A pneumonia might not sound like something you necessarily want to avoid in life, or not something that ‘coughs’ you awake. However, outcome data on pneumonia in non-hospitalised individuals do indicate it’s not a benign condition. A large study in Germany showed a 30-day mortality of 6.3%. Obviously, this was mainly driven by age (mortality was 2.2% below 65 years old) and nursing home status, but also other comorbidities such as having a ‘neurological disorder’ impacted on outcome. Furthermore, several factors that are known to be more frequent among pwMS were linked with a more severe disease course, for example having swallowing difficulties or a restricted mobility.
Of note, pneumonia is one of the most frequently reported infections while being treated with Ocrevus. At 96-weeks of follow up in the Ocrevus trials, 9.4 episodes of pneumonia/URTI were seen per 100 patient-years in the interferon-beta group and 13.3 episodes in the Ocrevus group. As we are talking here about events per 100 patient-years (i.e. events while being treated for 100 sequential years with Ocrevus), the frequency of pneumonia remains low but the low risk does increase with 41% and is likely to increase further with ongoing treatment. Fortunately, we have access to the PPSV23 pneumonia vaccine which has an efficacy of 60 to 70% in preventing invasive disease caused by the serotypes in the vaccine. In people starting with immunosuppressive treatments, it is highly recommended but not obligatory to have the PPSV23 vaccine in combination with the annual flu vaccine. This is what we call immunoprophylaxis.
Although this is also the official recommendation in Switzerland, Diem et al. report that 41.3% of the pwMS under their care did not get a pneumonia vaccination before going onto Ocrevus treatment. The reasons for being unvaccinated that came out of the (limited) survey were:
- 60% lack of adherence to the recommendation by the pwMS themselves,
- 14% insufficient information on vaccinations provided by the neurologist,
- 22% disease activity,
- 2% pregnancy.
First, it is unclear why disease activity had such a big influence on the vaccine policy, as essentially all pwMS that go onto treatment have had recent disease activity to some extent. Second, the reasons why 60% of the pwMS in this cohort did not comply with the vaccine advice remained largely elusive. Younger people, people with concomitant psychiatric diseases and people that were already on an MS treatment were less likely to get vaccinated.
To be honest, the numbers of pwMS not having their pre-Ocrevus vaccination are high but I do not know if the Barts-MS centre would get better grades. Although we strongly emphasise the importance of the pneumonia vaccination pre-Ocrevus, we don’t have the data available on how many pwMS going on Ocrevus actually received the vaccine beforehand. As we have noticed that many pwMS have difficulties getting access to the pneumonia vaccine through their GP’s, Barts-MS definitely won’t be getting A-levels. Nonetheless, the article does illustrate the “state-of-the-art” when it comes to preventive medicine in pre-COVID-19 times, and it’s currently unclear whether adoption of vaccines is going to be worse or better post-COVID-19. There is no doubt about the fact that vaccine hesitancy, similar to smoking, is an individual behaviour influenced by a range of factors.
The most important reasons I see nowadays for vaccine hesitancy among pwMS are the following:
First, there is the fact that both neurologists and pwMS feel the infection risk does not apply to their patients or themselves, respectively, and have been complacent about infection prevention. In this setting, people allow arguments such as the importance of “natural immunity” (which is exactly how vaccines work) and perceived but unsubstantiated risks between vaccination and MS relapse to guide their management. The reality is that many people are terrified about flying on a plane, follow all sorts of diets for neuroprotection in MS but do not get the annual flu shot. However, COVID-19 has it made it very clear that small risks do matter and that ICU’s are filled with people of all ages with ánd without other diseases that might weaken them. The same rationale applies to the pneumonia or flu vaccine. Importantly, I do agree the nadir of a relapse is not the right moment to talk about vaccinations (nor to initiate a new therapy), and it would be best to defer vaccinations until the relapse is no longer active/progressive.
