MS and vaccines as a health care provider

[8bitheart]

I'm a non-trad at the beginning of her journey (just starting to take pre-reqs), and have recently been diagnosed with clinically isolated syndrome (the episode has remitted and I have no residual functional impairment). I'm starting a platform drug ASAP which will hopefully delay conversion to MS for some time. I had my MMR series as a youngster (titer results sufficed for undergrad) and Hep B in grad school (about a decade ago). I updated my Tdap a few years ago. Given that MS is an autoimmune disease, I've been trying to find reputable information on the impact of vaccination on disease progression in MS sufferers. The National MS Society's website sites two studies, one from the NEJM in 2001 that concluded that neither tetanus, hep B, nor influenza vaccines increased short-term risk of MS exacerbations and the other from the CDC in 2003 saying that risk of developing MS was not increased by Hep B, flu, Tdap, measles, or rubella vaccines. I'm going to talk to my neurologist about this when I see him next month but thought that in the meantime I'd ask a few questions to folks who may have some personal or anecdotal experience with this. My questions are:

1. Are positive titers for MMR and Hep B enough to satisfy requirements for medical school? Before the demyelinating disease crashed the party, I'd have been happy to re-vaccinate. Now my enthusiasm has waned a bit.

2. How often and what kinds of vaccines are required over the course of a career in medicine in the U.S.? I've read that annual flu vaccines are a must. Any others?

3. Is anyone familiar with any literature that suggests that it's not a good idea for a person with MS to enter medicine because of the vaccine requirement (or because of the risk of exposure to infectious diseases for that matter)? I know that there are other important considerations, but I'll save those for another day.

4. Does anyone know of anyone who successfully made it through med school despite having MS or some other vulnerability of the immune system? I'd hate to get into med school or to the point of the clinical years only to discover that it was all a waste because the required vaccines kicked my MS into high gear, resulting in needing to leave school. There are few MS-related posts on SDN, which are largely positive and encouraging. No mention of vaccines, though.

Frankly, I just want to go with the tidbit of findings I've read so far and continue to pursue my passion, but I'd be remiss to not find out more about this. I know that my decision should derive predominantly from consultation with my neurologist, but curiosity about what folks on the front lines have experienced is killing this cat. My PM&R says to go for it without hesitation, but this was before I started thinking about the vaccine issue. It probably wouldn't have even crossed my mind, but I'm looking to do some volunteer work at a local hospital and of course documentation of certain vaccines is a requirement.

Thanks in advance for your responses.

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[cbrons]

edit - sorry I just think this is probably a troll post

 

[ACSurgeon]

I'm a non-trad at the beginning of her journey (just starting to take pre-reqs), and have recently been diagnosed with clinically isolated syndrome (the episode has remitted and I have no residual functional impairment). I'm starting a platform drug ASAP which will hopefully delay conversion to MS for some time. I had my MMR series as a youngster (titer results sufficed for undergrad) and Hep B in grad school (about a decade ago). I updated my Tdap a few years ago. Given that MS is an autoimmune disease, I've been trying to find reputable information on the impact of vaccination on disease progression in MS sufferers. The National MS Society's website sites two studies, one from the NEJM in 2001 that concluded that neither tetanus, hep B, nor influenza vaccines increased short-term risk of MS exacerbations and the other from the CDC in 2003 saying that risk of developing MS was not increased by Hep B, flu, Tdap, measles, or rubella vaccines. I'm going to talk to my neurologist about this when I see him next month but thought that in the meantime I'd ask a few questions to folks who may have some personal or anecdotal experience with this. My questions are:

1. Are positive titers for MMR and Hep B enough to satisfy requirements for medical school? Before the demyelinating disease crashed the party, I'd have been happy to re-vaccinate. Now my enthusiasm has waned a bit.

2. How often and what kinds of vaccines are required over the course of a career in medicine in the U.S.? I've read that annual flu vaccines are a must. Any others?

3. Is anyone familiar with any literature that suggests that it's not a good idea for a person with MS to enter medicine because of the vaccine requirement (or because of the risk of exposure to infectious diseases for that matter)? I know that there are other important considerations, but I'll save those for another day.

