51
|
Solmaz I, Anlar B. Immunization in multiple sclerosis and other childhood immune-mediated disorders of the central nervous system: A review of the literature. Eur J Paediatr Neurol 2021; 33:125-134. [PMID: 34214824 DOI: 10.1016/j.ejpn.2021.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 04/05/2021] [Accepted: 06/07/2021] [Indexed: 12/14/2022]
Abstract
Childhood is a period where most vaccines are administered in order to build-up immunological memory, and immunization against vaccine-preventable diseases is an essential part of child care and health. The administration of vaccines to children with inflammatory diseases is a frequent point of concern for parents and physicians. Published information on the relation between vaccines and autoinflammatory diseases of the central nervous system (CNS) consists of case and cohort studies and reviews, in great majority on adult patients. Vaccines do not have any established causative or triggering effects on these diseases. Another issue is the immunization schedule of patients with autoinflammatory CNS diseases, specifically the interactions between the disorder, the clinical status, the treatment and the vaccine. In this review, we summarize the existing information between autoinflammatory disorders of the CNS and vaccines in childhood and underline the points to be considered under various treatment regimens.
Collapse
Affiliation(s)
- Ismail Solmaz
- Hacettepe University, Faculty of Medicine, Department of Pediatric Neurology, 06230, Ankara, Turkey.
| | - Banu Anlar
- Hacettepe University, Faculty of Medicine, Department of Pediatric Neurology, 06230, Ankara, Turkey
| |
Collapse
|
52
|
Woopen C, Schleußner K, Akgün K, Ziemssen T. Approach to SARS-CoV-2 Vaccination in Patients With Multiple Sclerosis. Front Immunol 2021; 12:701752. [PMID: 34234787 PMCID: PMC8256163 DOI: 10.3389/fimmu.2021.701752] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 06/07/2021] [Indexed: 12/18/2022] Open
Abstract
For more than a year now, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been causing the coronavirus disease (COVID-19) pandemic with high mortality and detrimental effects on society, economy, and individual lives. Great hopes are being placed on vaccination as one of the most potent escape strategies from the pandemic and multiple vaccines are already in clinical use. However, there is still a lot of insecurity about the safety and efficacy of vaccines in patients with autoimmune diseases like multiple sclerosis (MS), especially under treatment with immunomodulatory or immunosuppressive drugs. We propose strategic approaches to SARS-CoV-2 vaccination management in MS patients and encourage fellow physicians to measure the immune response in their patients. Notably, both humoral and cellular responses should be considered since the immunological equivalent for protection from SARS-CoV-2 after infection or vaccination still remains undefined and will most likely involve antiviral cellular immunity. It is important to gain insights into the vaccine response of immunocompromised patients in order to be able to deduce sensible strategies for vaccination in the future.
Collapse
Affiliation(s)
| | | | | | - Tjalf Ziemssen
- Center of Clinical Neuroscience, Department of Neurology, University Hospital Carl Gustav Carus Dresden, Technical University of Dresden, Dresden, Germany
| |
Collapse
|
53
|
COVID-19 vaccines in multiple sclerosis treated with cladribine or ocrelizumab. Mult Scler Relat Disord 2021; 52:102983. [PMID: 33990054 PMCID: PMC8093161 DOI: 10.1016/j.msard.2021.102983] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/12/2021] [Accepted: 04/22/2021] [Indexed: 02/07/2023]
Abstract
Since the recent approval of vaccines against COVID-19, efficacy concerns emerged for MS patients treated with immunosuppressive drugs. We report our experience in four patients, under cladribine (two) or under ocrelizumab (two) treatment, all with low lymphocyte count, three of them vaccinated after 3 months from the last dose with good immune response, one (under ocrelizumab) after 2 months, without developing an appropriate title of antibodies. This experience suggests that the discriminant for the response to the vaccine is not the lymphocyte count but the timing of the vaccination.
Collapse
|
54
|
Nesbitt C, Rath L, Zhong M, Cheng AC, Butzkueven H, Wesselingh R, Skibina O, Monif M, Yeh W, Brotherton JM, Reddel S, Van Der Walt A. Vaccinations in patients with multiple sclerosis: review and recommendations. Med J Aust 2021; 214:350-354.e1. [PMID: 33866556 DOI: 10.5694/mja2.51012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 01/19/2021] [Accepted: 02/03/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Cassie Nesbitt
- Alfred Health, Melbourne, VIC.,Monash University, Melbourne, VIC
| | | | - Michael Zhong
- Alfred Health, Melbourne, VIC.,Monash University, Melbourne, VIC
| | - Allen C Cheng
- Alfred Health, Melbourne, VIC.,Monash University, Melbourne, VIC
| | | | - Robb Wesselingh
- Alfred Health, Melbourne, VIC.,Monash University, Melbourne, VIC
| | | | - Mastura Monif
- Alfred Health, Melbourne, VIC.,Monash University, Melbourne, VIC
| | - Wei Yeh
- Alfred Health, Melbourne, VIC.,Monash University, Melbourne, VIC
| | | | | | | |
Collapse
|
55
|
Shi Y, Guo M, Yang W, Liu S, Zhu B, Yang L, Yang C, Liu C. Is SARS-CoV-2 vaccination safe and effective for elderly individuals with neurodegenerative diseases? Expert Rev Vaccines 2021; 20:375-383. [PMID: 33787439 PMCID: PMC8054494 DOI: 10.1080/14760584.2021.1911653] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction Coronavirus Disease 2019 (COVID-19) poses a substantial threat to the lives of the elderly, especially those with neurodegenerative diseases, and vaccination against viral infections is recognized as an effective measure to reduce mortality. However, elderly patients with neurodegenerative diseases often suffer from abnormal immune function and take multiple medications, which may complicate the role of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines. Currently, there is no expert consensus on whether SARS-CoV-2 vaccines are suitable for patients with neurodegenerative diseases. Areas covered We searched Pubmed to conduct a systematic review of published studies, case reports, reviews, meta-analyses, and expert guidelines on the impact of SARS-CoV-2 on neurodegenerative diseases and the latest developments in COVID-19 vaccines. We also summarized the interaction between vaccines and age-related neurodegenerative diseases. The compatibility of future SARS-CoV-2 vaccines with neurodegenerative diseases is discussed. Expert opinion Vaccines enable the body to produce immunity by activating the body’s immune response. The pathogenesis and treatment of neurodegenerative diseases is complex, and these diseases often involve abnormal immune function, which can substantially affect the safety and effectiveness of vaccines. In short, this article provides recommendations for the use of vaccine candidates in patients with neurodegenerative diseases.
