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Immunization

Immunization Guidance and Multiple Sclerosis

COVID-19 Vaccines and Multiple Sclerosis

Specific Vaccine Guidance for People Living With Multiple Sclerosis

  • updated to match circulating influenza viruses. The CDC recommends routine, annual influenza vaccination for everyone over 6 months of age with rare exceptions. CDC officials have determined it is safe to get COVID-19 vaccines at the same time as other vaccines, including the influenza vaccine.
    • Influenza Vaccines and MS Relapses: Clinicians should delay vaccination of people with MS who are experiencing a relapse until clinical resolution or until the relapse is no longer active (e.g., the relapse is no longer progressive but may be associated with residual disability).
    • Immune Response to Influenza Vaccine: A meta-analysis and systematic review published in 2021 in Multiple Sclerosis and Related Disorders found people with MS developed adequate immune response to the influenza vaccine as compared to controls without MS.
    • Influenza Vaccine Timing: Clinicians should recommend that patients with MS receive the influenza vaccination annually, unless there is a specific contraindication (e.g., prior severe reaction).
    • Live Vaccines for People With MS: Clinicians should recommend against using live-attenuated vaccines in people with MS who currently receive immunosuppressive/immunomodulating (ISIM) therapies or have recently discontinued these therapies. Some of these therapies also have restrictions from the U.S. Food and Drug Administration (FDA) for the timing of a live vaccine after discontinuing an ISIM therapy. Refer to the ISIM therapy’s prescribing information for specific requirements.
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    The Centers for Disease Control and Prevention (CDC) reviews the composition of the U.S. influenza vaccine each year, and the vaccine is updated to match circulating influenza viruses. The CDC recommends routine, annual influenza vaccination for everyone over 6 months of age with rare exceptions. CDC officials have determined it is safe to get COVID-19 vaccines at the same time as other vaccines, including the influenza vaccine.
    • Influenza Vaccines and MS Relapses: Clinicians should delay vaccination of people with MS who are experiencing a relapse until clinical resolution or until the relapse is no longer active (e.g., the relapse is no longer progressive but may be associated with residual disability).
    • Immune Response to Influenza Vaccine: A meta-analysis and systematic review published in 2021 in Multiple Sclerosis and Related Disorders found people with MS developed adequate immune response to the influenza vaccine as compared to controls without MS.
    • Influenza Vaccine Timing: Clinicians should recommend that patients with MS receive the influenza vaccination annually, unless there is a specific contraindication (e.g., prior severe reaction).
    • Live Vaccines for People With MS: Clinicians should recommend against using live-attenuated vaccines in people with MS who currently receive immunosuppressive/immunomodulating (ISIM) therapies or have recently discontinued these therapies. Some of these therapies also have restrictions from the U.S. Food and Drug Administration (FDA) for the timing of a live vaccine after discontinuing an ISIM therapy. Refer to the ISIM therapy’s prescribing information for specific requirements.

  • hepatitis B vaccine is recommended for all infants, unvaccinated children under the age of 19 and adults at risk of contracting this potentially life-threatening disease.
  • Hepatitis B Vaccine and MS: A 2021 review of hepatitis B vaccination studies in MS concluded that the hepatitis B vaccine does not increase a person's risk of developing MS.
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  • vaccine is indicated in females ages 9 to 26 and is designed to prevent the HPV 6, 11, 16 and/or 18-related cervical cancer, cervical dysplasias, and vulvar and vaginal dysplasias later in life. Immunomodulatory MS treatments can reduce immune surveillance against HPV. Receiving an HPV vaccine before starting a DMT and screening for HPV/cervical dysplasia following the immune compromised guidelines is recommended (Moscicki et al, 2025).
  • Side Effects From the HPV Vaccine: A large-scale study of patient registries in Denmark and Sweden found no increased risk of developing MS among nearly 800,000 people who received this vaccine (Scheller et al., 2015).
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    • Human Papillomavirus (HPV) Vaccine Recommendations: This vaccine is indicated in females ages 9 to 26 and is designed to prevent the HPV 6, 11, 16 and/or 18-related cervical cancer, cervical dysplasias, and vulvar and vaginal dysplasias later in life. Immunomodulatory MS treatments can reduce immune surveillance against HPV. Receiving an HPV vaccine before starting a DMT and screening for HPV/cervical dysplasia following the immune compromised guidelines is recommended (Moscicki et al, 2025).
    • Side Effects From the HPV Vaccine: A large-scale study of patient registries in Denmark and Sweden found no increased risk of developing MS among nearly 800,000 people who received this vaccine (Scheller et al., 2015).

