Newsletter: COVID19 vaccines and mental health

19/05/2021

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Vaccination

Vaccines against COVID-19 are now widely available across Europe but what does this mean for the person with MS and are there any nursing considerations as a result?

Many people with MS are approaching their nurse seeking advice regarding the vaccinations for COVID-19 that are now available and what this means for them. Guidance from the MS International Federation (MSIF, March 2021) states that all people with MS should be vaccinated against COVID-19. The current COVID-19 vaccines available are safe for people with MS and they should therefore be vaccinated as soon as the vaccine is available to them. It takes some time after vaccination to achieve immunity, so it is important to remind people to maintain precautions and safety measures after initial vaccination including wearing a mask, social distancing and frequent hand washing.

We have compiled a list of some of the more common questions you may be asked, along with answers developed from guidance currently available from the MS International Federation (MSIF) and other national organisations.1-3

Which COVID-19 vaccination is best for someone with MS?

There are several COVID-19 vaccines available in different countries around the world, which work in various ways (Table 1). Live attenuated vaccines are not suitable for people with MS, due to the way some of the available DMTs work. Currently (March 2021), none of the vaccines that are approved for COVID-19 are live vaccines. Therefore, all of the current vaccines available are suitable. It is too soon to compare the available COVID-19 vaccines and to say if one might be better than the other. The advice for your person with MS is to have the vaccine for COVID-19 as soon as it becomes available to them.

COVID-19 vaccine	Mechanism of action
Pfizer-BioNTech (Comirnaty) Moderna (Moderna mRNA)	Messenger RNA (mRNA) vaccines: have the genetic code for the coronavirus ‘spike’ protein made as an “mRNA”
AstraZeneca/Oxford (Covishield) Gamaleya Research Institute (Gam-COVID-Vac or Sputnik V)	Non-replicating viral vector vaccines: have the genetic code for the spike protein in a viral vector
Sinovac (CoronaVac)	Inactivated virus vaccines: use an inactivated form of the whole coronavirus
NovaVax (NVX-CoV2373)	Protein vaccines: have the coronavirus spike protein itself (not the genetic code), along with something that boosts the immune system (an ‘adjuvant’) to ensure the spike protein is targeted
No vaccines currently approved	Live attenuated vaccines use a weakened, but replicating virus. People with MS should avoid receiving these types of vaccines

Table 1: Mechanism of action of currently available COVID-19 vaccines (MSIF, March 2021)

Have the COVID-19 vaccinations been studied in people with MS?

It is not known how many people in the COVID-19 vaccine clinical trials had MS, so data on the safety and effectiveness of COVID-19 vaccines specifically for people with MS are not yet available. Guidance is therefore based on data from the general population and guided by prior experience regarding vaccination of people with MS.

From the initial trial results that have been reported, the vaccine is between 70-95% effective in the total trial population. Pfizer-BioNTech plan to check how effective the vaccine is for people with weakened ('compromised') immune systems. This will be done through a clinical trial and through their ongoing monitoring of people in the months and years after taking the vaccine. There is currently no evidence that people with MS are at higher risk of complications from the mRNA, non-replicating viral vector, inactivated virus or protein COVID-19 vaccines, compared to the general population.

Is the vaccine less effective if I am currently taking a DMT for my MS?

It is possible that people on some MS treatments might have a reduced response to the vaccines. Table 2 outlines currently approved DMTs and points to consider when thinking about COVID-19 vaccines. If the risk of the person’s MS worsening outweighs the risk of COVID-19, the DMT schedule should not be altered due to the vaccine. If the person’s MS is stable, the adjustments outlined in the table could be considered to enhance the effectiveness of the vaccine.