Collapse
Affiliation(s)
- Yan Shi
- Department of Anesthesiology and Perioperative Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing China
| | - Minna Guo
- Department of Anesthesiology and Perioperative Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing China
| | - Wenjing Yang
- Department of Anesthesiology and Perioperative Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing China
| | - Shijiang Liu
- Department of Anesthesiology and Perioperative Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing China
| | - Bin Zhu
- Department of Critical Care Medicine, The Third Affiliated Hospital of Soochow University, Changzhou China
| | - Ling Yang
- Department of Cardiology, The Third Affiliated Hospital of Soochow University, Changzhou China
| | - Chun Yang
- Department of Anesthesiology and Perioperative Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing China
| | - Cunming Liu
- Department of Anesthesiology and Perioperative Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing China
| |
Collapse
|
56
|
Santoro JD, Saucier LE, Tanna R, Wiegand SE, Pagarkar D, Tempchin AF, Khoshnood M, Ahsan N, Van Haren K. Inadequate Vaccine Responses in Children With Multiple Sclerosis. Front Pediatr 2021; 9:790159. [PMID: 34926358 PMCID: PMC8678906 DOI: 10.3389/fped.2021.790159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 11/10/2021] [Indexed: 01/05/2023] Open
Abstract
Objective: Immunizations against Hepatitis B virus (HBV) and Varicella Zoster virus (VZV), are recommended for patients with pediatric onset multiple sclerosis (POMS) and may be required prior to initiation of some disease modifying therapies. However, the efficacy of routine vaccine administration in POMS has never been studied. We sought to assess the humoral mediated vaccine response to HBV and VZV in children with POMS. Methods: A multi-center retrospective chart-based review of 62 patients with POMS was performed. Clinical data and antibody titers against HBV and VZV were collected prior to initiation of disease modifying therapy or steroids and compared to institutional control data, using t-test and chi squared analysis. Results: There were low rates of immunity against both HBV and VZV (33 and 25% respectively) among individuals with POMS. Fifteen individuals (24%) were non-immune to both. Compared to institutional control data, individuals with POMS were significantly less likely to be immune to and HBV (p = 0.003, 95% CI: 0.22-0.75) and VZV (p < 0.001, 95% CI: 0.09-0.39). Interpretation: Individuals with POMS have low rates of antibody-mediated immunity against HBV and VZV, despite receiving the appropriate vaccinations. This suggests an association between POMS and systemic immune dysregulation although further study is needed.
Collapse
Affiliation(s)
- Jonathan D Santoro
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, United States.,Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Laura E Saucier
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Runi Tanna
- Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Sarah E Wiegand
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, United States
| | - Dania Pagarkar
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Adam F Tempchin
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Mellad Khoshnood
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, United States
| | - Nusrat Ahsan
- Division of Neurology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, United States.,Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Keith Van Haren
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, United States
| |
Collapse
|
57
|
Immunogenicity of The Influenza Vaccine in Multiple Sclerosis Patients: A Systematic Review and Meta-Analysis. Mult Scler Relat Disord 2020; 48:102698. [PMID: 33385826 DOI: 10.1016/j.msard.2020.102698] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 12/04/2020] [Accepted: 12/12/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Multiple sclerosis is a neurodegenerative disease thought to be of autoimmune origin. It can lead to development of neurological symptoms and increase the risk of infection from communicable diseases. Thus, vaccines are endorsed to mitigate this risk. However, it has not yet been confirmed whether the dysfunctional immune system of these patients combined with taking immunosuppressants can lead to a dampened immunity in response to the influenza vaccine. Infection with the influenza virus is a concern for multiple sclerosis patients. Previous research on multiple sclerosis patients who have received the influenza vaccine focuses on safety and relapse rates. Studies that focus on the immune response mounted against the vaccine in this patient cohort are scant. This study serves to provide a comprehensive picture of the immunogenicity of the influenza vaccine in MS patients. METHODS A systematic review of compiled research was conducted. Data obtained from the research was used in a meta-analysis using risk differences with a 95% confidence interval. RESULTS Across the various strains incorporated into the influenza vaccine analyzed in this paper, there was no statistical difference in immune response mounted against the influenza vaccine between healthy controls and multiple sclerosis patients. CONCLUSION The results of this study suggest that multiple sclerosis patients can mount an adequate immune response to the influenza vaccine when compared to healthy controls. Most of the immunotherapies these patients are on do not appear to affect this immune response. Therefore, the influenza vaccine should continue to be recommended to multiple sclerosis patients.
Collapse
|
58
|
Sirbu CA, Florea AA, Ghinescu MC, Docu-Axelerad A, Sirbu AM, Bratu OG, Radu FI. Vaccination in multiple sclerosis - Challenging practices (Review). Exp Ther Med 2020; 20:217. [PMID: 33149781 DOI: 10.3892/etm.2020.9347] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 10/05/2020] [Indexed: 12/13/2022] Open
Abstract
Infections are an ever-present problem in the medical community, even more so for patients with multiple sclerosis (MS), for whom these infections have been linked to relapses and neurological disabilities. Even though it was believed that MS can be caused by an infection, research does not support this theory. MS is a chronic inflammatory disease considered to be autoimmune. Vaccination is proven to be one of the most effective means to prevent infections, but still it is surrounded by controversy in the general populations, as well as in the MS group. Vaccines are generally considered safe for MS patients. The exceptions from this, which turn into contraindications, are a medical history of allergic reactions to one of the vaccine components and immunosuppressed patients in the particular case of live vaccines. Given the presumed autoimmunity of the disease, some medication for MS is immunosuppressive and any live vaccine should be administered before starting treatment. Although there is still confusion regarding this subject, the current guidelines have clearer recommendations about vaccinations in MS patients and especially in treated MS patients.
Collapse
Affiliation(s)
- Carmen Adella Sirbu
- Department of Medical-Surgical and Prophylactical Disciplines, Faculty of Medicine, Titu Maiorescu University, 031593 Bucharest, Romania.,Department of Neurology, 'Dr Carol Davila' Central Military Emergency University Hospital, 010242 Bucharest, Romania
| | - Anca Alexandra Florea
- Department of Neurology, 'Dr Carol Davila' Central Military Emergency University Hospital, 010242 Bucharest, Romania
| | - Minerva Claudia Ghinescu
- Department of Medical-Surgical and Prophylactical Disciplines, Faculty of Medicine, Titu Maiorescu University, 031593 Bucharest, Romania
| | - Any Docu-Axelerad
- Department of Neurology, Faculty of Medicine, 'Ovidius' University of Constanta, 900527 Constanta, Romania
| | - Anca Maria Sirbu
- Department of Endocrinology, National Institute of Endocrinology, CI Parhon, 011863 Bucharest, Romania
| | - Ovidiu Gabriel Bratu
- Department of Urology, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania.,Urology, 'Dr Carol Davila' Central Military Emergency University Hospital, 010242 Bucharest, Romania
| | - Florentina Ionita Radu
- Department of Medical-Surgical and Prophylactical Disciplines, Faculty of Medicine, Titu Maiorescu University, 031593 Bucharest, Romania.,Gastroenterology, 'Dr Carol Davila' Central Military Emergency University Hospital, 010242 Bucharest, Romania
| |
Collapse
|
59
|
Effects of MS disease-modifying therapies on responses to vaccinations: A review. Mult Scler Relat Disord 2020; 45:102439. [PMID: 32769063 PMCID: PMC7395588 DOI: 10.1016/j.msard.2020.102439] [Citation(s) in RCA: 93] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 07/31/2020] [Accepted: 07/31/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Development of long-term immunologic memory relies upon humoral and cellular immune responses. Vaccinations aim to stimulate these responses against pathogens. Several studies have evaluated the impact of multiple sclerosis disease-modifying therapies on immune response to vaccines. Findings from these studies have important implications for people with multiple sclerosis who require vaccination and are using disease-modifying therapies. METHODS Searches using PubMed and other engines were conducted in May 2020 to collect studies evaluating the impact of various disease-modifying therapies on immune responses to vaccination. RESULTS Several studies demonstrated preserved immune responses in people treated with beta-interferons to multiple vaccine types. Limited data suggest vaccine responses to be preserved with dimethyl fumarate treatment, as well. Vaccine responses were reduced to varying degrees in those treated with glatiramer acetate, teriflunomide, sphingosine-1-phosphate receptor modulators, and natalizumab. The timing of vaccination played an important role in those treated with alemtuzumab. Humoral vaccine responses were significantly impaired by B cell depleting anti-CD20 monoclonal antibody therapies, particularly to a neoantigen. Data are lacking on vaccine responses in patients with multiple sclerosis taking cladribine and high-dose corticosteroids. Notably, the majority of these studies have focused on humoral responses, with few examining cellular immune responses to vaccination. CONCLUSIONS Prior investigations into the effects of individual disease-modifying therapies on immune responses to existing vaccines can serve as a guide to expected responses to a SARS-CoV-2 vaccine. Responses to any vaccination depend on the vaccine type, the type of response (recall versus response to a novel antigen), and the impact of the individual disease-modifying therapy on humoral and cellular immunity in response to that vaccine type. When considering a given therapy, clinicians should weigh its efficacy against MS for the individual patient versus potential impact on responses to vaccinations that may be needed in the future.
