The Safety and Scheduling of COVID Vaccination in Patients With MS

Stephen Krieger, MD


February 25, 2021

This transcript has been edited for clarity.

Hi. I'm Dr Stephen Krieger from Mount Sinai Hospital in New York, reporting to you from Medscape on the current situation with multiple sclerosis (MS) patients and the COVID-19 vaccines. There could be a no more timely issue than this, as we've been inundated with questions from our patients about the COVID-19 vaccines and what they should do. Here's how we've been trying to address this issue.

We are responding to our patients via phone calls, emails, MyChart messages, and 5 minutes at the end of every in-person or virtual visit devoted to talking about vaccination for COVID-19. The main message we are trying to get across to people with MS is, "Yes, get vaccinated for COVID-19."

The data for the Pfizer and Moderna vaccines, which are the ones available in the United States at the time of this recording, are fantastic. I've been telling my patients that the efficacy is better than we could have expected or hoped for, with 95% risk reductions in COVID-19 infection for those receiving these vaccines. There's also outstanding emerging data from the AstraZeneca trial and the Johnson & Johnson trial.

My personal view is that because the Pfizer and Moderna vaccines are not live virus vaccines, they are safe and effective for people with MS. In principle, this makes me favor them a little bit over the vaccines developed by AstraZeneca and Johnson & Johnson, which do use a live virus as part of their mechanism. However, that is not a replicating virus. It's not the same as giving someone with MS a true live virus vaccine. Therefore, I think it's better to be vaccinated than not vaccinated. And I've told my patients that if they get to the front of the line and they're offered the AstraZeneca or Johnson & Johnson vaccine, I'd much rather that they get it than go without.

The National Multiple Sclerosis Society has a nice position statement on its website about the vaccines for people with MS, which I've been directing my patients to look at.

When it comes to COVID-19 vaccines and MS treatments in general, the good news is that there are no major concerns or interactions. It is possible that some of our particularly cell-depleting agents, like our anti-B-cell agents, may make the vaccines a bit less likely to be effective. However, they do not make the vaccines any less safe. Again, I do want for my patients on these therapies to get vaccinated. I'd rather that they have the chance of protection from COVID-19 than being unprotected from it.

With respect to medicines given infrequently in MS, like ocrelizumab, there's a lot of discussion about trying to time this so that your patients can receive a vaccination as far after that most recent dose as possible. For one of the two-dose vaccines, this should occur at month 4 after their last ocrelizumab infusion, with the second dose at month 5, and then a month later they receive their 6-month ocrelizumab infusion. That would be ideal, but in truth, we can't always get the timing quite right. We don't know when the vaccines will be available for everyone. Therefore, I just tell my patients that I don't want them getting the vaccine within a couple of weeks of an ocrelizumab infusion, but if they can try to time it to be delayed after the last one, that would be for the best. For medicines like oral cladribine and alemtuzumab that are also given in very infrequent cycles, the idea of having at least several months pass since the last course of treatment before the vaccine is given would be ideal.

How to Talk to Vaccine-Skeptical Patients

I also have a few thoughts on addressing skepticism about getting vaccinated among our patients. Some people feel that the vaccines are too new to be trusted. While I understand where they're coming from, I do point out that the technology for these vaccines has been developed for years and was scaled up very effectively to meet the need as COVID-19 occurred. This wasn't developed overnight.

Some people are concerned or skeptical because they feel that the development was rushed. To that I point out that usually when a vaccine is being developed, one has to run trials that take a very long time for enough people to get the condition that you're trying to prevent in order to know that the vaccine worked. But these vaccines were developed in the midst of this global pandemic. It's not that they rushed to development; it's that the disease rushed in. So many people developed COVID-19 while the vaccines were being developed that they quickly got the answer, which was that they actually did work to prevent the disease. So, addressing the concern that it was developed in a rushed way, I think it was developed as quickly as it could be, which was the right thing.

I also point out that the production of the vaccines began before they knew if they would work. As a result, when the data were positive and the regulatory approvals came in, they could load the trucks and send them out. So we're not sitting here waiting for 6 months for the vaccines to be created.

For those patients who are skeptical or concerned about the vaccine, I note that it's there to protect them and their family, to protect the community. I recommend that they review resources on the websites of the National MS Society or, more broadly, the Centers for Disease Control and Prevention (CDC). Hospitals also have information on their websites about the vaccine. You don't have to reinvent the wheel and start from scratch when you're trying to get good information to your patients.

On a more personal note, I've also learned a lot from reading about how to talk to people about the vaccine, in particular from a series of tweet threads from Dr Kimberly Manning at Grady Hospital. She has shared valuable lessons about how to talk to people about their concerns and skepticism over these vaccines, trying to really listen and understand their reasons, meeting your patients where they are, and trying to overcome some of those barriers. By doing so, we can foster their trust in the vaccines and in us as we try to partner with the communities that we serve.

And I also point out to my patients who are skeptical that millions of healthcare workers, myself included, have gotten vaccinated first. We were on the front lines when people needed our care, and we've been on the front lines getting these vaccines. I'm not recommending anything for my patients in this regard that I haven't and wouldn't do for myself.

Finally, for every patient that is skeptical and hesitant about the vaccines, I also have people with MS who want to get to the front of the line for vaccines and want me to do whatever I can to get them there. Addressing the priority and the access to the vaccines is also a big challenge. I point out to my patients that the good news is that MS was not found to increase the risk of contracting COVID or the risk for COVID-related mortality. The bad news is that means MS wasn't on the list of CDC priority indications to get the vaccine sooner. However, MS is, of course, a chronic neurologic disease, which different states are prioritizing differently. This is state dependent, but we have been writing letters of support for our patients, pointing out that they do have a chronic autoimmune neurologic disease, and in some states that may move them up the ladder of priority to get the vaccine sooner than later. I tell them to check the state websites for guidelines and the latest on availability, which we ourselves have been doing.

That is a brief snapshot of this moment in time with COVID vaccinations in general and for MS patients in particular. I hope some of these tips and ideas are helpful for you in your practice.

I'm Stephen Krieger from Mount Sinai in New York.

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