DMT	Adjustments in the administration
Glatiramer acetate, teriflunomide, dimethyl fumarate, beta interferons, natalizumab	Not thought to reduce the efficacy of the vaccination No adjustments necessary
Fingolimod, siponimod, ozanimod	Reduced vaccine response may be seen but, for those people already receiving treatment, it is not advisable to stop the DMT in order to increase immune response to the vaccine For people with MS starting treatment, consider administering the vaccine so that the second vaccine injection is two to four weeks before starting the DMT Dosing alterations are not recommended
Ocrelizumab	For people with MS starting treatment, consider administering the vaccine so that the second vaccine injection is two to four weeks before starting ocrelizumab If the person with MS has recently had a course of ocrelizumab, they should wait ≥12 weeks before having the vaccination Ocrelizumab should be resumed ≥4 weeks after the second vaccine injection
Alemtuzumab	For people with MS starting treatment, consider administering the vaccine so that the second vaccine injection is at least 4 weeks before starting DMT Reduced response to a vaccine may be seen soon after treatment; recommendation for those already receiving treatment is to wait at least 3 months after scheduled dose before having the vaccine Treatment should be resumed ≥4 weeks after the second vaccine injection
Cladribine	For people with MS starting treatment, consider administering the vaccine so that the second vaccine injection is at least 4 weeks before starting DMT (US guidance is 2–4 weeks post vaccination) Treatment should be resumed ≥4 weeks after the second vaccine injection (US guidance for cladribine is for next course to be administered 2–4 weeks post vaccination) It is important to note that US guidance states that for those already taking cladribine, the limited currently available data does not suggest that the timing of the vaccine in relation to cladribine dosing is likely to make a difference in vaccine response3,4

Table 2: Administration adjustments to DMTs when considering COVID-19 vaccination

Recommendations on delaying second or further doses of alemtuzumab, cladribine and ocrelizumab due to the COVID-19 outbreak differ between countries. Check recommendations in your own country

A recent real-world study in Israel investigated the efficacy for people with MS to develop protective humoral response following the Pfizer-BNT162b2-COVID-19 vaccination.4 The study found that untreated COVID-19-vaccinated MS patients developed protective SARS-CoV-2 humoral responses similar to healthy vaccinees. For MS patients treated with high-efficacy DMTs, the immune response to COVID-19 vaccination varied. 23% of patients treated with ocrelizumab developed humoral IgG response irrespective to normal absolute lymphocyte count. Most fingolimod-treated MS patients had very low lymphocyte count and failed to develop SARS-COV-2 antibodies. All MS patients treated with cladribine developed a high level of antibodies indicating that it does not impair humoral response to COVID-19 vaccination.

Can I have a COVID-19 vaccine if I’m having an MS relapse or taking steroids?

Current guidance is that a person with MS should not have the vaccination if they are having a relapse. The person should be advised to wait 2 weeks after completing a course of steroids to treat a relapse, before being vaccinated. 

Should I stop taking my DMT before I get the vaccine? If so, how long should I stop it for and when might l be able to restart?

People with MS should continue taking their DMT as prescribed, unless they are advised otherwise by their nurse or other HCP. Stopping some DMTs abruptly can cause severe worsening of MS. It is important to communicate to the person with MS that delaying the start of a DMT, or altering DMT timing, is not a safety issue but a strategy to allow the vaccine to be fully effective. As discussed previously, the decision of when the person with MS receives their COVID-19 vaccine should include an evaluation of COVID-19 risk and the current status of the person’s MS.

Will my MS be worse after having the vaccine and for how long?

The current COVID-19 vaccines do not contain live viruses and will not cause COVID-19 disease. These types of vaccine are not likely to trigger an MS relapse or to worsen chronic MS symptoms. A recent real-world study found no increased risk of relapse activity over a median follow-up of 20 and 38 days after first and second vaccine doses, respectively.5 The risk of getting COVID-19 far outweighs any risk of having an MS relapse from the vaccine.

Will I have any side effects from the COVID-19 vaccination?

As with all vaccines, there is a risk of side effects with the COVID-19 vaccines. A recent real-world study demonstrated that people with MS had similar rates of adverse reactions to those reported in the general population following vaccination against COVID-19.5 The most common reactions seen in the study were pain at the injection site, fatigue, headaches, and chills or fever. A fever can make a person’s MS symptoms worsen temporarily, but they should return to prior levels after the fever is gone. In general, any side effects happen shortly after the vaccination and are not associated with more serious or lasting illness.

Sources:

MS, the Coronavirus and vaccines – updated global advice. MS International Federation, March 2021. Available at https://www.msif.org/news/2020/02/10/the-coronavirus-and-ms-what-you-need-to-know/
MS and the COVID-19 vaccines. The UK MS Society, March 2021. Available at https://www.mssociety.org.uk/care-and-support/ms-and-coronavirus-care-and-support/ms-and-covid-19-vaccines
COVID-19 vaccine considerations for MS healthcare providers. The US National MS Society, April 2021. https://www.nationalmssociety.org/coronavirus-covid-19-information/multiple-sclerosis-and-coronavirus/covid-19-vaccine-guidance/Timing-MS-Medications-with-COVID-19-Vaccines
Humoral immune response to COVID-19 mRNA vaccine in patients with MS treated with high-efficacy disease-modifying therapies. Achiron A, et al. Ther Adv Neurol Disord. 2021;14:1–8
Covid-19 vaccination in patients with MS: What we have learnt by February 2021. Achiron A, et al. Multiple Sclerosis Journal 2021

Spotlight on long COVID…what is it and does it impact people with MS?