Collapse
|
60
|
Riva A, Barcella V, Benatti SV, Capobianco M, Capra R, Cinque P, Comi G, Fasolo MM, Franzetti F, Galli M, Gerevini S, Meroni L, Origoni M, Prosperini L, Puoti M, Scarpazza C, Tortorella C, Zaffaroni M, Moiola L. Vaccinations in patients with multiple sclerosis: A Delphi consensus statement. Mult Scler 2020; 27:347-359. [PMID: 32940128 DOI: 10.1177/1352458520952310] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Patients with multiple sclerosis (MS) are at increased risk of infection. Vaccination can mitigate these risks but only if safe and effective in MS patients, including those taking disease-modifying drugs. METHODS A modified Delphi consensus process (October 2017-June 2018) was used to develop clinically relevant recommendations for making decisions about vaccinations in patients with MS. A series of statements and recommendations regarding the efficacy, safety and timing of vaccine administration in patients with MS were generated in April 2018 by a panel of experts based on a review of the published literature performed in October 2017. RESULTS Recommendations include the need for an 'infectious diseases card' of each patient's infectious and immunisation history at diagnosis in order to exclude and eventually treat latent infections. We suggest the implementation of the locally recommended vaccinations, if possible at MS diagnosis, otherwise with vaccination timing tailored to the planned/current MS treatment, and yearly administration of the seasonal influenza vaccine regardless of the treatment received. CONCLUSION Patients with MS should be vaccinated with careful consideration of risks and benefits. However, there is an urgent need for more research into vaccinations in patients with MS to guide evidence-based decision making.
Collapse
Affiliation(s)
- Agostino Riva
- III Division of Infectious Diseases, ASST Fatebenefratelli-Sacco, L. Sacco Hospital, Milan, Italy
| | - Valeria Barcella
- Department of Neurology and Multiple Sclerosis Center, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Simone V Benatti
- Department of Infectious Diseases, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Marco Capobianco
- SCDO Neurology and Regional Reference Multiple Sclerosis Center, Azienda Ospedaliero-Universitaria San Luigi Gonzaga, Orbassano, Italy
| | - Ruggero Capra
- Multiple Sclerosis Center, Spedali Civili of Brescia, Montichiari, Italy
| | - Paola Cinque
- Division of Infectious Diseases, San Raffaele Scientific Institute, Milan, Italy/Institute of Experimental Neurology and Multiple Sclerosis Center IRCCS, San Raffaele Hospital, Milan, Italy
| | - Giancarlo Comi
- Institute of Experimental Neurology and Multiple Sclerosis Center IRCCS, San Raffaele Hospital, Milan, Italy
| | - Maria Michela Fasolo
- Division of Infectious Diseases, Department of Infectious Diseases, ASST Fatebenefratelli-Sacco, University Hospital, Milan, Italy
| | - Fabio Franzetti
- Infectious Diseases Unit, Busto Arsizio Hospital, Varese, Italy
| | - Massimo Galli
- Department of Clinical Sciences, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Simonetta Gerevini
- Division of Neuroradiology, IRCCS San Raffaele Scientific Institute, Milan, Italy; Neuroradiology Department, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Luca Meroni
- III Division of Infectious Diseases, ASST Fatebenefratelli-Sacco, L. Sacco Hospital, Milan, Italy
| | - Massimo Origoni
- Department of Gynecology and Obstetrics, Vita-Salute San Raffaele University, IRCCS Ospedale San Raffaele, Milano, Italy
| | - Luca Prosperini
- Department of Neuroscience, San Camillo-Forlanini Hospital, Rome, Italy
| | - Massimo Puoti
- SC Infectious Diseases, ASST Niguarda Ca' Grande Hospital, Milan, Italy
| | - Cristina Scarpazza
- Multiple Sclerosis Center, Spedali Civili of Brescia, Montichiari, Italy/Department of General Psychology, University of Padova, Padova, Italy
| | - Carla Tortorella
- Department of Neuroscience, San Camillo-Forlanini Hospital, Rome, Italy
| | - Mauro Zaffaroni
- Multiple Sclerosis Center, Hospital of Gallarate, ASST della Valle Olona, Gallarate, Italy
| | - Lucia Moiola
- Multiple Sclerosis Center, IRCCS San Raffaele Hospital, Milan, Italy/Neurology Department, IRCCS San Raffaele Hospital, Milan, Italy
| |
Collapse
|
61
|
Baker D, Amor S, Kang AS, Schmierer K, Giovannoni G. The underpinning biology relating to multiple sclerosis disease modifying treatments during the COVID-19 pandemic. Mult Scler Relat Disord 2020; 43:102174. [PMID: 32464584 PMCID: PMC7214323 DOI: 10.1016/j.msard.2020.102174] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 04/29/2020] [Accepted: 04/30/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND SARS-CoV-2 viral infection causes COVID-19 that can result in severe acute respiratory distress syndrome (ARDS), which can cause significant mortality, leading to concern that immunosuppressive treatments for multiple sclerosis and other disorders have significant risks for both infection and ARDS. OBJECTIVE To examine the biology that potentially underpins immunity to the SARS-Cov-2 virus and the immunity-induced pathology related to COVID-19 and determine how this impinges on the use of current disease modifying treatments in multiple sclerosis. OBSERVATIONS Although information about the mechanisms of immunity are scant, it appears that monocyte/macrophages and then CD8 T cells are important in eliminating the SARS-CoV-2 virus. This may be facilitated via anti-viral antibody responses that may prevent re-infection. However, viral escape and infection of leucocytes to promote lymphopenia, apparent CD8 T cell exhaustion coupled with a cytokine storm and vascular pathology appears to contribute to the damage in ARDS. IMPLICATIONS In contrast to ablative haematopoietic stem cell therapy, most multiple-sclerosis-related disease modifying therapies do not particularly target the innate immune system and few have any major long-term impact on CD8 T cells to limit protection against COVID-19. In addition, few block the formation of immature B cells within lymphoid tissue that will provide antibody-mediated protection from (re)infection. However, adjustments to dosing schedules may help de-risk the chance of infection further and reduce the concerns of people with MS being treated during the COVID-19 pandemic.
Collapse
Key Words
- ace2, angiotensin converting enzyme two
- ards, acute respiratory distress syndrome
- asc, antibody secreting cells
- cns, central nervous system
- dmt, disease modifying therapies
- (hsct), haematopoietic stem cell therapy
- irt, immune reconstitution therapies
- ms, multiple sclerosis
- rbd, receptor binding domain
- rna, ribonucleic acid
- sars, severe acute respiratory syndrome
Collapse
Affiliation(s)
- David Baker
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, E1 2AT; United Kingdom.
| | - Sandra Amor
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, E1 2AT; United Kingdom; Pathology Department, VUmc, Amsterdam UMC, Amsterdam, The Netherlands.
