time the vaccine reponse may be blunted. Whilst we know the blood is cleared of B cells the bone marrow and lymph glands may not be and this is where the vaccine response will be generated. A blunted response does not mean no response. If we wanted an optimal vaccine response you may say delay/stop the ocrelizumab and let your B cells return but then your MS may return and that would not be good.

            We could take some of Roches (Regeneron)/Astrazeneca anti-COVID-19 and give you 3-6 months of protection whilst you have reduced B cells and then he issue of vaccination is not an issue. It would offer a solution to health care workers on ocrelizumab. But that would be off label At the moment we don’t have the data and we dont know what the protective level of anitbodies are…it may be zero because T cells are enough.

            The early data is key, if we had the support we perhaps could have done that there are now a number of people on ocrelizumab who have had the vaccine these pioneers could have informed… but many hve been missed

          • I am finding all this discussion and debate very helpful for me in deciding about the best timing for the vaccination.
            At present, I’m thinking that I’ll need to clarify which vaccine I’ll be given and ask about having the shortened gap between doses on clinical grounds. Then I’ll need to check if my neurologist has altered her position on needing a 6 week gap between vaccination and infusion. If she’s happy to move to 4 weeks and I can get the shortened interval I’ll have first dose 4 months after infusion and 2nd dose at 5 months leaving 4 weeks to my infusion.
            I’ll doubt it’ll be that simple tho.

        • Top 10: United Kingdom, United States, Canada, Australia, Germany, Netherlands, France, Italy, Switzerland, Spain we have many readers from around the World

  • Thanks for the update Prof K, all very clear.

    Please look after yourselves and stay safe, things at the Royal London don’t sound too good. Same goes to all working on the covid wards everywhere. Lots of love xx

  • “If you are due to receive to AstraZeneca/Oxford vaccine […] the second dose should be given 3 months after starting your MS treatment.” – In the case of Cladribine is this not when lymphocyte count is likely to be at its lowest?

    • That is about right however, remember the drug is gone 1-7 days after the last dose the CD8 which are the cells most likely to be anti viral are only depleted by 30-40% and the memory CD8 T cells by 10-20% these are the cells that will get boosted and the B cells can start to recover. If you want to wait until you start to replete then it is easy to get both doses in in before your next course. What happens to plasma cells they have low levesl of Deoxycytidine kinase.

  • Hello. I had my first two infusions of Ocrevus in July and August 2020.

    My next infusion is due on 18th January. Should I delay this until after I receive my Covid vaccine? Have not yet been invited for my Covid vaccine.

    Thanks for any advice

    Thanks

  • Thank you! This is my best resource since my primary care doctor and Neuro really aren’t communicating about this topic. Stay well!

    • The article is from 9 December it is not worth reading.

      There were three cases of transverse myelitis (a) one considered possibly related (b) one considered unrelated as they had undiagnosed MS and (c) one in the placebo group so deffinately unrelated but these are all explained in the published paper in the Lancet.

      transverse myelitis has occurred after adenovirus infection, the experiment is not ongoing there must have been hundereds of thousands of people no vaccinated with the oxford/Az vaccine i UK and also in India, if this is going to be a major problem it will soon raise its ugly head but it is 3 in 11,000 and there have been allot more than 11,000 injected in the trials.

      We know that AZ have to do more trials the half dose stuff is meaningless unless a proper study is done and will no doubt slow/stop approval elsewhere, however as we have seen the regulators, presumably at the request of the UK government have disregarded the trial data anyway as the dosing schedule was not the planned approach

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