Long COVID is the name being used for cases in which people continue to experience COVID-19 symptoms after the infection has passed. It includes both ongoing symptomatic COVID-19 (from 4 to 12 weeks) and post-COVID-19 syndrome (12 weeks or more).

Many of the risk factors for severity of acute COVID-19, such as age, male gender, obesity and ethnicity do not appear to enhance the chance of long COVID. There seems no clear correlation between severity of the acute disease and long-term sequelae. It is therefore difficult to foresee which people might go on to suffer from long COVID. Many estimates of long COVID suggest that greater than 10% of acute cases have features that do not resolve over the subsequent months. Extrapolated to the current global burden of COVID-19, this suggests potentially over five million current “long haulers.”

Common lingering symptoms include fatigue, shortness of breath, and chest pains, as well as muscle pains, headache, a fast or pounding heartbeat, and the loss of smell or taste. Problems with memory, concentration, brain fog and sleep have also been commonly reported. A recent study found that 80% of non-hospitalised COVID-19 “long haulers” experience prominent and persistent brain fog and 85% experience fatigue that affects their cognition and quality of life. People with long COVID often find themselves too unwell to return to activities such as work and education for weeks to months after infection.

Long Covid-19 is an important emerging entity requiring multidisciplinary expertise and long Covid-19 is an important emerging entity requiring multidisciplinary expertise and Long COVID-19 is an important emerging entity requiring multidisciplinary expertise and care. The long-term impact of long COVID on quality of life and potential return to normalcy, through lost productivity and lingering cognitive dysfunction, may be substantial as the pandemic continues. What does this mean for people with MS? At this point in time, we don’t know as we do not have the data to assess how it is affecting or how it will affect our patients. Long COVID has many symptoms similar to those seen in MS (fatigue, memory problems, brain fog) and people with MS are therefore fully aware of how these symptoms can be managed. People with MS have really valuable life experience and can offer advice and support to those living with long COVID, especially around fatigue management.

Sources:

COVID-19 rapid guideline: managing the long-term effects of COVID-19. National Institute for Health and Care Excellence (UK); 2020 Dec 18.

Persistent neurologic symptoms and cognitive dysfunction in non‐hospitalized Covid‐19 “long haulers”. Graham EL, et al. Annals of Clinical and Translational Neurology, March 2021

Vaccination for people with MS: What do the guidelines say?

Vaccination is one of the most effective and cost-efficient methods for protecting people with MS from infections. It is therefore important that people with MS undergo an appropriate vaccination programme.

The American Academy of Neurology (AAN) recently reviewed their immunisation guidelines in people with MS. A group of British neurologists have also reviewed the literature and provided recommendations regarding vaccines in adults with MS. Key recommendations from these guidelines are outlined below:

No definite evidence suggests that MS is caused by vaccinations or that risk for MS diagnosis is increased after vaccination
Routine vaccinations are recommendable for people with MS, particularly because of increased risk for infections with immunosuppressive therapies. For maximal efficacy, vaccinations should be offered prior to starting immunosuppressive therapies for MS
BCG vaccine may be considered in unvaccinated adults where prevalence of tuberculosis is high; other vaccines in different countries/regions may be advised if incidence of the associated disease is substantial
People with MS should receive annual influenza vaccination (the inactivated injectable influenza vaccine is preferred to the live one), unless other contraindications are present
Latent and chronic infections (e.g., tuberculosis, hepatitis) should be screened for prior to starting certain immunosuppressive therapies
Live-attenuated vaccines are generally not recommended for those on immunosuppressive therapies. Specific recommendations are as follows:
- Fingolimod: avoid live vaccines during treatment and 3 months after discontinuation
- Teriflunomide: avoid live vaccines during treatment and 6 months after stopping
- Dimethyl fumarate: avoid live vaccines until lymphocyte counts have returned to above 800/mm3 after stopping treatment
- Alemtuzumab: avoid live vaccines 6 weeks before, during, and after recent treatment
- Ocrelizumab: avoid live vaccines during and after treatment, until B cell depletion has occurred
- Cladribine: not recommended until immune reconstitution has occurred
- During a relapse, vaccinations should be delayed until remission

Reviewing and updating immunisations should be an integral part of routine MS care. Patient education is required proactively on the part of the primary, secondary and tertiary healthcare professionals to present correct information and to promote opportunities for people with MS to be vaccinated.

