• Kenneth Makus

Blame Edward Jenner for the complexity. Covid Vaccination perspective.

Hello all, over the last few months I have developed a keen interest in vaccines for good reasons including read a book on vaccinations and watching various You-tube videos. The science is fascinating and while there is always an uncommon to rare risk of harm with vaccinations in general, vaccines are an amazing public health tool. I will never forget losing a very young patient as medical student to a condition that would have been prevented by a vaccine. Of Edward Jenner it was said, that he saved millions and hurt thousands. Having stated this so far I have not read of any major safety issues with the vaccines but will keep monitoring the situation. There are various reports of issues on the internet but so far I have not seen anything definite that causes me a lot of concern. The one vaccine that I am currently monitoring is the Astra Zeneca product. We are frequently asked which vaccine is better. At this time we are generally given a choice which one we get. I got the first dose of the Pfizer vaccine several weeks ago and it went well.

For most of my patients there is no problem getting the vaccine. The exception are MS patients on certain medications. I have a link on my website to a Canadian article from the MS consortium on vaccines. The following information is from that article:

S1P antagonists (fingolimod [Gilenya], siponimod [Mayzent] and ozanimod [Zeposia]) likely reduce the vaccines’ immune response and therefore their efficacy. For optimized immune response to vaccination, people on S1P antagonists should receive the full dosing regimen for COVID vaccines available in Canada (2 doses). No dosing modification of S1P antagonists is recommended for vaccination. If the vaccine is administered before the start of treatment, a delay of four weeks is recommended.

Lymphocyte depletors (cladribine [Mavenclad] and alemtuzumab [Lemtrada]) should be used with caution during the pandemic because of theoretical risks of infection during the cell depletion phase. It is believed that cell repletion allows for an adequate immune response to vaccines from six months after each yearly cycle for both drugs. A delay of only three months may be acceptable if lymphocytes have recovered to near normal. Furthermore, the next treatment cycle may be delayed if required for maximizing vaccination response, depending on disease activity. If the vaccine is administered before the start of treatment, a delay of four weeks is recommended.

Intravenous anti-CD20 medications (ocrelizumab [Ocrevus] and rituximab [Rituxan]) are the only MS treatments for which some evidence suggests both an increased susceptibility to COVID-19, and a more severe COVID-19 course of infection. Vaccination should preferably be delayed as late from previous infusion as is reasonable (e.g. 4-6 months) with subsequent infusion at least four weeks after the vaccine booster (second dose). If the vaccine is administered before the start of treatment, a delay of four weeks is recommended.

The one reality is that with some of the MS treatments patients are not likely to mount as good a response. Thus for patients on Gilenya or Mayzent I am informing them to use the two dose vaccines and not to extend the time between shots. There are also some complexities regarding Ocrevus as noted above. The final concern relates to the new Kesimpta drug. The MS consortium is advising caution as we have limited information. We would have to discuss this new drug (which is related to Ocrevus) in more detail in person or by virtual appointments.

Stay well and safe.

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