4. Does anyone know of anyone who successfully made it through med school despite having MS or some other vulnerability of the immune system? I'd hate to get into med school or to the point of the clinical years only to discover that it was all a waste because the required vaccines kicked my MS into high gear, resulting in needing to leave school. There are few MS-related posts on SDN, which are largely positive and encouraging. No mention of vaccines, though.

Frankly, I just want to go with the tidbit of findings I've read so far and continue to pursue my passion, but I'd be remiss to not find out more about this. I know that my decision should derive predominantly from consultation with my neurologist, but curiosity about what folks on the front lines have experienced is killing this cat. My PM&R says to go for it without hesitation, but this was before I started thinking about the vaccine issue. It probably wouldn't have even crossed my mind, but I'm looking to do some volunteer work at a local hospital and of course documentation of certain vaccines is a requirement.

Thanks in advance for your responses.

You can opt out of the flu vaccine if you have a medical condition that puts you at risk for complications. I'm no neurologist or ID doc - they would know if you have a true contraindication.

 

[soulofmpatel]

"4. Does anyone know of anyone who successfully made it through med school despite having MS or some other vulnerability of the immune system? I'd hate to get into med school or to the point of the clinical years only to discover that it was all a waste because the required vaccines kicked my MS into high gear, resulting in needing to leave school. There are few MS-related posts on SDN, which are largely positive and encouraging. No mention of vaccines, though."

You are basically asking for medical advice, but I'll bite.

I know two neurologists with multiple sclerosis. I know one pediatrician and two internists with the disease. Everyone faces challenges in life; don't give up your dreams. Consider starting a high efficacy disease modifying therapy if you develop multiple sclerosis.

There is some evidence that vaccines can bring out multiple sclerosis relapses (possibly), but there is no evidence that vaccination worsens the overall prognosis in multiple sclerosis, and routine vaccination is recommended in individuals with multiple sclerosis. Of note, the yellow fever vaccine has been linked to multiple sclerosis relapses, but there were methodological problems with this study.

Live vaccinations (i.e. the shingles vaccine) are contraindicated if you are on certain disease modifying therapies (i.e. rituxan, cytoxan) but are not a problem with injectibles such as copaxone, rebif, betaseron, extavia, or avonex.

Of note, one of the neurologists I know complained that people treated her differently in residency when the found out she had MS, so you may want to keep it a secret if you don't have obvious clinical symptoms

See my sources below:

JAMA Neurol. 2014 Dec 1;71(12):1506-13. doi: 10.1001/jamaneurol.2014.2633.
Vaccines and the risk of multiple sclerosis and other central nervous system demyelinating diseases.
Langer-Gould A1, Qian L2, Tartof SY2, Brara SM3, Jacobsen SJ2, Beaber BE3, Sy LS2, Chao C2, Hechter R2, Tseng HF2.

Arch Neurol. 2012 Jan;69(1):144; author reply 144-5. doi: 10.1001/archneurol.2011.1519.
Methodological issues with the risk of relapse study in patients withmultiple sclerosis after yellow fever vaccination.
Pool V, Gordon DM, Decker M.

 

[blueharbor]

Is there a vaccine for stupidity? You might look into getting it if there is.

 

[G_Marker]

edit - sorry I just think this is probably a troll post

OP has a legitimate concern. I'm not sure if you're referring to your previous post or OP's as a 'troll post.' Though there's a lot of controversy about anti-vaxers refusing to give their children vaccines (thereby ultimately harming them and their children's peers more than helping them), there have been studies that have shown links between vaccines and autoimmune diseases, like MS.

Certain childhood diseases have been linked to increased risk for certain autoimmune diseases in susceptible individuals (like measles, mumps, rubella -> type 1 diabetes). It's not a complete far-cry to go from that to vaccines, which (so far as my tiny premed knowledge is concerned) trigger an autoimmune response like the actual disease they are vaccinating against. There have also been lots of studies linking vaccines to autoimmune diseases in certain genetically predisposed individuals.