  • MMR vaccine according to the U.S. vaccination schedule or were born after 1957 and received one dose. Refer to the CDC’s measles immunity guidance for more information.
  • Safety for People Living With MS: People with MS who have not received the MMR vaccine or are unsure of their vaccine status and are considering starting DMT should consider getting the MMR vaccine and have a discussion with their doctor. Since the MMR vaccine is a live attenuated vaccine, its administration should be avoided by people with MS taking certain DMTs. Refer to the DMT special considerations below for live virus vaccines and prescribing information for each DMT and the MMR vaccine.
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    • MMR Vaccine Recommendations: The CDC considers most people protected for life and not needing a booster dose if they have had two doses of MMR vaccine according to the U.S. vaccination schedule or were born after 1957 and received one dose. Refer to the CDC’s measles immunity guidance for more information.
    • Safety for People Living With MS: People with MS who have not received the MMR vaccine or are unsure of their vaccine status and are considering starting DMT should consider getting the MMR vaccine and have a discussion with their doctor. Since the MMR vaccine is a live attenuated vaccine, its administration should be avoided by people with MS taking certain DMTs. Refer to the DMT special considerations below for live virus vaccines and prescribing information for each DMT and the MMR vaccine.

  • CDC recommends the 2-dose JYNNEOS vaccine for people who have been exposed to mpox or who may be more likely to get mpox, even if they have a weakened immune system.Vaccination with JYNNEOS is safe for people with MS, including those who are immunocompromised. While the ACAM2000 vaccine is also available, this vaccine should be avoided by people with MS." c-nmssatomrichtext_nmssatomrichtext-host="">
    The CDC recommends the 2-dose JYNNEOS vaccine for people who have been exposed to mpox or who may be more likely to get mpox, even if they have a weakened immune system.Vaccination with JYNNEOS is safe for people with MS, including those who are immunocompromised. While the ACAM2000 vaccine is also available, this vaccine should be avoided by people with MS.

  • Pneumococcal vaccination is recommended for all adults 50 years or older.
  • Pneumococcal Vaccine Recommendations: According to the AAN recommendations on immunizations for people with MS, pneumococcal vaccines should be considered for individuals with compromised pulmonary function, including those who use a wheelchair on a full-time basis or are bed-bound.
  • Safety for People Living With MS: Pneumococcal vaccines are inactivated and safe for people with MS.
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    • Pneumococcal Vaccine Dosages: Pneumococcal vaccination is recommended for all adults 50 years or older.
    • Pneumococcal Vaccine Recommendations: According to the AAN recommendations on immunizations for people with MS, pneumococcal vaccines should be considered for individuals with compromised pulmonary function, including those who use a wheelchair on a full-time basis or are bed-bound.
    • Safety for People Living With MS: Pneumococcal vaccines are inactivated and safe for people with MS.

  • RSV Vaccine Recommendations: The CDC recommends everyone 75 years and older receive a single dose of an RSV vaccine. People who are 60 to 74 years of age who are at increased risk of severe RSV disease should also receive a single dose of an RSV vaccine. People 60 to 74 years of age who are at increased risk of severe RSV disease include those with certain chronic medical conditions, such as lung or heart disease, people who are immunocompromised or are taking immunosuppressive therapies, or those living in nursing homes.
  • RSV Vaccine Dosing: The RSV vaccine is not currently an annual vaccine, meaning people only need a single dose and do not need to get a booster dose every RSV season. Eligible adults can get an RSV vaccine at any time, but the best time to get vaccinated is in late summer and early fall before RSV usually starts to spread in communities.
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    • RSV and Other Vaccines: RSV vaccines may be given at the same time as other vaccines.
    • RSV Vaccine Protection: The RSV vaccines protect against respiratory syncytial virus, which can cause a variety of respiratory illnesses and symptoms.
    • RSV Vaccine Recommendations: The CDC recommends everyone 75 years and older receive a single dose of an RSV vaccine. People who are 60 to 74 years of age who are at increased risk of severe RSV disease should also receive a single dose of an RSV vaccine. People 60 to 74 years of age who are at increased risk of severe RSV disease include those with certain chronic medical conditions, such as lung or heart disease, people who are immunocompromised or are taking immunosuppressive therapies, or those living in nursing homes.
    • RSV Vaccine Dosing: The RSV vaccine is not currently an annual vaccine, meaning people only need a single dose and do not need to get a booster dose every RSV season. Eligible adults can get an RSV vaccine at any time, but the best time to get vaccinated is in late summer and early fall before RSV usually starts to spread in communities.

