Updates on 2nd booster, omicron and monoclonal antibodies for pre-exposure prophylaxis:
2nd Booster Vaccine
As of March 29, 2022 the CDC has authorized the use of a 2nd booster dose to certain immunocompromised individuals and those over age 50 who received an initial booster dose at least 4 months ago. Those eligible can get an additional mRNA vaccine. Those who received Johnson and Johnson’s vaccine for their first shot and booster are also eligible for an mRNA second booster.
Further information about vaccine dosing is available below and at the CDC website.
The new COVID-19 variant (BA.1.1) was identified in Massachusetts December 2021. At this time, a variant of Omicron known as BA.2 is becoming more common in Massachusetts. People with Omicron infection can spread the virus even if vaccinated, so we recommend continued mask wearing and social distancing. There have been breakthrough infections among the vaccinated. There is data the mRNA vaccines are effective at neutralizing omicron in the laboratory and at preventing infection.
Treatment for COVID-19
If you test positive for COVID-19, you may be eligible for treatment either with oral antiviral medications or an infusion. Please let your doctor know as soon as possible if you test positive as these medications need to be given with the first week of symptoms.
We advise all patients to have a low threshold to self-test in case of exposure or symptoms, and to contact your health care providers promptly for nirmatrelvir/ritonavir (Paxlovid) prescription (or mAb infusion if you have a contraindication to contraindication to Paxlovid.) Early access to Paxlovid is likely the most effective strategy in preventing severe Covid infection. Paxlovid is a five-day oral antiviral that reduces risk of hospitalization by approximately 90 percent.
Additional monoclocal antibody treatment for COVID is available now in Massachusetts. Sotrovimab, a monoclonal antibody, previously used, is no longer authorized for use in the Northeast due to resistance against the BA.2 omicron subvariant. There is limited supply available of Bebtelovimab, an alternate monoclonal antibody, which has shown to be effective in the laboratory against the BA.2 omicron subvariant.
Monoclonal antibodies for pre-exposure prophylaxis (Evusheld)
The FDA has issued an emergency use authorization for AstraZeneca’s Evusheld, which is a monoclonal antibody indicated for pre-exposure prophylaxis of COVID-19 in individuals who are moderately or severely immunocompromised and may not mount an adequate immune response to COVID-19 vaccination.
More information about the medication is available from the FDA here.
- Where can I get Evusheld?
MGB has a supply of drug for patients on certain disease modifying medications (at this time patients on ocrevus and rituximab, as well as fingolimod, Siponimod and ozanimod are eligible). The MS center will reach out to eligible patients. Please do not call the center the center at this time. You can also receive Evusheld during your scheduled infusion appointment, if you receive certain MS medications in the infusion center. It is also possible to receive Evusheld at infusion sites funded by the state of Massachusetts and managed by Gothams. More information is here.
- What is the recommended dose of Evushield?
On 2/24/22 the FDA revised the dose of Evusheld to be increased to 300mg (300 mg of tixagevimab and 300 mg of cilgavimab.)
- What if I already received the 150mg dose of Evushield?
The patients who have already been treated are no less protected than they were prior to the FDA dose modification, and epidemic improvement has made us all safer. The incidence of BA.1.1 Omicron variant, more resistant to Evusheld protection, is down in Massachusetts. BA.2 is becoming the most common variant in the next few weeks and Evusheld appears to be fully active against BA.2. You are eligible to receive a second 150mg dose, or a full 300mg dose in the future. This will depend on clinic resources and drug availability. Depending on timing of your previous Evusheld treatment, it may be advisable to wait a few months prior to your second dose. Please, discuss with your doctor.
- Can I get Evusheld if I've been exposed or have COVID-19?
This treatment is not authorized for COVID-19 treatment or for prevention of infection if you've been exposed.
- Does Evusheld work against the Omicron variant?
This is an area of active investigation, but studies have shown efficacy against Omicron and the BA.2 subvariant in the laboratory.
For more information about monoclonal antibodies for post-exposure prophylaxis and treatment of MS patients with COVID-19 please visit our other page here.
General Information on the COVID-19 Vaccines
The currently approved vaccines are mRNA vaccines produced by Pfizer and Moderna, and a modified adenovirus vector virus vaccine produced by Johnson and Johnson. We do not know which vaccine you will receive. This will depend on where you live, your insurance, and other distribution factors. The Pfizer vaccine requires two doses separated by 3 weeks, the Moderna vaccine requires two doses separated by 4 weeks, and the Johnson and Johnson vaccine is a single dose vaccine.
In April 2021, distribution of the Johnson and Johnson vaccine was briefly put on hold while the CDC and FDA reviewed an extremely rare side effect of cerebral venous sinus thrombosis (a blood clot in one of the veins in the brain) associated with low platelets. However, given the rarity of this side effect when balanced with the benefits of the vaccine, distribution of the Johnson and Johnson vaccine has now resumed.
Please contact your primary care provider immediately if you develop any of the following symptoms within one month of receiving the Johnson and Johnson vaccine.
- Headache that is constant, worse with positional changes (bending over), or associated with nausea, vomiting, or vision changes
- Headache that resolved within 24 hours of vaccine administration but then recurred
- Abdominal pain, leg swelling (bilateral or unilateral), chest pain, shortness of breath, or bruising/petechiae
When should I get the vaccines?
