Vaccine Trumpism for President!

V

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

https://cartoonmovement.com/cartoon/anti-trumpism-vaccine

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!)

Twitter: @SmetsIde

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

Abstract

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.

About the author

Ide Smets

20 comments

  • What’s The 45th President of the United States Donald J Trump have to do with Vaccinations?
    Your Political jabs are Funny. ? Not enough news about DJT 45, so drugs getting more press so
    people won’t take vaccinations?
    Our 45th President of the United States initiated Operation Warp Speed.
    It enabled Historic Vaccine Development and Saved Countless lives.
    https://search.hhs.gov/searchblox/hhs_news/index.html?query=Operation+warp+speed&HHS=Search&cname=hhs_news&page=1&pagesize=10&sort=relevance&sortdir=desc&adsCname=hhs_news&adsDisplay=true&tune=false&default=AND

      • Ok I got this (as I isolate lonely in my home)
        easily overlooked is that Yanks such as myself who read this blog need to appreciate culturally that British humor is distinctly different and more charged with satire than American humor. (Google it or watch British TV). the cartoon reposted here was created by some political cartoonist on a different site. I really don’t care about anyone’s political affiliation but I do care very much about people understanding health issues without political bias. If the political cartoon didn’t resonate with you, then let’s explore why it might be important and resonate with others…..

        Donald Trump is connected to vaccine hesitancy because he has said long before his presidency, during his campaigns, and as President that he believes vaccines cause autism. (believe what you want but understand Trump’s position on it). See 2012 trump interview Donald Trump Discusses Autism and.
        See 2016 republican debate. Donald Trump Discusses Autism and Vaccines. And As President, Trump set up a safety commission to study relationship of vaccines to autism, causing concern to be voiced in medical community about Trumps’s anti vaccine anti science stance. in the American Journal of Public Medicine. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5678397/. The UK Independent in Dec 2016 went so far to say that 1 in 3 Trump supporters believe vaccines cause autism probably because Trump himself asserts it.
        One in three Donald Trump supporters believe vaccines cause autism – so does the President-elect | The Independent | The

        Trump developed Wrap speed but is also the only living president who didn’t go on pro vaccine advertising campaigns and took vaccine privately and secretly. (Talk among yourselves)

        Ok, so what, you ask, Trump and his Republican supporters are anti vaccine.??? And how does that affect MSers and why is it on this site??? Well, Vaccine Hesitancy during a pandemic is a big @#$&* public health deal, especially to immune compromised. Despite the presence of new dangerous variants, Recent polls show majority of Republicans are still anti-mask and anti Covid vaccine. https://poll.qu.edu/national/release-detail?ReleaseID=3695. Last month, even a Republican Governor from Arkansas says it’s worrisome that Trump Supporters have vaccine hesitancy but explains it’s due to a natural resistance to government. GOP governor: Vaccine hesitancy among Trump voters is ‘natural resistance to government’ | TheHill
        Dr Faucci said last month that Republican vaccine hesitancy is one of the biggest risks to corona virus control efforts.

        https://www.bloomberg.com/news/articles/2021-03-14/fauci-says-vaccine-hesitancy-among-republicans-poses-a-big-risk

  • Definitely needs to be credited with operation warp speed, but that was probably due to an attempt to -lease voters and get re-elected than any serious commitment to vaccination as a public health measure.
    https://www.insider.com/how-donald-trump-became-an-anti-vaccinationist-2019-9

    https://www.nytimes.com/2020/03/09/health/trump-vaccines.html

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5678397/

    https://www.latimes.com/business/story/2020-09-08/trump-anti-vaxx-record

    And others

  • “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.”
    This is from the previous post from Prof. G. and perhaps is the answer?: “We are so convinced about the early treatment that we are doing the ATTACK-MS trial, which will explore if access to the highly effective treatment natalizumab, 2 months earlier than what happens in routine practice, improves outcomes.”
    Shoulhd one wait 1-2 months for the vaccine to work or start highly effective treatment e.g. ocrelizumab asap in pwMS with high disease activity?

    • No definitely not! The minimal delay that needs to be respected between a vaccine and starting a DMT is only 2-4 weeks (depending on which guideline you follow). So administering a vaccine is in most cases no source of delay, and even if the vaccine also requires a booster (not the case in pneumonia vaccine) you can already give the first dose before starting the treatment.

      Giving the vaccine before treatment is especially relevant for OCR as there are still some uncertainties regarding the efficacy of vaccines once the treatment has started. The good thing about natalizumab/ATTACK-MS is that vaccine responses are intact while being on natalizumab. Only live vaccines such as the vaccine against mumps or yellow fever essentially are contraindicated.

