Covid-19 vaccines and MS: Part two

Q: Hi Alasdair, thank you for coming to chat with us again.

It's a pleasure! Isn't it good news that the vaccines are at last being rolled out? 

Q: Yes, it's fantastic! When we did the previous video we were just in the process of starting, it's gone really quickly hasn't it?  One of the most common questions we’ve had is can you still transmit the virus once you've been vaccinated? 

No one knows the answer to that question unfortunately. It is a frustrating thing but none of the trials actually looked at whether these vaccines impaired transmission. This is something we're going to have to work out after the vaccines have been rolled out, so we don't yet know. 

I think the consequence of that is that if you're with someone who's been vaccinated or you are yourself vaccinated, as I was this week, you should assume that you're still as capable of passing on Covid-19 as you were before the vaccine. So I'm afraid it's all the usual stuff such as social distancing and washing hands for a little while longer. 

Q: You said that you've been vaccinated. How was it, how are you feeling? I think most people don’t seem to think that it's much different from having the annual flu vaccine. 

I think that's right. I was very excited to be vaccinated! I had a sore arm for about 12 hours or so afterwards, but that was it. 

Q: Well that's good. You have sort of covered this one already but can you stop shielding once you've been vaccinated? 

My advice is that people don't change their behaviour at all once they've been vaccinated I’m afraid and that includes not stopping shielding. Obviously the thing about shielding is that you want to reduce the chance of getting the infection and vaccination will help in that considerably but it's not 100%. None of the vaccines are 100% and whilst the rate of Covid-19 infections are so high in most parts of the country, my general advice is that you should not change your behaviour. If you are shielding, stay shielding.

Q: There are a few different vaccines out now and we have had people asking if they should mix vaccines if they're offered a different one for the second dose. Is that okay or should it be avoided? 

This has been given some thought in the Department of Health and the advice is that you should try and get the same vaccine second time round as you had first time. There may become circumstances where that's just not possible, say if there's a local issue with delivery or supply. In that very unlikely situation, it is possible to have a second dose from a different vaccine to the one that you had first time around, but try to avoid it if you can. 

Q: Are there any vaccines that would be preferable for people with MS? 

The preferable vaccine is the one that you actually get offered. That's the one you can have so I would strongly recommend accepting the first offer you have! 

Q: Okay so we spoke about how you felt when you had your vaccine but what side effects should people expect and are there any risks of it triggering any sort of MS symptoms or relapses? 

I think I can confidently say that, having looked at the trials, side effects are almost exactly the same as your annual flu vaccine. In other words, many people get some minor symptoms and very, very few people get any serious side effects. 

In the Oxford trial there was one person with MS who had a vaccine and some days later seemed to have a worsening of their MS symptoms but we know that can happen with the flu vaccine as well. There was also one person who did not have a preceding history of MS or anything like that who had transverse myelitis and that too can happen after the influenza vaccine. 

As a reminder, there were 11,000 people in that trial so we're talking about tiny, tiny percentages. My basic take-home message is if you're someone who's accepted the risks of the annual flu vaccine then take the Covid-19 vaccine because you're not taking any greater risks. 

Q: A few people with MS have already started to have the vaccines so is there any news popping up about how they are feeling afterwards? 

I've not heard anything and there have been no systematic studies or case reports. So far it's a situation of no news rather than good news or bad news. I think this is true for any particular group of people with this or that disease. We don't yet know if there is any selective reason why they might have better or worse experiences with this vaccine so we're just going to have to wait.

If we go back to the flu vaccine example though, we know that people with MS tolerate vaccines very well. It doesn't exacerbate their disease and they don't get any worse side effects as a general rule so I'm pretty sure that's what's going to be the conclusion with the Covid-19 vaccine. 

Q: We spoke last time about different DMTs but there's still some confusion around them, which is understandable. First of all, can you talk a little more about Ocrevus and the timing of when to have the treatment if you’re going to have the Covid-19 vaccine? 

The first thing to say is that this is not a discussion about whether the vaccine will suddenly become dangerous. Anyone with MS on any treatment can have this vaccine and it will not be dangerous. The discussion is about whether the vaccine will be effective. In some situations, which I'll go on and talk about, it's possible that you'll have the vaccine and get no benefit from it. Please let me repeat that this is not about the vaccine causing any harm. So if you’re in doubt, have the vaccine.  

If we take ocrelizumab, Ocrevus as an example, we'd strongly recommend that if you're contemplating starting the treatment (and haven't already been on it) but have the option of a vaccine, take the vaccine and wait at least six weeks before receiving ocrelizumab. In other words, you have to allow the vaccine six weeks to take effect. 

If you've had ocrelizumab before or you're being offered it now and there's little chance of getting a vaccine soon, which is quite common, then I suggest getting your ocrelizumab in first. 

Then there's a question about how long should you wait after having had ocrelizumab before having the Covid-19 vaccine in a way that optimizes the chances of it being effective. There are different views on this. Some people say wait six months after an ocrelizumab infusion, some say wait for three months, while others say to go ahead, get the vaccine and hope for the best. 
I don't think there's anything definite in the advice that we can give here but I would certainly leave a delay of between three and six months after the ocrelizumab infusion before you have the vaccine.  

Q: There have also been a few people asking us about medication that will give you a low white blood cell count, such as Tecfidera, Gilenya and so on. Should these people still have the vaccine? 

Drugs which reduce the lymphocyte count include fingolimod or Gilenya, but also other medications like Tecfidera, cladribine or dimethyl fumarate, which can cause a low lymphocyte count from time to time. If you've got a low lymphocyte count then your immune system is suppressed and might not respond as well to a vaccine as a healthy person with a normal lymphocyte count and that is true. 

We know that people on fingolimod have slightly reduced responses to vaccines in general. However there isn't a magic lymphocyte number that says below this or above this and you're going to have efficacy or you're not going to have efficacy from a vaccination. It isn't practical or sensible to stop your fingolimod treatment for instance and wait however long it takes your lymphocyte count to come back in order to have a vaccine, so our advice is strongly to stay on the drug that you're on and to have the vaccine. To repeat what I said earlier, it will cause you no harm and it may well do you good.

Q: Now here at the MS trust we try to answer any questions we can but if you are a person with MS and you have specific questions about the vaccine, where is the best place to turn to? 

Your MS team are the right people to ask about whether your MS treatment means that you should time the vaccine for a particular date, so I would I would refer to them for that.
Otherwise, the government Department of Health website has a nice review of the roll-out strategy and when people might be able to get the vaccine, for instance. There are also some common questions answered there. 

Q: Excellent. Thank you so much for chatting to us again! It's been really useful and we're looking forward to hearing more about people having the vaccine and hopefully being able to go back to normal life. 

Yes we're all longing for that, aren't we? I agree with that!

 

Read Professor Alasdair Coles' Q&A on Covid-19 vaccines: part one