While I wouldn't go around touting these as evidence that none of us should be vaccinated (that would be very dangerous!), I think it's important that we not just roll our eyes at someone (especially patients!) without considering the evidence they bring to the table. I would not be surprised if children are someday screened for certain predisposing alleles and are selectively given vaccines based on their genome (ie, children at high genetic risk for __ autoimmune disease won't receive __ vaccines).

 

[Goro]

I'd had several students who were immunocompromised, mainly from being transplant recipients.

"4. Does anyone know of anyone who successfully made it through med school despite having MS or some other vulnerability of the immune system? I'd hate to get into med school or to the point of the clinical years only to discover that it was all a waste because the required vaccines kicked my MS into high gear, resulting in needing to leave school. There are few MS-related posts on SDN, which are largely positive and encouraging. No mention of vaccines, though."

 

[cbrons]

OP has a legitimate concern. I'm not sure if you're referring to your previous post or OP's as a 'troll post.' Though there's a lot of controversy about anti-vaxers refusing to give their children vaccines (thereby ultimately harming them and their children's peers more than helping them), there have been studies that have shown links between vaccines and autoimmune diseases, like MS.

no there haven't.

It's not a complete far-cry to go from that to vaccines, which (so far as my tiny premed knowledge is concerned) trigger an autoimmune response like the actual disease they are vaccinating against.

It is a complete far-cry and your statement makes no sense whatsoever.

VACCINES — Concerns have been raised, particularly in the lay press, regarding the risk of inducing autoimmune disease by vaccination in patients with autoimmune disorders; the scientific evidence clearly favors the value of vaccination. Patients suffering from an autoimmune disease might have a generally heightened susceptibility to autoimmunity, but there are no well-designed epidemiologic studies showing a significant increase in any autoimmune disease following vaccination of these patients. Other studies indicate there is no difference in the occurrence following vaccination of severe systemic adverse effects, including autoimmune disorders, with vaccines using adjuvant compared with non-adjuvanted vaccines. Indeed, many patients with autoimmune disease are relatively poor immune responders to vaccine antigens and may require additional boosters. The protective value of vaccines in patients with autoimmune disease is well-established based by sound epidemiologic data, while the possibility that vaccines may induce or exacerbate autoimmune disease remains speculative [59,60].

Overview of autoimmunity
Literature review current through: Dec 2014.
http://www.uptodate.com/contents/overview-of-autoimmunity

 

[Psai]

OP has a legitimate concern. I'm not sure if you're referring to your previous post or OP's as a 'troll post.' Though there's a lot of controversy about anti-vaxers refusing to give their children vaccines (thereby ultimately harming them and their children's peers more than helping them), there have been studies that have shown links between vaccines and autoimmune diseases, like MS.

Certain childhood diseases have been linked to increased risk for certain autoimmune diseases in susceptible individuals (like measles, mumps, rubella -> type 1 diabetes). It's not a complete far-cry to go from that to vaccines, which (so far as my tiny premed knowledge is concerned) trigger an autoimmune response like the actual disease they are vaccinating against. There have also been lots of studies linking vaccines to autoimmune diseases in certain genetically predisposed individuals.

While I wouldn't go around touting these as evidence that none of us should be vaccinated (that would be very dangerous!), I think it's important that we not just roll our eyes at someone (especially patients!) without considering the evidence they bring to the table. I would not be surprised if children are someday screened for certain predisposing alleles and are selectively given vaccines based on their genome (ie, children at high genetic risk for __ autoimmune disease won't receive __ vaccines).

"There have been lots of studies blah blah blah". Doesn't post a single study

 

[8bitheart]

Eek, I've never been accused of trolling before but could see how my post might be interpreted as such. I appreciate everyone's responses, which have helped allay my concerns. Sure, I'm a little embarrassed that I didn't poke around more before posting. Articles like the JAMA one referenced by soulofmpatel popped up right away when I searched again. I think what it boils down to is that I was feeling anxious about my situation in general (what does having MS mean for my future, especially in medicine?). The vaccine piece became the focal point because I saw it listed as a requirement on a hospital volunteer application I had just read. Since most things right now are filtered through my 'newly diagnosed w/ CIS' lens, this was prime fodder for the what-ifs. For better or worse, people reassurance-seek all over these threads. If it had been transparent to me that that was my motivation for posting, I would have just continued lurking and sorted things out the reasonable way, by consulting with my neurologist and reading the empirical literature for clarification. I doubted that any additional vaccines required would accelerate my disease or preclude me from training to be doctor; I just didn't know for sure and wanted to hear from people who had personal experience with it.