| | - Angray S Kang
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, E1 2AT; United Kingdom; Centre for Oral Immunobiology and Regenerative Medicine, Institute of Dentistry, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom
| | - Klaus Schmierer
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, E1 2AT; United Kingdom; Clinical Board:Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Gavin Giovannoni
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, E1 2AT; United Kingdom; Clinical Board:Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| |
Collapse
|
62
|
Bar-Or A, Calkwood JC, Chognot C, Evershed J, Fox EJ, Herman A, Manfrini M, McNamara J, Robertson DS, Stokmaier D, Wendt JK, Winthrop KL, Traboulsee A. Effect of ocrelizumab on vaccine responses in patients with multiple sclerosis: The VELOCE study. Neurology 2020; 95:e1999-e2008. [PMID: 32727835 DOI: 10.1212/wnl.0000000000010380] [Citation(s) in RCA: 237] [Impact Index Per Article: 59.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 04/20/2020] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE The phase IIIb A Study to Evaluate the Effects of Ocrelizumab on Immune Responses in Participants With Relapsing Forms of Multiple Sclerosis (VELOCE) study (NCT02545868) assessed responses to selected vaccines in ocrelizumab (OCR)-treated patients with relapsing multiple sclerosis. METHODS Patients were randomized 2:1 into the OCR group (n = 68; OCR 600 mg) or control group (n = 34; interferon beta or no disease-modifying therapy). All received tetanus toxoid (TT)-containing vaccine, Pneumovax (23-valent pneumococcal polysaccharide vaccine [23-PPV]), and keyhole limpet hemocyanin (KLH). The OCR group was subdivided into OCR1 (n = 33) and OCR2 (n = 35) at randomization. The OCR1 group received Prevnar (13-valent conjugate pneumococcal vaccine) 4 weeks after 23-PPV; the OCR2 and control groups received influenza vaccine. Vaccinations started 12 weeks after OCR initiation (OCR group) or on day 1 (control group). RESULTS Positive response rate to TT vaccine at 8 weeks was 23.9% in the OCR vs 54.5% in the control group. Positive response rate to ≥5 serotypes in 23-PPV at 4 weeks was 71.6% in the OCR and 100% in the control group. Prevnar did not enhance response to pneumococcal serotypes in common with Pneumovax. Humoral response to KLH was decreased in the OCR vs control group. Seroprotection rates at 4 weeks against 5 influenza strains ranged from 55.6% to 80.0% in the OCR2 group and 75.0% to 97.0% in the control group. CONCLUSION Peripherally B-cell-depleted OCR recipients mounted attenuated humoral responses to clinically relevant vaccines and the neoantigen KLH, suggesting that use of standard nonlive vaccines while on OCR treatment remains a consideration. For seasonal influenza vaccines, it is recommended to vaccinate patients on OCR because a potentially protective humoral response, even if attenuated, can be expected. CLASSIFICATION OF EVIDENCE This study provides Class II evidence confirming that the humoral response to nonlive vaccines in patients with relapsing multiple sclerosis after OCR treatment is attenuated compared with untreated or interferon beta-treated patients, but they can still be expected to be protective. CLINICALTRIALSGOV IDENTIFIER NCT02545868.
Collapse
Affiliation(s)
- Amit Bar-Or
- From the Department of Neurology and Center for Neuroinflammation and Experimental Therapeutics (A.B.-O.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; The Minneapolis Clinic of Neurology (J.C.C.), MN; F. Hoffmann-La Roche Ltd (C.C., J.E., M.M., D.S.), Basel, Switzerland; Central Texas Neurology Consultants (E.J.F.), Round Rock; Genentech, Inc (A.H.), South San Francisco, CA; John McNamara Consulting Ltd (J.M.), Cambridge, UK; Department of Neurology (D.S.R.), Multiple Sclerosis Division, University of South Florida College of Medicine, Tampa; Territory Neurology and Research Institution (J.K.W.), Tucson, AZ; Division of Infectious Diseases (K.L.W.), Oregon Health & Science University, Portland; and University of British Columbia (A.T.), Vancouver, Canada.
| | - Jonathan C Calkwood
- From the Department of Neurology and Center for Neuroinflammation and Experimental Therapeutics (A.B.-O.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; The Minneapolis Clinic of Neurology (J.C.C.), MN; F. Hoffmann-La Roche Ltd (C.C., J.E., M.M., D.S.), Basel, Switzerland; Central Texas Neurology Consultants (E.J.F.), Round Rock; Genentech, Inc (A.H.), South San Francisco, CA; John McNamara Consulting Ltd (J.M.), Cambridge, UK; Department of Neurology (D.S.R.), Multiple Sclerosis Division, University of South Florida College of Medicine, Tampa; Territory Neurology and Research Institution (J.K.W.), Tucson, AZ; Division of Infectious Diseases (K.L.W.), Oregon Health & Science University, Portland; and University of British Columbia (A.T.), Vancouver, Canada
| | - Cathy Chognot
- From the Department of Neurology and Center for Neuroinflammation and Experimental Therapeutics (A.B.-O.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; The Minneapolis Clinic of Neurology (J.C.C.), MN; F. Hoffmann-La Roche Ltd (C.C., J.E., M.M., D.S.), Basel, Switzerland; Central Texas Neurology Consultants (E.J.F.), Round Rock; Genentech, Inc (A.H.), South San Francisco, CA; John McNamara Consulting Ltd (J.M.), Cambridge, UK; Department of Neurology (D.S.R.), Multiple Sclerosis Division, University of South Florida College of Medicine, Tampa; Territory Neurology and Research Institution (J.K.W.), Tucson, AZ; Division of Infectious Diseases (K.L.W.), Oregon Health & Science University, Portland; and University of British Columbia (A.T.), Vancouver, Canada
| | - Joanna Evershed
- From the Department of Neurology and Center for Neuroinflammation and Experimental Therapeutics (A.B.-O.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; The Minneapolis Clinic of Neurology (J.C.C.), MN; F. Hoffmann-La Roche Ltd (C.C., J.E., M.M., D.S.), Basel, Switzerland; Central Texas Neurology Consultants (E.J.F.), Round Rock; Genentech, Inc (A.H.), South San Francisco, CA; John McNamara Consulting Ltd (J.M.), Cambridge, UK; Department of Neurology (D.S.R.), Multiple Sclerosis Division, University of South Florida College of Medicine, Tampa; Territory Neurology and Research Institution (J.K.W.), Tucson, AZ; Division of Infectious Diseases (K.L.W.), Oregon Health & Science University, Portland; and University of British Columbia (A.T.), Vancouver, Canada
| | - Edward J Fox
- From the Department of Neurology and Center for Neuroinflammation and Experimental Therapeutics (A.B.-O.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; The Minneapolis Clinic of Neurology (J.C.C.), MN; F. Hoffmann-La Roche Ltd (C.C., J.E., M.M., D.S.), Basel, Switzerland; Central Texas Neurology Consultants (E.J.F.), Round Rock; Genentech, Inc (A.H.), South San Francisco, CA; John McNamara Consulting Ltd (J.M.), Cambridge, UK; Department of Neurology (D.S.R.), Multiple Sclerosis Division, University of South Florida College of Medicine, Tampa; Territory Neurology and Research Institution (J.K.W.), Tucson, AZ; Division of Infectious Diseases (K.L.W.), Oregon Health & Science University, Portland; and University of British Columbia (A.T.), Vancouver, Canada
| | - Ann Herman
- From the Department of Neurology and Center for Neuroinflammation and Experimental Therapeutics (A.B.-O.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; The Minneapolis Clinic of Neurology (J.C.C.), MN; F. Hoffmann-La Roche Ltd (C.C., J.E., M.M., D.S.), Basel, Switzerland; Central Texas Neurology Consultants (E.J.F.), Round Rock; Genentech, Inc (A.H.), South San Francisco, CA; John McNamara Consulting Ltd (J.M.), Cambridge, UK; Department of Neurology (D.S.R.), Multiple Sclerosis Division, University of South Florida College of Medicine, Tampa; Territory Neurology and Research Institution (J.K.W.), Tucson, AZ; Division of Infectious Diseases (K.L.W.), Oregon Health & Science University, Portland; and University of British Columbia (A.T.), Vancouver, Canada
| | - Marianna Manfrini