  • Shingrix have been done in people with MS. However, in two clinical studies with Shingrix, there was no increase in immune-mediated conditions.
  • Shingrix Vaccine Recommendations: The CDC recommends Shingrix, an inactivated vaccine, for the prevention of herpes zoster (shingles) and related complications in adults 50 years of age and older. The CDC also recommends that anyone age 19 or older considering starting on an immunosuppressive therapy complete the course of the shingles vaccine before starting therapy.
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    • Shingrix and MS: No studies of Shingrix have been done in people with MS. However, in two clinical studies with Shingrix, there was no increase in immune-mediated conditions.
    • Shingrix Vaccine Recommendations: The CDC recommends Shingrix, an inactivated vaccine, for the prevention of herpes zoster (shingles) and related complications in adults 50 years of age and older. The CDC also recommends that anyone age 19 or older considering starting on an immunosuppressive therapy complete the course of the shingles vaccine before starting therapy.

  • vaccine has not been studied in people with MS, it should be made available to any person with MS directly exposed to smallpox, as the risks associated with not getting vaccinated would be too great." c-nmssatomrichtext_nmssatomrichtext-host="">
    Smallpox Vaccine Risk: While this vaccine has not been studied in people with MS, it should be made available to any person with MS directly exposed to smallpox, as the risks associated with not getting vaccinated would be too great.

  • varicella vaccine." c-nmssatomrichtext_nmssatomrichtext-host="">
    Varicella Vaccine Recommendations: People with MS who have never had chicken pox, lack evidence of prior immunity and are considering starting a DMT should consider this vaccine. Refer to the prescribing information for each DMT and the varicella vaccine.

  • Archives of Neurology in 2011 of people with relapsing-remitting MS who received yellow fever vaccination prior to travel reported worsening of MS symptoms in 5 of 7 patients. In contrast, two recent studies found that yellow fever vaccination among 55 people with MS was not associated with increased relapse rates or disease exacerbations (Papeix, et al., 2021; Huttner, et al., 2020).
  • Yellow Fever Vaccine Recommendations: Since the effects of yellow fever vaccination in people with MS receiving disease-modifying treatments has not been fully studied, the CDC’s recommendation for administering yellow fever vaccine to people with MS is to consider the risk of yellow fever virus infection at the destination, the individual’s exposure (i.e., amount of time they will be in a yellow fever endemic area), and the vaccine-associated risks.
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    • Yellow Fever Vaccine Risk: A small study published in the Archives of Neurology in 2011 of people with relapsing-remitting MS who received yellow fever vaccination prior to travel reported worsening of MS symptoms in 5 of 7 patients. In contrast, two recent studies found that yellow fever vaccination among 55 people with MS was not associated with increased relapse rates or disease exacerbations (Papeix, et al., 2021; Huttner, et al., 2020).
    • Yellow Fever Vaccine Recommendations: Since the effects of yellow fever vaccination in people with MS receiving disease-modifying treatments has not been fully studied, the CDC’s recommendation for administering yellow fever vaccine to people with MS is to consider the risk of yellow fever virus infection at the destination, the individual’s exposure (i.e., amount of time they will be in a yellow fever endemic area), and the vaccine-associated risks.

    Special Considerations for Vaccines and Disease-Modifying Therapies

    • A person with MS should not receive a live-virus vaccine following a course of Lemtrada.