Second, vaccine mis- and over-information by newspapers and social media and also politicians/policy makers are a problem. Admittedly, this might be more of an issue on mainland Europe than in the UK. To illustrate the influence of media and culture: a Belgian example. The overall vaccination rate among people aged +85 is 81% in Belgium, but when analysing it according to regions: Brussels (French>Dutch) 67%, Wallonia (French) 68% and in Flanders (Dutch) 89%. When reading newspapers and following newsfeeds, it sometimes feels like the reporting on Donald Trump has been replaced by reporting on vaccination efficacy and clotting events. This information overload almost makes you feel bad about not having an opinion about and questioning whether you should go Moderna, Pfizer or Astra-Zeneca. However, these vaccines are subject to the same checks and balances as all other drugs or treatments recommended by physicians. In addition, the decision of European politicians to suspend/age-restrict vaccination with Astra-Zeneca because of rare clotting events while clots secondary to COVID-19 are about 41,000 times more likely is undoubtedly feeding vaccine hesitancy, and a barrier for accurate risk assessment and uptake of vaccination in the future.
Importantly, information and counselling can modify views, and this is one of the biggest challenges for HCP, healthcare systems and nations now and in the future. Vaccinations are a key tool to derisk immunosuppressive treatments for pwMS and allow pwMS to focus on overcoming MS-related disability rather than having to deal with potentially harmful infections. Therefore, HCP and healthcare systems need to invest in trustworthiness, reflect on the most effective way of tapping into inaccurate vaccine beliefs and get the vaccine message across. Make vaccines great again! (and indeed Trump needs to be credited for operation Warp Speed!)
Disclaimer: Please note that the opinions expressed here are those of Ide Smets and do not necessarily reflect the position of the Barts and The London School of Medicine and Dentistry nor Barts Health NHS Trust.
Neurol Neuroimmunol Neuroinflamm. 2021 Apr 2;8(3):e991.doi: 10.1212/NXI.0000000000000991. Print 2021 May.
Vaccine Hesitancy in Patients With Multiple Sclerosis: Preparing for the SARS-CoV-2 Vaccination Challenge
Lara Diem 1, Christoph Friedli 2, Andrew Chan 2, Anke Salmen 2, Robert Hoepner 2
- PMID: 33811158
- PMCID: PMC8018793
- DOI: 10.1212/NXI.0000000000000991
Objective: Vaccine hesitancy is a complex public health issue referring to concerns about safety, efficacy, or need for vaccination. Using pneumococcal vaccination, which is recommend in anti-CD20-treated multiple sclerosis (MS) patients, as a model, we assessed vaccination behavior in patients with MS to prepare for the upcoming SARS-CoV-2 vaccination challenge.
Methods: By a medical chart review, we retrospectively identified patients with MS treated with ocrelizumab at the University Hospital Bern in 2018-2020. Pneumococcal vaccination was discussed with the patients during clinical visits and highlighted in the after-visit summary addressed to the general practitioner before ocrelizumab initiation as part of our clinical standard of care.
Results: Pneumococcal vaccination was performed in 71/121 (58.7%) of patients, and 50/121 (41.3%) patients were not vaccinated. Patients who did not get a pneumococcal vaccination were younger (no vaccination vs vaccination; mean [95% CI] 40.1 [36.1-44.1] vs 45.4 [41.9-48.8], p = 0.028) and had more frequently a relapsing remitting disease course (no vaccination vs vaccination, n [%]; 43/50 [86.0%] vs 49/71 [69.0%], p = 0.031). Furthermore, patients who did not get vaccination had more frequently a history of comorbid psychiatric disorder (no vaccination vs vaccination, n (%); 12/50 [24.0] vs 7/71 [9.8], p = 0.035).
Conclusion: Our study demonstrated that in our single-center cohort, 41.3% of patients with MS do not get the recommended pneumococcal vaccination. Future research should focus on vaccine hesitancy in the vulnerable cohort of patients with MS to improve the safety of MS immunotherapies.