- From the Department of Neurology and Center for Neuroinflammation and Experimental Therapeutics (A.B.-O.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; The Minneapolis Clinic of Neurology (J.C.C.), MN; F. Hoffmann-La Roche Ltd (C.C., J.E., M.M., D.S.), Basel, Switzerland; Central Texas Neurology Consultants (E.J.F.), Round Rock; Genentech, Inc (A.H.), South San Francisco, CA; John McNamara Consulting Ltd (J.M.), Cambridge, UK; Department of Neurology (D.S.R.), Multiple Sclerosis Division, University of South Florida College of Medicine, Tampa; Territory Neurology and Research Institution (J.K.W.), Tucson, AZ; Division of Infectious Diseases (K.L.W.), Oregon Health & Science University, Portland; and University of British Columbia (A.T.), Vancouver, Canada
| | - John McNamara
- From the Department of Neurology and Center for Neuroinflammation and Experimental Therapeutics (A.B.-O.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; The Minneapolis Clinic of Neurology (J.C.C.), MN; F. Hoffmann-La Roche Ltd (C.C., J.E., M.M., D.S.), Basel, Switzerland; Central Texas Neurology Consultants (E.J.F.), Round Rock; Genentech, Inc (A.H.), South San Francisco, CA; John McNamara Consulting Ltd (J.M.), Cambridge, UK; Department of Neurology (D.S.R.), Multiple Sclerosis Division, University of South Florida College of Medicine, Tampa; Territory Neurology and Research Institution (J.K.W.), Tucson, AZ; Division of Infectious Diseases (K.L.W.), Oregon Health & Science University, Portland; and University of British Columbia (A.T.), Vancouver, Canada
| | - Derrick S Robertson
- From the Department of Neurology and Center for Neuroinflammation and Experimental Therapeutics (A.B.-O.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; The Minneapolis Clinic of Neurology (J.C.C.), MN; F. Hoffmann-La Roche Ltd (C.C., J.E., M.M., D.S.), Basel, Switzerland; Central Texas Neurology Consultants (E.J.F.), Round Rock; Genentech, Inc (A.H.), South San Francisco, CA; John McNamara Consulting Ltd (J.M.), Cambridge, UK; Department of Neurology (D.S.R.), Multiple Sclerosis Division, University of South Florida College of Medicine, Tampa; Territory Neurology and Research Institution (J.K.W.), Tucson, AZ; Division of Infectious Diseases (K.L.W.), Oregon Health & Science University, Portland; and University of British Columbia (A.T.), Vancouver, Canada
| | - Daniela Stokmaier
- From the Department of Neurology and Center for Neuroinflammation and Experimental Therapeutics (A.B.-O.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; The Minneapolis Clinic of Neurology (J.C.C.), MN; F. Hoffmann-La Roche Ltd (C.C., J.E., M.M., D.S.), Basel, Switzerland; Central Texas Neurology Consultants (E.J.F.), Round Rock; Genentech, Inc (A.H.), South San Francisco, CA; John McNamara Consulting Ltd (J.M.), Cambridge, UK; Department of Neurology (D.S.R.), Multiple Sclerosis Division, University of South Florida College of Medicine, Tampa; Territory Neurology and Research Institution (J.K.W.), Tucson, AZ; Division of Infectious Diseases (K.L.W.), Oregon Health & Science University, Portland; and University of British Columbia (A.T.), Vancouver, Canada
| | - Jeanette K Wendt
- From the Department of Neurology and Center for Neuroinflammation and Experimental Therapeutics (A.B.-O.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; The Minneapolis Clinic of Neurology (J.C.C.), MN; F. Hoffmann-La Roche Ltd (C.C., J.E., M.M., D.S.), Basel, Switzerland; Central Texas Neurology Consultants (E.J.F.), Round Rock; Genentech, Inc (A.H.), South San Francisco, CA; John McNamara Consulting Ltd (J.M.), Cambridge, UK; Department of Neurology (D.S.R.), Multiple Sclerosis Division, University of South Florida College of Medicine, Tampa; Territory Neurology and Research Institution (J.K.W.), Tucson, AZ; Division of Infectious Diseases (K.L.W.), Oregon Health & Science University, Portland; and University of British Columbia (A.T.), Vancouver, Canada
| | - Kevin L Winthrop
- From the Department of Neurology and Center for Neuroinflammation and Experimental Therapeutics (A.B.-O.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; The Minneapolis Clinic of Neurology (J.C.C.), MN; F. Hoffmann-La Roche Ltd (C.C., J.E., M.M., D.S.), Basel, Switzerland; Central Texas Neurology Consultants (E.J.F.), Round Rock; Genentech, Inc (A.H.), South San Francisco, CA; John McNamara Consulting Ltd (J.M.), Cambridge, UK; Department of Neurology (D.S.R.), Multiple Sclerosis Division, University of South Florida College of Medicine, Tampa; Territory Neurology and Research Institution (J.K.W.), Tucson, AZ; Division of Infectious Diseases (K.L.W.), Oregon Health & Science University, Portland; and University of British Columbia (A.T.), Vancouver, Canada
| | - Anthony Traboulsee
- From the Department of Neurology and Center for Neuroinflammation and Experimental Therapeutics (A.B.-O.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; The Minneapolis Clinic of Neurology (J.C.C.), MN; F. Hoffmann-La Roche Ltd (C.C., J.E., M.M., D.S.), Basel, Switzerland; Central Texas Neurology Consultants (E.J.F.), Round Rock; Genentech, Inc (A.H.), South San Francisco, CA; John McNamara Consulting Ltd (J.M.), Cambridge, UK; Department of Neurology (D.S.R.), Multiple Sclerosis Division, University of South Florida College of Medicine, Tampa; Territory Neurology and Research Institution (J.K.W.), Tucson, AZ; Division of Infectious Diseases (K.L.W.), Oregon Health & Science University, Portland; and University of British Columbia (A.T.), Vancouver, Canada
| |
Collapse
|
63
|
Neurological immunotherapy in the era of COVID-19 - looking for consensus in the literature. Nat Rev Neurol 2020; 16:493-505. [PMID: 32641860 PMCID: PMC7341707 DOI: 10.1038/s41582-020-0385-8] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2020] [Indexed: 01/08/2023]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic is concerning for patients with neuroimmunological diseases who are receiving immunotherapy. Uncertainty remains about whether immunotherapies increase the risk of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or increase the risk of severe disease and death upon infection. National and international societies have developed guidelines and statements, but consensus does not exist in several areas. In this Review, we attempt to clarify where consensus exists and where uncertainty remains to inform management approaches based on the first principles of neuroimmunology. We identified key questions that have been addressed in the literature and collated the recommendations to generate a consensus calculation in a Delphi-like approach to summarize the information. We summarize the international recommendations, discuss them in light of the first available data from patients with COVID-19 receiving immunotherapy and provide an overview of management approaches in the COVID-19 era. We stress the principles of medicine in general and neuroimmunology in particular because, although the risk of viral infection has become more relevant, most of the considerations apply to the general management of neurological immunotherapy. We also give special consideration to immunosuppressive treatment and cell-depleting therapies that might increase susceptibility to SARS-CoV-2 infection but reduce the risk of severe COVID-19. In this Review, the authors synthesize recommendations on the management of neuroimmunological disease in the context of the COVID-19 pandemic. They consider these recommendations alongside the first available data from patients, and provide an overview of management approaches in the COVID-19 era. The risk that the coronavirus disease 2019 (COVID-19) pandemic poses for people who are receiving immunotherapy for neuroimmunological disease remains unclear. Guidelines and statements have been published by societies and individuals, but the level of consensus differs for different aspects; we use a Delphi-like process to clarify where consensus exists. Without evidence, management of neuroimmunological diseases in the context of COVID-19 requires application of the first principles of immunotherapy, taking into account disease-related, patient-related, physician-related, environment-related and COVID-19-related factors. In general, corticosteroids, intravenous immunoglobulin and/or plasma exchange for the treatment of acute neuroimmunological deteriorations can be administered with low risk in the COVID-19 pandemic. In general, ongoing immunotherapy should not be stopped because of the COVID-19 pandemic; treatment initiation and optimization are also recommended. For some aspects of immunotherapy in the context of COVID-19, consensus in the literature is low, and collection of data in patient registries is important for resolving these uncertainties.