    • For patients testing positive in tuberculosis screening, treat by standard medical practice prior to therapy with Aubagio. No clinical data is available on the efficacy and safety of live vaccinations in patients taking Aubagio. Vaccination with live vaccines is not recommended.
      The long half-life of Aubagio should be considered when contemplating administration of a live vaccine after stopping Aubagio. You should advise patients that the use of some vaccines should be avoided during treatment with Aubagio and for at least 6 months after discontinuation.

    • Patients without a healthcare professional confirmed history of chickenpox or without documentation of a full course of vaccination against varicella zoster virus (VZV) should be tested for antibodies to VZV before initiating Gilenya. VZV vaccination is recommended prior to commencing treatment with Gilenya for antibody-negative patients. Following vaccination, treatment with Gilenya should be postponed for 1 month to allow the full effect of vaccination to occur. It is recommended that pediatric patients, if possible, complete all immunizations in accordance with current immunization guidelines prior to initiating Gilenya therapy.

    • HPV infections, including papilloma, dysplasia, warts and HPV-related cancer, have been reported in patients treated with Gilenya in the postmarketing setting. Vaccination against HPV should be considered prior to treatment initiation with Gilenya, taking into account vaccination recommendations. Cancer screening, including a Papanicolaou (Pap) test, is recommended as per standard of care for patients using an immunosuppressive therapy.

    • Because vaccination with live-attenuated vaccines is not recommended during treatment and after discontinuation until B-cell repletion, administer all immunizations according to immunization guidelines at least 4 weeks prior to initiation of Ocrevus® or Kesimpta® for live-attenuated vaccines and, whenever possible, at least 2 weeks prior to initiation for inactivated vaccines. Reference the prescribing information for important warnings around vaccination of infants born to mothers treated with these medications during pregnancy.

    • Vaccination of patients who are antibody-negative for varicella zoster virus is
      recommended prior to initiation of Mavenclad®. Administer all immunizations according to immunization guidelines prior to starting Mavenclad. Administer live-attenuated vaccines at least 4 to 6 weeks prior to starting Mavenclad because of a risk of active vaccine infection. Avoid vaccination with live-attenuated vaccines during and after Mavenclad treatment while the patient’s white blood cell counts are not within normal limits.

    • Patients without a healthcare professional confirmed history of chickenpox, or without documentation of a full course of vaccination against VZV, should be tested for antibodies to VZV before initiating Mayzent treatment. For antibody-negative patients, a full course of vaccination with varicella vaccine is recommended prior to commencing treatment with Mayzent. Following the vaccine, initiation of treatment with Mayzent should be postponed for 4 weeks to allow the full effect of vaccination to occur.
      Patients should avoid the use of live-attenuated vaccines should while taking Mayzent and for 4 weeks after stopping treatment. Vaccinations may be less effective if administered during Mayzent treatment. Mayzent treatment discontinuation is recommended 1 week prior to and until 4 weeks after a planned vaccination.

    • Patients without a healthcare professional-confirmed history of chickenpox or without documentation of a full course of vaccination against VZV should be tested for antibodies to VZV before initiating Zeposia. A full course of vaccination for antibody-negative patients with varicella vaccine is recommended prior to starting treatment with Zeposia. Following vaccination, initiation of treatment with Zeposia should be postponed for 4 weeks to allow the full effect of vaccination to occur. No clinical data is available on the efficacy and safety of vaccinations in patients taking Zeposia. Vaccinations may be less effective if administered during Zeposia treatment. If live- attenuated vaccine immunizations are required, administer at least 1 month prior to initiation of Zeposia. Avoid the use of live-attenuated vaccines during and for 3 months after treatment with Zeposia.

    • MS experts are not in agreement about the risks for a person with MS whose close family member receives a live-attenuated vaccine. The family should discuss with the healthcare provider how best to handle this situation.