In general, we recommend that our patients follow the vaccination program guidelines developed by the Massachusetts Department of Public Health. View the Massachusetts Department of Health Website
If you are on rituximab, or ocrelizumab if possible, we would recommend getting vaccinated at least 3 months or longer after your infusion, and waiting at least 4 weeks after getting fully vaccinated before your next infusion to maximize the effectiveness. You are considered fully vaccinated after having the second dose of the Pfizer or Moderna vaccines, or one dose of the Johnson and Johnson vaccine. However, if this timing is not possible, then we recommend getting vaccinated whenever feasible.
- After receiving rituximab or ocrelizumab your B cells are suppressed. B cells are a type of white blood cell important to mounting vaccine responses and providing immunity. As the rituximab or ocrelizumab wears off and your B cells start to come back, you may be more likely to mount a response to the vaccine. However, we also know that patients on B cell therapies who get COVID may be more severely affected, so the decision and timing of vaccination should be a risk/benefit discussion with your neurologist.
If you have had vaccine related adverse reactions, or allergic reactions please consult your primary care provider prior to getting vaccinated.
If you have new or worsening neurologic symptoms in the days or weeks after receiving vaccination, please, consult your neurologist.
Are the vaccines safe for patients with MS?
The vaccines were not tested in patients with MS or with other autoimmune diseases. However, inactivated vaccines such as the flu, shingles, and pneumonia vaccines are generally safe and recommended in patients with MS. The COVID-19 vaccines in the general population were found to be safe. The most common adverse effects were local pain, redness, and swelling at injection sites, as well as transient fatigue, muscle pains, joint pains, chills, or fevers. Data thus far has suggested that the COVID-19 vaccinations are safe for patients with MS and not associated with increased risk of relapse.
- Detailed safety information for the Pfizer vaccine
- Detailed safety information for the Moderna vaccine
- Detailed safety information for the Johnson and Johnson vaccine
Are the vaccines effective for patients with MS?
The COVID-19 vaccines were not tested in patients with MS or with other autoimmune diseases. We believe that having MS will not negatively impact the efficacy of the vaccines; however, receiving some disease modifying treatments might impact overall vaccine efficacy and durability. This is an area of ongoing research. There is more information below based on what we know so far about the effectiveness of the COVID-19 vaccine and other (non-COVID-19) vaccines in MS patients on disease modifying therapies.
Will the vaccines worsen my MS?
We do not have this information specifically for the COVID vaccines. However, results of large trials have shown that other vaccines do not cause MS, worsen MS, or cause relapses10, 11. It is important to note that fever can exacerbate preexisting MS symptoms but should not cause new symptoms. Please reach out to your doctor if you have persistent symptoms or new symptoms associated with the COVID vaccination.
Who can get the vaccine?
People ages 12 and older who live, work, or study in Massachusetts can get vaccinated against COVID-19. People ages 5-17 can only get the Pfizer vaccine. People age 18 and older can get any vaccine. The vaccine is safe and effective. You don’t need an ID or insurance to get it.
Table 1: Vaccine efficacy studies in patients on MS disease modifying treatments
|Medication||Vaccine effectiveness when compared to patients not on disease modifying therapy||Further details and references|
|Copaxone (glatiramer acetate)||As effective||
Patients on Copaxone receiving the flu vaccine had similar responses to healthy controls
Patients on Copaxone receiving the COVID-19 vaccine had similar responses to MS patients not on disease modifying treatments
|Avonex, Betaseron, Plegridy, Rebif (interferons)||As effective||Patients on interferon beta-1a 44mcg three times weekly had no difference in their ability to mount an immune response to the flu vaccine compared to controls|
|Aubagio (teriflunomide)||As effective||Patients on Aubagio had similar responses to the flu vaccine compared to those on interferons.3
|Tecfidera (dimethyl fumarate)
Vumerity (diroxel fumarate)
|As effective||Patients on Tecfidera mounted similar immune responses to pneumococcus, meningococcus and tetanus vaccines as those on interferons.4
|Possibly less effective||Most patients on Gilenya were able to mount immune responses to the flu vaccine but response rates were less than patients not on Gilenya.5 Patients on Siponimod also had lower response rates to the flu vaccine compared to controls.6 Emerging evidence suggests that patients on these treatments may not be able to mount a full response against COVID19 after receiving a complete series of vaccinations.7, 8
|Tysabri (natalizumab)||Possibly less effective||A lower proportion of patients on Tysabri responded to tetanus vaccines compared to controls though this was not a statistically significant difference.9 Smaller studies have shown that fewer patients on Tysabri responded to the H1N1 vaccine10 and flu vaccine1 compared to controls.
|Possibly less effective||A study on tetanus, pneumococcus, and flu vaccines showed that those on Ocrevus did mount immune responses to all three vaccines, but to a lesser degree than patients not on disease modifying therapy or on interferons. Emerging evidence suggests that patients on these treatments may not be able to mount a strong response against COVID19 after receiving a complete series of vaccinations.
|Mavenclad (cladribine)||Unknown||Two recent studies suggest that patients on Mavenclad mount successful immune response to common vaccinations:
MAGNIFY-MS study show protective antibody levels for at least six months following seasonal influenza and varicella zoster vaccines, irrespective of vaccine timing relative to cladribine dosing. Initial findings from the CLOCK-MS vaccine sub-study show protective influenza antibody levels at four weeks post-vaccination in MS patients taking Cladribine.
In both studies, protective antibody levels were maintained or increased independent of lymphocyte counts.
* No data is available for Vumerity, Zeposia or Kesimpta, but these medications are grouped with those disease modifying therapies of similar classes.