Sources:

Practice guideline update summary: Vaccine-preventable infections and immunization in multiple sclerosis. Farez MF, et al. Neurology 2019;93:584-94

Protecting people with MS through vaccination. Reyes S, et al. Pract Neurol 2020;20:435–445

Mental health and wellbeing during COVID-19: Things to consider

The COVID-19 pandemic has presented new uncertainties that have challenged the coping resources of many people with MS, causing disruptions in lifestyle habits and choices that affect wellness. Anxiety, depression, loneliness, and sedentary behaviour are common in MS and may have been increased by the physical distancing necessitated by the pandemic. The promotion of physical, nutritional and emotional wellness through health behaviours has never been more important, and rehabilitation providers play a critical role in promoting wellness in the population with MS. Some recommendations to consider include:

Physical wellness	Reinforce the importance of sitting less and moving more on a daily basis by engaging in lifestyle physical activity and/or exercise Can include simple modifications such as multiple short bouts of ambulatory and wheelchair-based physical activity in or outside the home throughout the day Highlight importance of engaging in physical activity or exercise, maintaining a current routine, and consulting with professionals before making substantial changes
Nutritional wellness	Encourage people with MS to maintain simple healthy diet habits that include: make at least half the plate at meals fruits and vegetables (excluding starchy vegetables) choose healthy fats that include olive oil and grapeseed oil as well as fish and poultry that are lower in saturated fat add whole foods Remind people with MS that diet is important because it affects MS disability, emotional wellness, and quality of life
Emotional wellness	Assess and address emotional wellness as part of standard care, both during the COVID-19 crisis and after it has passed Collaborate with patients to generate a comprehensive plan for addressing psychosocial distress, symptom management, and adherence to other lifestyle recommendations Telehealth psychological care with a professional is an effective mode of care for people with MS along with a range of online and self-help strategies; this can help people cope with the anxiety, increased isolation, and uncertainty that many are experiencing during the COVID-19 pandemic

Sources:

Health behaviours, wellness and multiple sclerosis amid COVID-19. Motl R, et al. Archives of Physical Medicine and Rehabilitation 2020;101:1839-41

MS News from our Community

EMSP conference in collaboration with MS Nurse PRO

EMSP Virtual Conference 2021, registrations are now open!

This year, the conference is brought to you in collaboration with MS Nurse PRO, marking the milestone of the first-ever European MS nursing community event
The theme will be “MS Care in a Changing World”, with a special focus on connecting the carers with the people affected by MS for an improved care
To make the conference as inclusive as possible, participation is free for patients, MS societies, patient advocates, nurses and carers

One million steps

Are you a keen a fitness enthusiast looking for a challenge, or someone who wants to improve or start to live an active life and looking to fundraise for a cause? If so, then this event is for you.

Supporting the idea of ‘Donating miles/steps for one million people affected by MS’, it lends an opportunity to all participants to ‘raise friends and therefore raise funds’ while leading an active lifestyle during this global pandemic. To participate please register in the link here: https://donate.emsp.org/event/one-million-steps

Whether it’s along a stunning coastline, or on your favourite streets, trails, parks, at home, work place or shopping mall - your ‘500 Miles or One Million Steps’ Challenge for a million people affected by MS can be an unforgettable experience for you– with your friends, family, co-workers as you can join as a team or just do it yourself and have an amazing sense of achievement.
Just a year ago, no one could have predicted the unprecedented impact of COVID-19 on the lives of millions. As we all pass through consecutive ‘unlock’ phases, it is imperative we take stock, adopt the new normal, repair and restart the healing and rebuilding process
Join our ‘One Million Steps’ challenge and help raise funds for ‘One Million People affected by MS in Europe’. The challenge will be launched on 12th May 2021, International Nurses Day, which will illustrate the support of healthcare workers for people affected by MS. It is open for all participants across Europe and overseas and for all fitness levels. You can complete the steps at your own pace. You can join as a team or just do it by yourself. The challenge will culminate on 3rd December 2021, International Day of Disabled Persons
Supporting the idea of ‘Donating miles/steps for one million people affected by MS’, it lends an opportunity to all participants to ‘raise friends and therefore raise funds’ while leading an active lifestyle during this global pandemic. To participate please register in the link here: https://donate.emsp.org/event/one-million-steps

MS NursED World MS Day webinar

MS NursED in collaboration with the IOMSN, are excited to host an educational webinar for MS nurses on 29 May at 13:00 CEST, Staying well with MS: management strategies for nurses in a changing environment.