Collapse
|
64
|
Reyes S, Ramsay M, Ladhani S, Amirthalingam G, Singh N, Cores C, Mathews J, Lambourne J, Marta M, Turner B, Gnanapavan S, Dobson R, Schmierer K, Giovannoni G. Protecting people with multiple sclerosis through vaccination. Pract Neurol 2020; 20:435-445. [DOI: 10.1136/practneurol-2020-002527] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2020] [Indexed: 12/28/2022]
Abstract
Vaccination is one of the most effective and cost-efficient methods for protecting people with multiple sclerosis (MS) from infections. However, use of vaccines has often been problematic because of misguided concerns that they may exacerbate the disease and/or that some disease-modifying therapies may influence the immune response to immunisations and/or their safety. People with MS risk higher morbidity and mortality from vaccine-preventable infections. It is, therefore, important to address any patient’s reluctance to accept vaccination and to provide clear guidance for clinicians on which vaccinations to consider proactively. We have reviewed the current literature and provide recommendations regarding vaccines in adults with MS, including specific advice regarding vaccination safety in patients receiving—or going to receive—disease-modifying therapies, vaccination during pregnancy, pretravel counselling and patient education.
Collapse
|
65
|
Risiken und Chancen von Immuntherapien in Zeiten der Coronavirus-2019-Pandemie. DGNEUROLOGIE 2020. [PMCID: PMC7284681 DOI: 10.1007/s42451-020-00205-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Immuntherapien stellen die essenzielle Grundlage der Behandlung von neuroinflammatorischen Erkrankungen dar. In Zeiten der Coronavirus-2019 (COVID-19)-Pandemie ergibt sich im klinischen Alltag jedoch zunehmend die Frage, ob eine Immuntherapie bei neurologischen Patienten aufgrund des potenziellen Infektionsrisikos eingeleitet, intensiviert, pausiert oder gar beendet werden sollte. Unsicherheit besteht v. a. deshalb, weil verschiedene nationale und internationale Fachgesellschaften diesbezüglich unterschiedliche Empfehlungen veröffentlichten. In diesem Artikel soll ein Überblick über die Wirkmechanismen von Immuntherapien und den daraus abzuleitenden Infektionsrisiken in Bezug auf COVID-19 (durch den Coronavirus verursachte Erkrankung) gegeben werden. Potenzielle Chancen und vorteilhafte Effekte einzelner Substrate in der Akuttherapie von COVID-19 werden diskutiert.
Collapse
|
66
|
Jakimovski D, Weinstock-Guttman B, Ramanathan M, Dwyer MG, Zivadinov R. Infections, Vaccines and Autoimmunity: A Multiple Sclerosis Perspective. Vaccines (Basel) 2020; 8:vaccines8010050. [PMID: 32012815 PMCID: PMC7157658 DOI: 10.3390/vaccines8010050] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 01/21/2020] [Accepted: 01/24/2020] [Indexed: 12/13/2022] Open
Abstract
Background: Multiple sclerosis (MS) is a chronic neuroinflammatory and neurodegenerative disease that is associated with multiple environmental factors. Among suspected susceptibility events, studies have questioned the potential role of overt viral and bacterial infections, including the Epstein Bar virus (EBV) and human endogenous retroviruses (HERV). Furthermore, the fast development of immunomodulatory therapies further questions the efficacy of the standard immunization policies in MS patients. Topics reviewed: This narrative review will discuss the potential interplay between viral and bacterial infections and their treatment on MS susceptibility and disease progression. In addition, the review specifically discusses the interactions between MS pathophysiology and vaccination for hepatitis B, influenza, human papillomavirus, diphtheria, pertussis, and tetanus (DTP), and Bacillus Calmette-Guerin (BCG). Data regarding potential interaction between MS disease modifying treatment (DMT) and vaccine effectiveness is also reviewed. Moreover, HERV-targeted therapies such as GNbAC1 (temelimab), EBV-based vaccines for treatment of MS, and the current state regarding the development of T-cell and DNA vaccination are discussed. Lastly, a reviewing commentary on the recent 2019 American Academy of Neurology (AAN) practice recommendations regarding immunization and vaccine-preventable infections in the settings of MS is provided. Conclusion: There is currently no sufficient evidence to support associations between standard vaccination policies and increased risk of MS. MS patients treated with immunomodulatory therapies may have a lower benefit from viral and bacterial vaccination. Despite their historical underperformance, new efforts in creating MS-based vaccines are currently ongoing. MS vaccination programs follow the set back and slow recovery which is widely seen in other fields of medicine.
Collapse
Affiliation(s)
- Dejan Jakimovski
- Buffalo Neuroimaging Analysis Center, Department of Neurology, University at Buffalo, State University of New York, Buffalo, NY 14203, USA
- Correspondence:
| | - Bianca Weinstock-Guttman
- Jacobs MS Center, Department of Neurology, University at Buffalo, State University of New York, Buffalo, NY 14203, USA
| | - Murali Ramanathan
- School of Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, NY 14214, USA
| | - Michael G. Dwyer
- Buffalo Neuroimaging Analysis Center, Department of Neurology, University at Buffalo, State University of New York, Buffalo, NY 14203, USA
| | - Robert Zivadinov
- Buffalo Neuroimaging Analysis Center, Department of Neurology, University at Buffalo, State University of New York, Buffalo, NY 14203, USA
- Center for Biomedical Imaging at Clinical Translational Science Institute, University at Buffalo, State University of New York, Buffalo, NY 14203, USA
| |
Collapse
|
67
|
Signoriello E, Bonavita S, Sinisi L, Russo CV, Maniscalco GT, Casertano S, Saccà F, Lanzillo R, Morra VB, Lus G. Is antibody titer useful to verify the immunization after VZV Vaccine in MS patients treated with Fingolimod? A case series. Mult Scler Relat Disord 2020; 40:101963. [PMID: 31986424 DOI: 10.1016/j.msard.2020.101963] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 01/12/2020] [Accepted: 01/19/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND Fingolimod (FTY720, Gilenya) is a second line therapy to treat relapsing MS not responding to first-line treatments and/or with a high disease activity (according to Italian Regulatory authorities). Before starting Fingolimod, patients' immunity to varicella zoster virus (VZV) needs to be assessed and seronegative patients vaccinated. To test susceptibility and response, IgG antibodies are tested after immunization. Since Fingolimod determines a reduction of circulating B lymphocytes and immunoglobulins, we aimed at describing the trend of VZV antibodies in seronegative vaccinated patients with MS before and after treatment. METHODS A total of 23 patients vaccinated for VZV before starting Fingolimod treatment, were recruited in this observational retrospective study involving five MS Centers in Campania (Italy). Of these, 12 patients were excluded for missing data. Patients received two doses of Varivax® Vaccine. After vaccination patients were re-tested and were all positive for IgG-VZV. We re-tested IgG-VZV in the same laboratory after a mean time of 2.42 years from Fingolimod therapy start. RESULTS During Fingolimod therapy we observed a global reduction of antibody titer and a disappearance in 7/11 patients. Titer disappearance was more probable in patients with lower post-vaccination titer. Of the 7 patients with vanishing IgG-VZV, three suspended Fingolimod for adverse event. In two of them, we observed a reappearance of antibody titer after treatment cessation. In one patient chickenpox infection occurred one year later. DISCUSSION AND CONCLUSIONS Our observational study shows that Fingolimod could influence antibody titer probably through its effect on B lymphocytes, but the efficacy of the vaccination should be verified. In conclusion, it is necessary to pay attention to therapies acting on B lymphocytes as they could influence the antibody titer and efficacy of vaccination making the search for other markers of vaccine efficacy desirable such as cell-mediated immunity with proliferation and induction of memory T lymphocytes in response to viral glycoproteins.