To be clear, I'm all about drawing conclusions and making decisions based upon sound, replicable evidence from reputable sources. I know that vaccines are safe and essential. I know that vaccines don't increase the risk of developing MS or autism spectrum disorders or anything of the like. I also now know that, unless it's a question of giving a live virus to an immunocompromised person, vaccines are fine for a person with MS and that there are plenty of immunocompromised trainees and doctors out there.

Thanks again all.

 

[8bitheart]

Of note, one of the neurologists I know complained that people treated her differently in residency when the found out she had MS, so you may want to keep it a secret if you don't have obvious clinical symptoms

Thanks for the suggestion. From what I've read about disclosure, I don't plan on telling anyone. I don't have any observable signs and hope it stays that way so that I can keep it under wraps.

 

[peanutsss]

.....

 

[8bitheart]

Ditto to this. I have a family member who does this, similar situation to you.

As far as the titers question, I know I used titers on some of my vaccine requirements.

That's good to hear. Thanks.

 

[G_Marker]

"There have been lots of studies blah blah blah". Doesn't post a single study

I don't have any interest in spending time doing research for an internet forum. If you are interested, look it up. The link that first came to my mind when I wrote that post was between a 2009 flu vaccine used in Europe and childhood-onset narcolepsy.

My point remains valid, whether or not I wrote a research paper on it. @8bitheart has a legitimate concern about autoimmune disease and vaccines. To be clear, I'm not saying that anyone in particular should avoid vaccines because of the autoimmune disease link... just that it's there and an area that deserves research and concern by the scientific community.

 

[Psai]

So what you're saying is that you actually don't know if there are studies and you just made it up as a talking point to seem like you have scientific evidence on your side

 

[mimelim]

I don't have any interest in spending time doing research for an internet forum. If you are interested, look it up. The link that first came to my mind when I wrote that post was between a 2009 flu vaccine used in Europe and childhood-onset narcolepsy.

My point remains valid, whether or not I wrote a research paper on it. @8bitheart has a legitimate concern about autoimmune disease and vaccines. To be clear, I'm not saying that anyone in particular should avoid vaccines because of the autoimmune disease link... just that it's there and an area that deserves research and concern by the scientific community.

If you are going to make reference to "studies" and someone calls you out on it, you should probably be able to provide them, otherwise it pretty much looks like you made it up to win an argument.

 

[WingedOx]

OP has a legitimate concern. I'm not sure if you're referring to your previous post or OP's as a 'troll post.' Though there's a lot of controversy about anti-vaxers refusing to give their children vaccines (thereby ultimately harming them and their children's peers more than helping them), there have been studies that have shown links between vaccines and autoimmune diseases, like MS.

Certain childhood diseases have been linked to increased risk for certain autoimmune diseases in susceptible individuals (like measles, mumps, rubella -> type 1 diabetes). It's not a complete far-cry to go from that to vaccines, which (so far as my tiny premed knowledge is concerned) trigger an autoimmune response like the actual disease they are vaccinating against. There have also been lots of studies linking vaccines to autoimmune diseases in certain genetically predisposed individuals.

While I wouldn't go around touting these as evidence that none of us should be vaccinated (that would be very dangerous!), I think it's important that we not just roll our eyes at someone (especially patients!) without considering the evidence they bring to the table. I would not be surprised if children are someday screened for certain predisposing alleles and are selectively given vaccines based on their genome (ie, children at high genetic risk for __ autoimmune disease won't receive __ vaccines).

I'm SO having your sign my disability paperwork for my chronic lyme disease someday when I no longer feel like working.

 

[Snakes]

@8bitheart, I'm going to PM you.