    Studies of Vaccines With Specific Disease-Modifying Therapies

    • Neurology in 2015, evaluated the effectiveness of the flu vaccine in fingolimod-treated patients. Researchers found that most fingolimod-treated patients with MS were able to mount immune responses with the vaccine, and the majority met criteria indicating seroprotection. However, response rates were reduced compared with placebo-treated patients. Overall, there was some decrease in vaccination-induced immune responses among the fingolimod treated patients." c-nmssatomrichtext_nmssatomrichtext-host="">
      A blinded, randomized, multicenter, placebo-controlled study, published in Neurology in 2015, evaluated the effectiveness of the flu vaccine in fingolimod-treated patients. Researchers found that most fingolimod-treated patients with MS were able to mount immune responses with the vaccine, and the majority met criteria indicating seroprotection. However, response rates were reduced compared with placebo-treated patients. Overall, there was some decrease in vaccination-induced immune responses among the fingolimod treated patients.

    • Neurology in 2013, investigated the effect of teriflunomide on the efficacy and safety of the influenza vaccine. It found that teriflunomide-treated patients generally mounted effective immune responses to seasonal influenza vaccination. Researchers concluded that teriflunomide generally does not adversely impact the ability of MS patients to mount immune responses to influenza vaccination." c-nmssatomrichtext_nmssatomrichtext-host="">
      A study, published in Neurology in 2013, investigated the effect of teriflunomide on the efficacy and safety of the influenza vaccine. It found that teriflunomide-treated patients generally mounted effective immune responses to seasonal influenza vaccination. Researchers concluded that teriflunomide generally does not adversely impact the ability of MS patients to mount immune responses to influenza vaccination.

    • Neurology in 2013, assessed immunocompetence in patients after alemtuzumab treatment by measuring antibody responses to several vaccines before and after treatment. Researchers concluded that serum antibodies against common viruses remained detectable after treatment, and there was retained ability to mount an immune response against new antigens after treatment with alemtuzumab." c-nmssatomrichtext_nmssatomrichtext-host="">
      A small case-control study, published in Neurology in 2013, assessed immunocompetence in patients after alemtuzumab treatment by measuring antibody responses to several vaccines before and after treatment. Researchers concluded that serum antibodies against common viruses remained detectable after treatment, and there was retained ability to mount an immune response against new antigens after treatment with alemtuzumab.

    • Neurology in 2020 compared the immune response in people treated with ocrelizumab to a control group treated with interferon-β or no disease modifying therapy. The study investigators concluded that standard non-live vaccines, including the influenza vaccine, can be expected to be protective in people taking ocrelizumab." c-nmssatomrichtext_nmssatomrichtext-host="">
      A study published in Neurology in 2020 compared the immune response in people treated with ocrelizumab to a control group treated with interferon-β or no disease modifying therapy. The study investigators concluded that standard non-live vaccines, including the influenza vaccine, can be expected to be protective in people taking ocrelizumab.

    • Neurology in 2017 assessed influenza and pneumococcal vaccine response in three groups taking siponimod who do not have MS compared to another group without MS taking placebo. The study found no effect on response to the pneumococcal vaccine in those taking siponimod. Stopping siponimod at least 7 days before vaccination and resuming at least 2 weeks after may improve response to the influenza vaccine. The investigators concluded siponimod has limited effect on vaccine efficacy." c-nmssatomrichtext_nmssatomrichtext-host="">
      A study published in Neurology in 2017 assessed influenza and pneumococcal vaccine response in three groups taking siponimod who do not have MS compared to another group without MS taking placebo. The study found no effect on response to the pneumococcal vaccine in those taking siponimod. Stopping siponimod at least 7 days before vaccination and resuming at least 2 weeks after may improve response to the influenza vaccine. The investigators concluded siponimod has limited effect on vaccine efficacy.

    • Neuroimmunology & Neuroinflammation in 2018 investigated vaccine response in individuals taking dimethyl fumarate (DMF) compared to those taking non-PEGylated interferon (IFN). The immune response in DMF-treated individuals was comparable to those treated with IFN." c-nmssatomrichtext_nmssatomrichtext-host="">
      A study from Neurology Neuroimmunology & Neuroinflammation in 2018 investigated vaccine response in individuals taking dimethyl fumarate (DMF) compared to those taking non-PEGylated interferon (IFN). The immune response in DMF-treated individuals was comparable to those treated with IFN.