Collapse
Affiliation(s)
- E Signoriello
- Multiple Sclerosis Center, Second Division of Neurology, Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Italy.
| | - S Bonavita
- Multiple Sclerosis Center, Second Division of Neurology, Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Italy
| | - L Sinisi
- Multiple Sclerosis Center, Division of Neurology, San Paolo Hospital, ASL Napoli 1 Centro
| | - C V Russo
- Department of Neurological Sciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Italy
| | - G T Maniscalco
- Multiple Sclerosis Center, Department of Neurology and Stroke Unit and o "AORN A.Cardarelli", Naples, Italy
| | - S Casertano
- Multiple Sclerosis Center, Second Division of Neurology, Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Italy
| | - F Saccà
- Department of Neurological Sciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Italy
| | - R Lanzillo
- Department of Neurological Sciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Italy
| | - V Brescia Morra
- Department of Neurological Sciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Italy
| | - G Lus
- Multiple Sclerosis Center, Second Division of Neurology, Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Italy
| |
Collapse
|
68
|
Zheng C, Kar I, Chen CK, Sau C, Woodson S, Serra A, Abboud H. Multiple Sclerosis Disease-Modifying Therapy and the COVID-19 Pandemic: Implications on the Risk of Infection and Future Vaccination. CNS Drugs 2020; 34:879-896. [PMID: 32780300 PMCID: PMC7417850 DOI: 10.1007/s40263-020-00756-y] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The coronavirus 2019 (COVID-19) pandemic is expected to linger. Decisions regarding initiation or continuation of disease-modifying therapy for multiple sclerosis have to consider the potential relevance to the pandemic. Understanding the mechanism of action and the possible idiosyncratic effects of each therapeutic agent on the immune system is imperative during this special time. The infectious side-effect profile as well as the route and frequency of administration of each therapeutic agent should be carefully considered when selecting a new treatment or deciding on risk mitigation strategies for existing therapy. More importantly, the impact of each agent on the future severe acute respiratory syndrome coronavirus type-2 (SARS-CoV-2) vaccine should be carefully considered in treatment decisions. Moreover, some multiple sclerosis therapies may have beneficial antiviral effects against SARS-CoV-2 while others may have beneficial immune-modulating effects against the cytokine storm and hyperinflammatory phase of the disease. Conventional injectables have a favorable immune profile without an increased exposure risk and therefore may be suitable for mild multiple sclerosis during the pandemic. However, moderate and highly active multiple sclerosis will continue to require treatment with oral or intravenous high-potency agents but a number of risk mitigation strategies may have to be implemented. Immune-modulating therapies such as the fumerates, sphinogosine-1P modulators, and natalizumab may be anecdotally preferred over cell-depleting immunosuppressants during the pandemic from the immune profile standpoint. Within the cell-depleting agents, selective (ocrelizumab) or preferential (cladribine) depletion of B cells may be relatively safer than non-selective depletion of lymphocytes and innate immune cells (alemtuzumab). Patients who develop severe iatrogenic or idiosyncratic lymphopenia should be advised to maintain social distancing even in areas where lockdown has been removed or ameliorated. Patients with iatrogenic hypogammaglobulinemia may require prophylactic intravenous immunoglobulin therapy in certain situations. When the future SARS-CoV-2 vaccine becomes available, patients with multiple sclerosis should be advised that certain therapies may interfere with mounting a protective immune response to the vaccine and that serological confirmation of a response may be required after vaccination. They should also be aware that most multiple sclerosis therapies are incompatible with live vaccines if a live SARS-CoV-2 vaccine is developed. In this article, we review and compare disease-modifying therapies in terms of their effect on the immune system, published infection rates, potential impact on SARS-CoV-2 susceptibility, and vaccine-related implications. We propose risk mitigation strategies and practical approaches to disease-modifying therapy during the COVID-19 pandemic.
Collapse
Affiliation(s)
- Crystal Zheng
- Raabe College of Pharmacy, Ohio Northern University, Ada, OH USA
| | - Indrani Kar
- System Pharmacy Services, University Hospitals of Cleveland, Cleveland, OH USA
| | - Claire Kaori Chen
- Specialty Pharmacy, University Hospitals of Cleveland, Cleveland, OH USA
| | - Crystal Sau
- Specialty Pharmacy, University Hospitals of Cleveland, Cleveland, OH USA ,Multiple Sclerosis and Neuroimmunology Program, University Hospitals of Cleveland, Case Western Reserve University School of Medicine, Cleveland Medical Center, Bolwell, 5th Floor, 11100 Euclid Avenue, Cleveland, OH 44106 USA
| | - Sophia Woodson
- Multiple Sclerosis and Neuroimmunology Program, University Hospitals of Cleveland, Case Western Reserve University School of Medicine, Cleveland Medical Center, Bolwell, 5th Floor, 11100 Euclid Avenue, Cleveland, OH 44106 USA
| | - Alessandro Serra
- Multiple Sclerosis and Neuroimmunology Program, University Hospitals of Cleveland, Case Western Reserve University School of Medicine, Cleveland Medical Center, Bolwell, 5th Floor, 11100 Euclid Avenue, Cleveland, OH 44106 USA ,VA Multiple Sclerosis Center of Excellence, Cleveland VA Medical Center, Cleveland, OH USA
| | - Hesham Abboud
- Multiple Sclerosis and Neuroimmunology Program, University Hospitals of Cleveland, Case Western Reserve University School of Medicine, Cleveland Medical Center, Bolwell, 5th Floor, 11100 Euclid Avenue, Cleveland, OH, 44106, USA.
| |
Collapse
|
69
|
Chisari CG, Toscano S, D’Amico E, Lo Fermo S, Zanghì A, Arena S, Zappia M, Patti F. An update on the safety of treating relapsing-remitting multiple sclerosis. Expert Opin Drug Saf 2019; 18:925-948. [DOI: 10.1080/14740338.2019.1658741] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Clara G. Chisari
- Department “GF Ingrassia”, Section of Neurosciences, Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - Simona Toscano
- Department “GF Ingrassia”, Section of Neurosciences, Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - Emanuele D’Amico
- Department “GF Ingrassia”, Section of Neurosciences, Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - Salvatore Lo Fermo
- Department “GF Ingrassia”, Section of Neurosciences, Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - Aurora Zanghì
- Department “GF Ingrassia”, Section of Neurosciences, Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - Sebastiano Arena
- Department “GF Ingrassia”, Section of Neurosciences, Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - Mario Zappia
- Department “GF Ingrassia”, Section of Neurosciences, Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - Francesco Patti
- Department “GF Ingrassia”, Section of Neurosciences, Multiple Sclerosis Center, University of Catania, Catania, Italy
| |
Collapse
|
70
|
Farez MF, Correale J, Armstrong MJ, Rae-Grant A, Gloss D, Donley D, Holler-Managan Y, Kachuck NJ, Jeffery D, Beilman M, Gronseth G, Michelson D, Lee E, Cox J, Getchius T, Sejvar J, Narayanaswami P. Practice guideline update summary: Vaccine-preventable infections and immunization in multiple sclerosis. Neurology 2019; 93:584-594. [DOI: 10.1212/wnl.0000000000008157] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 06/18/2019] [Indexed: 12/26/2022] Open
Abstract
ObjectiveTo update the 2002 American Academy of Neurology (AAN) guideline regarding immunization and multiple sclerosis (MS).MethodsThe panel performed a systematic review and classified articles using the AAN system. Recommendations were based on evidence, related evidence, principles of care, and inferences according to the AAN 2011 process manual, as amended.Major recommendations (Level B except where indicated)Clinicians should discuss the evidence regarding immunizations in MS with their patients and explore patients' opinions, preferences, and questions. Clinicians should recommend that patients with MS follow all local vaccine standards, unless there are specific contraindications and weigh local vaccine-preventable disease risks when counseling patients. Clinicians should recommend that patients with MS receive the influenza vaccination annually. Clinicians should counsel patients with MS about infection risks associated with specific immunosuppressive/immunomodulating (ISIM) medications and treatment-specific vaccination guidance according to prescribing information (PI) and vaccinate patients with MS as needed at least 4–6 weeks before initiating patients' ISIM therapy. Clinicians must screen for infections according to PI before initiating ISIM medications (Level A) and should treat patients testing positive for latent infections. In high-risk populations, clinicians must screen for latent infections before starting ISIM therapy even when not specifically mentioned in PI (Level A) and should consult specialists regarding treating patients who screen positive for latent infection. Clinicians should recommend against using live-attenuated vaccines in people with MS receiving ISIM therapies. Clinicians should delay vaccinating people with MS who are experiencing a relapse.