      • Correct, if the logistics work fast and you give the vaccine right away, more difficult if you have to refer the patient and wait for the vaccination. Perhaps its a matter of how to do this asap.

        • Indeed, totally true. The NHS requires GP’s to coordinate the vaccinations, which is good in terms of central coordination but bad in terms time and administrative burden. So if indeed, if it takes two to three months to get the vaccinations and then also the 4 week gap, that’s not practical at all if you have active MS.

      • Sorry, in relation to this, would there be any effect of high dose corticosteroid treatment given for a recent relapse on the efficacy of the vaccine?

        • There are no good studies to back this up, but it will probably slightly reduce the level of antibodies that are formed post-vaccination. Anyway, it’s definitely no reason to defer necessary vaccinations as safety is no issue.

  • Interesting. My neuro was adamant about hepatitis B (which I had done years before but no tither to show poll for) but more relaxed about pneumonia, I ended getting it but more by chance…

    • Indeed, increased risk of hepB reactivation is something very specific for ocrevus treatment (and less for cladribine for example), and in case of low titres it’s advisable to recommend a booster. The infection signal with Ocrevus has become more clear over the preceding years because pwMS use it long-term, and the recommendation for pneumonia and flu vaccine applies to almost all immunosuppressive treatments in MS and is thus not specifically for ocrevus. But I guess unconsciously people make a risk:benefit judgement and feel a pneumonia is likely going to be successfully managed by antibiotics while the management of HepB reactivation is much more complicated and requires longstanding treatment.

  • I got a whole bunch of vaccines, including for pneumonia, before I started Rituxan 2 years ago at age 45. I asked about getting the shingles vaccine and the pharmacist actually kind of chuckled at me! I mean I’m not far off from the age that the shingles vaccine is suggested and I assume I will still be on Rituxan then. I kind of wish I had pressed for it, have heard a lot of bad shingles stories.

    • Personally, I also think shingles vaccines should be offered to people going on immune suppressive treatment. The problem is that in many healthcare systems it’s not reimbursed and therefore quite costly. But if you can have it, and want to pay for it, I would definitely be in favour of the vaccine before starting immune suppression.

      • I’m interested in this. Being on fingolimod I knew I couldn’t have the shingles vaccine (I’m 70) and sad to say I wasn’t told of the issue before I started the drug. So when in 2018 I saw the Shingrix info I asked my hospital for advice because I would gladly have paid for a private vaccination. They asked their pharmacist to interrogate the data and I got back a sheaf of information. Attached was the neuro’s recommendation that on the basis of this evidence he didn’t recommend it. Have things changed? I hope to be starting cladribine in the next few months so am keeping fingers crossed that at some point I will be able to get a shingles jab.

        • Yes, the publication on the efficacy of Shingrex in immunosuppressed was only published in 2019, and the label was only recently changed (in 2020).

    • The old live vaccine had I think higher age range but the new one Shingrex is not live and FDA cleared at age 50.

      Can I get Shingrix before age 50?

      In its 2018 zoster vaccine recommendations, the Advisory Committee on Immunization Practices (ACIP) states that Shingrix may be used in adults age 50 years or older irrespective of prior receipt of varicella vaccine or live zoster vaccine (Zostavax).Feb 19, 2021″

      Why do you have to wait until 50 to get shingles vaccine?

      Dear L.C.: The shingles vaccine has only been tested in adults over age 50, and thus is not indicated for younger ages by the Food and Drug Administration. The vaccine is particularly important in older people because shingles is more common and has a higher risk of complications in older people.Nov 20, 2020

      https://www.google.com/search?q=shingrix+age+range&rlz=1CATQWC_enUS898&oq=shingrex+age&aqs=chrome.1.69i57j0i10l8.9227j0j15&sourceid=chrome&ie=UTF-8&safe=active&ssui=on

      • Yes, all true, but there is additionally recent evidence that the shingles vaccine is efficient in immune suppressed individuals irrespective of age. It has been tested in people with a malignancy receiving chemo, and was able to reduce herpes infection with 61%. Based on these data, it has now also (future) immune suppressed individuals on his label and can thus also be useful in the context of MS.

  • For someone like me, overwhelmed by the diagnosis of MS. My neuro pointed out to me I lack antibodies to few things, but at the time all I wanted was to start a treatment. Put me back to where I was I would still make the same decision of starting the treatment asap, unless the risk of infection is a certainty.

    • The risk of infection is a certainty when looking at it in big groups of pwMS and depending on the type of treatment that is evaluated.

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