The webinar will be available in English, French, German, Portuguese, Spanish and Polish and has Royal College of Nursing (RCN) accreditation.

In recognition of World MS day, MS NursED in collaboration with the IOMSN, are excited to host an educational webinar for MS nurses on 29 May at 13:00 CEST, Staying well with MS: management strategies for nurses in a changing environment.

Following the MS NursED November 2020 virtual conference and chaired by expert MS nurse and IOMSN representative Colleen Harris, this engaging event promises to be highly relevant to MS practice around the world. The webinar will provide a refresher on the Prof Christoph Kleinschnitz presentation from the 2020 virtual conference on MS immunology and lead into an up to date COVID-19 discussion, in which Colleen Harris will be joined by neurologists Prof Adi Vaknin and Prof Tomas Kalincik to review the current coronavirus landscape and vaccination in people with MS.

This engaging event will help you understand the challenges posed by COVID-19 and the ongoing vaccine programme in the management of MS and how best to advise patients. It will also provide opportunity to ask the faculty your questions.

The webinar will be available in English, French, German, Portuguese, Spanish and Polish and has Royal College of Nursing (RCN) accreditation.

This Medical Education program is funded and organized by Merck KGaA, Darmstadt, Germany. (The Healthcare business of Merck KGaA, Darmstadt, Germany operates as EMD Serono in the US and Canada). This program is intended for healthcare professionals only. This program is not intended for US healthcare professionals. Merck KGaA, Darmstadt, Germany only sponsors medical education programs for US healthcare professionals consistent with ACCME guidelines or similar grantors of accreditation, and consistent with US law and guidance.

GL-NONNI-00380| May 2021

Staying smart

Staying Smart, a new, interactive web zone to provide everyday tips and tricks to help those people with MS who experience cognitive difficulties

Thinking and memory problems affect more than half of all people with MS and can have a big impact on their day-to-day life
The MS Trust (UK) has launched a new, interactive zone on their website “Staying Smart”, for people with MS who want to learn more about how MS affects their thinking and memory, and take action to reduce the impact that cognition problems have on everyday life
Staying Smart incorporates research evidence, expert advice, and peer support and is designed to be accessible on all devices

To find out more information about how it can help people with MS, visit Staying Smart

Subscribe to EMSP's e-newsletter

Do you want to keep on top of latest news and developments in MS across Europe? Then register your details and sign up here for access to the EMSP Newsletter.

Ofatumumab approved for use in Europe, 30 March 2021

The European Commission (EC) has approved ofatumumab for the treatment of adults with relapsing-remitting MS (RRMS) who have active disease based on clinical or imaging features
Ofatumumab is a monoclonal antibody that binds to the CD20 receptor at the surface of B-cells. It is self-administered by a once-monthly injection, delivered subcutaneously
The EC’s decision was based on results from the ASCLEPIOS I and II studies, in which ofatumumab demonstrated superiority over teriflunomide in reducing the number of confirmed relapses in patients with relapsing forms of MS
Ofatumumab will be marketed under the name of Kesimpta

For more information visit the EMA website

Chariot MS

A trial focusing on people with MS with limited walking ability, begins recruitment

Chariot MS is an upcoming Phase 2 clinical trial which will test whether cladribine tablets can slow a worsening of hand and arm function in people with progressive MS and very limited walking abilities

ChariotMS will use the Nine Hole Peg Test, a measurement of hand and arm function. Enrolled patients will also undergo MRI scans to assess the treatment’s effect on brain lesions
ChariotMS is set to begin enrolment in 2021 at 20 centres across the United Kingdom. Trial participants will have EDSS scores between 6.5 and 8.5, meaning they cannot walk more than 20 meters (about 65 feet) using two crutches, or are completely unable to walk. All eligible patients will still retain some function in their arms and hands

MS Vibes

The first free on-demand streaming radio station dedicated to the MS community

MS Vibes includes a series of monthly educational podcasts, called “MS Journeys” covering subjects ranging from “real patients’ diagnosis journeys” to “the role of music in MS,” to “recognising changes in MS”

News to share?

Do you have news to share with our community of +7000 nurses from Europe and beyond? Send it to [email protected]. Any submission needs to be approved by the Syllabus Committee before being published. Next e-newsletter is planned for mid-September 2021 and submissions are accepted until end August. We accept submissions in all available languages of MS Nurse PRO.