    • review of multiple studies of immune response to vaccines in individuals taking DMTs, the authors concluded those taking natalizumab may mount an inadequate immune response to some vaccines. View the paper to learn more about immune responses in people taking other DMTs." c-nmssatomrichtext_nmssatomrichtext-host="">
      In a review of multiple studies of immune response to vaccines in individuals taking DMTs, the authors concluded those taking natalizumab may mount an inadequate immune response to some vaccines. View the paper to learn more about immune responses in people taking other DMTs.

    Studies of Vaccine Safety and Effectiveness in People With MS

    • New England Journal of Medicine, found that vaccination for tetanus, hepatitis B or influenza did not appear to increase the short-term risk of relapses (also called “attacks” or “exacerbations”) in people with MS. Subsequent studies support the findings that commonly administered vaccines (e.g., influenza, hepatitis B) do not increase the risk of relapse or disability progression in MS (Grimaldi et al., 2023; Mailand and Frederiksen, 2017; Moisset et al., 2024; Otero-Romero et al., 2023)." c-nmssatomrichtext_nmssatomrichtext-host="">
      A study by the Vaccines in Multiple Sclerosis Study Group, published in 2001 in the New England Journal of Medicine, found that vaccination for tetanus, hepatitis B or influenza did not appear to increase the short-term risk of relapses (also called “attacks” or “exacerbations”) in people with MS. Subsequent studies support the findings that commonly administered vaccines (e.g., influenza, hepatitis B) do not increase the risk of relapse or disability progression in MS (Grimaldi et al., 2023; Mailand and Frederiksen, 2017; Moisset et al., 2024; Otero-Romero et al., 2023).

    • Reynolds et al., 2023)." c-nmssatomrichtext_nmssatomrichtext-host="">
      People who have received a HSCT lose their immunity to various pathogens (e.g., influenza virus and Streptococcus pneumoniae) after transplant and require comprehensive revaccination. Inactivated vaccines can generally be given 3-6 months after transplant. Live attenuated vaccines should be limited to specific situations and should be administered at least 24 months post-transplantation (Reynolds et al., 2023).

    • Archives of Neurology in 2003, found that vaccination against hepatitis B, influenza, tetanus, measles, or rubella did not increase a person’s risk of developing MS or optic neuritis (which is often a first symptom of MS)." c-nmssatomrichtext_nmssatomrichtext-host="">
      A study by the National Immunization Program of the Centers for Disease Control and Prevention, published in the Archives of Neurology in 2003, found that vaccination against hepatitis B, influenza, tetanus, measles, or rubella did not increase a person’s risk of developing MS or optic neuritis (which is often a first symptom of MS).

    • Otero-Romero et al., 2023)." c-nmssatomrichtext_nmssatomrichtext-host="">
      Pregnant women are recognized as a priority group for vaccination. It is important to review vaccination status in women with MS with childbearing potential or who are pregnant. Inactivated vaccines are generally considered safe for women with MS during pregnancy and can be administered during the second and third trimester. Live attenuated vaccines are contraindicated during pregnancy (Otero-Romero et al., 2023).

    • Otero-Romero et al., 2023)." c-nmssatomrichtext_nmssatomrichtext-host="">
      Live attenuated vaccines should be completed after delivery and 4-6 weeks before starting on or resuming immunosuppressive DMTs. Inactivated vaccines can be administered at any time after delivery, ideally 2 weeks before starting on or resuming immunosuppressive DMTs. Newborns who have been exposed to anti-CD20 therapies during pregnancy should have B-cell levels measured. Live attenuated vaccines (i.e., rotavirus) should be delayed until the infant’s B-cell levels recover. Vaccines are safe in women with MS who are breastfeeding, except for the yellow fever vaccine (Otero-Romero et al., 2023).

    • JAMA Neurology, found no long-term association of vaccines with MS or any other acquired central nervous system demyelinating disease." c-nmssatomrichtext_nmssatomrichtext-host="">
      A review of data from the complete electronic medical health records of Kaiser Permanente Southern California between 2008 and 2011, published in JAMA Neurology, found no long-term association of vaccines with MS or any other acquired central nervous system demyelinating disease.

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