We can learn from other conditions and if they are seeing the same thing to MS they are more likely to be true. Here is a view on arthritis
Fagni F, Simon D, Tascilar K, Schoenau V, Sticherling M, Neurath MF, Schett G. COVID-19 and immune-mediated inflammatory diseases: effect of disease and treatment on COVID-19 outcomes and vaccine responses. Lancet Rheumatol. 2021 Aug 27. doi: 10.1016/S2665-9913(21)00247-2.
At the beginning of the COVID-19 pandemic, patients with immune-mediated inflammatory diseases were considered to be at high risk for SARS-CoV-2 infection and the development of severe COVID-19. Data collected over the past year, however, suggest that a diagnosis of inflammatory arthritis, psoriasis, or inflammatory bowel diseases does not increase risk for SARS-CoV-2 infection or severe COVID-19 compared with people without these diseases. ………………….., glucocorticoids and potentially B-cell-depleting treatments seem to worsen COVID-19 outcomes. Additionally, the first data on SARS-CoV-2 vaccination in patients with these diseases suggest that tolerability of vaccination in patients with immune-mediated inflammatory diseases is good, although the immune response to vaccination can be somewhat reduced in this patient group, particularly those taking………….CD20-targeted treatment.
Does it sound familiar…Sure it does
However information is rapidly appearing and some info is out of data before it arrives
Wolf A, Alvarez E. COVID-19 Vaccination in Patients With Multiple Sclerosis on Disease-Modifying Therapy. Neurol Clin Pract. 2021 Aug;11(4):358-361.
Advice =To maximize the immunologic response, it is suggested by the Canadian Network of MS Clinics (cnmsc.ca/Covid19VaccineGuidance)……For patients already on anti-CD20 DMT, waiting 12 weeks (as in the VELOCE study) after infusion to start the vaccination process is recommended.
This is not a magic solution and many people will not respond to vaccine using this approach and in fact most won’t.
It has also been proposed to delay vaccination until B-cell reconstitution or toward the end of an infusion cycle, but the risks of contracting COVID-19 need to be considered.
Good idea but one problem the dosing schedule is designed to remove B cells permenently so most people will not repopulate. Likewise to delay takes you outside of the protection of the label So will it be done.
The label says “In the Phase III studies, between each dose of Ocrevus, up to 5% of patients showed B-cell repletion
(> lower limit of normal (LLN) or baseline) at least at one time point. The extent and duration of
B-cell depletion was consistent in the PPMS and RMS trials.” In the phase II trials less than 5% of people had 1% B cells at 9 months 50% at 12 months 85-95%
So without a delay between infusion and vaccine, I think that many people are unlikely to respond. However this needs discussion
Now to learn from cancer and B cell cancers
Lee M. Greenberger, Larry A. Saltzman, Jonathon W. Senefeld, Patrick W. Johnson,
Louis J. DeGennaro, Gwen L. Nichols Anti-spike antibody response to SARS-CoV-2 booster vaccination in patients with B cell-derived hematologic malignancies Cancer cell DOI: https://doi.org/10.1016/j.ccell.2021.09.001
Among the 21 patients who completed therapy with anti-CD20 antibodies………12 patients were non-responders, 7 patients demonstrated seroconversion, and 2 patients demonstrated sero-elevation. Notably, 5 of the 7 patients who completed therapy with anti-CD20 antibodies ………….at least 7 months prior to the booster vaccination demonstrated seroconversion………………In contrast, many of the patients who recently had, or are maintained on, anti-CD20 antibody therapy prior to booster vaccination failed to seroconvert after booster vaccination. It has previously been reported that recovery of B cells begins 6–9 months after rituximab therapy (McLaughlin et al., 1998). Thus, these data suggest that recent treatment regimens containing anti-CD20 antibodiesmay suppress the response to booster vaccination.
The new Iron maiden song asks “Have you seen the writing on the wall”….
I think I have and the writing gets bigger and bigger. Will we push on through the wall and what happens if we do?
So more MS vaccine news
Ali A, Dwyer D, Wu Q, Wang Q, Dowling CA, Fox DA, Khanna D, Poland GA, Mao-Draayer Y. Characterization of humoral response to COVID mRNA vaccines in multiple sclerosis patients on disease modifying therapies. Vaccine. 2021 Sep 2:S0264-410X(21)01126-9.
Little is known about COVID-19 mRNA vaccine humoral immune responses in patients with central nervous system autoimmune demyelinating diseases, multiple sclerosis (MS) and neuromyelitis optica (NMO), who are on B-cell depleting therapies (BCDT) and other disease modifying therapies (DMTs). We conducted a single center prospective study to identify the clinical and immunological features associated with vaccine-induced antibody response in 53 participants before and after COVID-19 mRNA vaccination. This is the first report (another first) on the anti-spike RBD and anti-nucleocapsid antibody response, along with pre- and post-vaccine absolute lymphocyte counts (ALC) and flow cytometry analysis of CD19 and CD20 lymphocytes in patients with MS and NMO. We tested the hypothesis that patients on BCDT may have impaired COVID-19 vaccine humoral responses. Among patients on BCDT, 36.4% demonstrated a positive antibody response to spike RBD, in comparison to 100% in all other groups such as healthy controls, untreated MS, and patients on non-B cell depleting DMTs (p < 0.0001). Immunological data revealed lower baseline (pre-vaccination) levels of IgM in patients on BCDT (p = 0.003). Low CD19 and CD20 counts and a shorter interval from the last B cell depleting therapy infusion to the first vaccine dose were associated with a negative spike RBD antibody response (non-seroconverter) in patients on BCDT. Age, body mass index (BMI) and total treatment duration did not differ between seroconverters and non-seroconverters.
Hope the Writing on the wall is getting bigger for you too?
However, we are not looking in the right direction for the major problem when it comes to vaccination.
The JCVI (Jonit Commitee of Vaccinations and Immunity) needs to get its thinking cap on
Remember I’m a scientist and dont have to think about clinical issues
Disclaimer: Please note that the opinions expressed here are those of the author and do not reflect the positions of the Barts and The London School of Medicine and Dentistry nor Barts Health NHS Trust or Queen Mary Univeristy of London.