Collapse
|
71
|
Lebrun C, Vukusic S. Immunization and multiple sclerosis: Recommendations from the French multiple sclerosis society. Mult Scler Relat Disord 2019; 31:173-188. [DOI: 10.1016/j.msard.2019.04.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 03/29/2019] [Accepted: 04/05/2019] [Indexed: 12/18/2022]
|
72
|
Lebrun C, Vukusic S, Abadie V, Achour C, Ader F, Alchaar H, Alkhedr A, Andreux F, Androdias G, Arjmand R, Audoin B, Audry D, Aufauvre D, Autreaux C, Ayrignac X, Bailbe M, Benazet M, Bensa C, Bensmail D, Berger E, Bernady P, Bertagna Y, Biotti D, Blanchard-Dauphin A, Bonenfant J, Bonnan M, Bonnemain B, Borgel F, Botelho-Nevers E, Boucly S, Bourre B, Boutière C, Branger P, Brassat D, Bresch S, Breuil V, Brochet B, Brugeilles H, Bugnon P, Cabre P, Camdessanché JP, Carra-Dalière C, Casez O, Chamouard JM, Chassande B, Chataignier P, Chbicheb M, Chenet A, Ciron J, Clavelou P, Cohen M, Colamarino R, Collongues N, Coman I, Corail PR, Courtois S, Coustans M, Creange A, Creisson E, Daluzeau N, Davenas C, De Seze J, Debouverie M, Depaz R, Derache N, Divio L, Douay X, Dulau C, Durand-Dubief F, Edan G, Elias Z, Fagniez O, Faucher M, Faucheux JM, Fournier M, Gagneux-Brunon A, Gaida P, Galli P, Gallien P, Gaudelus J, Gault D, Gayou A, Genevray M, Gentil A, Gere J, Gignoux L, Giroux M, Givron P, Gout O, Grimaud J, Guennoc AM, Hadhoum N, Hautecoeur P, Heinzlef O, Jaeger M, Jeannin S, Kremer L, Kwiatkowski A, Labauge P, Labeyrie C, Lachaud S, Laffont I, Lanctin-Garcia C, Lannoy J, Lanotte L, Laplaud D, Latombe D, Lauxerois M, Le Page E, Lebrun-Frenay C, Lejeune P, Lejoyeux P, Lemonnier B, Leray E, Loche CM, Louapre C, Lubetzki C, Maarouf A, Mada B, Magy L, Maillart E, Manchon E, Marignier R, Marque P, Mathey G, Maurousset A, Mekies C, Merienne M, Michel L, Milor AM, Moisset X, Montcuquet A, Moreau T, Morel N, Moussa M, Naudillon JP, Normand M, Olive P, Ouallet JC, Outteryck O, Pacault C, Papeix C, Patry I, Peaureaux D, Pelletier J, Pichon B, Pittion S, Planque E, Pouget MC, Pourcher V, Radot C, Robert I, Rocher F, Ruet A, Ruet A, Saint-Val C, Salle JY, Salmon A, Sartori E, Schaeffer S, Stankhof B, Taithe F, Thouvenot E, Tizon C, Tourbah A, Tourniaire P, Vaillant M, Vermersch P, Vidil S, Wahab A, Warter MH, Wiertlewski S, Wiplosz B, Wittwer B, Zaenker C, Zephir H. Immunization and multiple sclerosis: Recommendations from the French Multiple Sclerosis Society. Rev Neurol (Paris) 2019; 175:341-357. [DOI: 10.1016/j.neurol.2019.04.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 03/31/2019] [Accepted: 04/11/2019] [Indexed: 10/26/2022]
|
73
|
|
74
|
Metze C, Winkelmann A, Loebermann M, Hecker M, Schweiger B, Reisinger EC, Zettl UK. Immunogenicity and predictors of response to a single dose trivalent seasonal influenza vaccine in multiple sclerosis patients receiving disease-modifying therapies. CNS Neurosci Ther 2018; 25:245-254. [PMID: 30044050 DOI: 10.1111/cns.13034] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 06/25/2018] [Indexed: 12/27/2022] Open
Abstract
AIMS To evaluate the immunogenicity and safety of a seasonal influenza vaccine in a cohort of multiple sclerosis (MS) patients receiving different immunomodulating/immunosuppressive therapies and assess predictors of immune response. METHODS A prospective, multicenter, non-randomized observational study including 108 patients receiving a trivalent seasonal influenza vaccination was conducted. Influenza-specific antibody titers (H1N1, H3N2, and influenza B) were measured to evaluate rates of seroprotection and seroconversion/significant titer increase. Univariable and multivariable analyses were performed to identify prognostic factors of vaccination outcomes. RESULTS Regarding the whole cohort, seroprotection rates >70% were achieved for each influenza strain. Interferon-treated patients reached high seroprotection rates (>84%). Good seroprotection rates were seen in patients treated with glatiramer acetate. In particular for H3N2, response rates were low in natalizumab-treated patients and in the small subgroup of fingolimod-treated patients. Patients with a previous disease-modifying therapy and a longer disease duration were less likely to respond sufficiently. No severe adverse events were reported. MS disease activity was not increased after a one-year follow-up period. CONCLUSION Vaccination led to good immunogenicity, especially in MS patients treated with interferons and glatiramer acetate. At least for the H1N1 strain, rates of seroprotection and seroconversion/significant titer increase were high (>70% and >60%, respectively) for all therapeutic subgroups. Patients with a longer duration of the disease are exposed to an increased risk of insufficient immune response to vaccination.
Collapse
Affiliation(s)
- Christoph Metze
- Department of Neurology, Neuroimmunology Section, Rostock University Medical Center, Rostock, Germany
| | - Alexander Winkelmann
- Department of Neurology, Neuroimmunology Section, Rostock University Medical Center, Rostock, Germany
| | - Micha Loebermann
- Department of Tropical Medicine and Infectious Diseases, Rostock University Medical Center, Rostock, Germany
| | - Michael Hecker
- Department of Neurology, Neuroimmunology Section, Rostock University Medical Center, Rostock, Germany
| | - Brunhilde Schweiger
- National Reference Centre for Influenza and Other Respiratory Viruses, Robert-Koch-Institut, Berlin, Germany
| | - Emil Christian Reisinger
- Department of Tropical Medicine and Infectious Diseases, Rostock University Medical Center, Rostock, Germany
| | - Uwe Klaus Zettl
- Department of Neurology, Neuroimmunology Section, Rostock University Medical Center, Rostock, Germany
| |
Collapse
|