Stay vigilant as the delta strain surges
This is a simple reminder for people with MS on an anti-CD20 therapy or a S1P-modulator not to trust your vaccine immunity.
Apologies, for yet another COVID-19 related Newsletter, but it is an important message.
The following information is important in view of the fact that many people with MS (pwMS) who are on an anti-CD20 (rituximab, ocrelizumab, ofatumumab, ublituximab) or an S1P modulator (fingolimod, siponimod, ozanimod and ponesimod) are more vulnerable because of blunted vaccine responses to the COVID-19 vaccines.
New data shows that vaccinated people from the general population are being infected with the delta variant of SARS-CoV-2 and are able to spread it (Riemersma et al. MedRxiv 11-Aug-2021). The amount of delta-variant virus in the nose of vaccinated infected people is as high as in people who are infected but not vaccinated. What this study doesn’t show, which is evident in the UK data, is that vaccine immunity does reduce your chances of getting infected. So in many people, vaccine immunity is sufficient to prevent infection.
Overall the data indicates that the delta variant is an immune escape variant, in some people, in terms of upper respiratory tract infection and its ability to spread. However, the delta variant is not necessarily an immune escape variant in terms of severe systemic disease. The vaccinated people who are infected and spreading the virus are at a much lower risk of getting severe infections or dying from this. The likely reason for this is that what protects people from being infected locally in the nose and upper respiratory tract is down to antibody responses and what protects you from systemic infection (pneumonia, etc.) is both antibody and T-cell immune responses.
The emerging global COVID-19 picture with the delta variant clearly concerns me. As it is now surging across the world I would encourage all vulnerable people with MS, particularly those on an anti-CD20 or an S1P modulator, to remain vigilant and to avoid crowded public spaces, to maintain social distancing if you can, to keep wearing masks and to wash your hands frequently. We now have several ocrelizumab-treated patients, who have been double-vaccinated, come down with COVID1-9 and have required hospital admission. This is not a theoretical risk it is a real risk.
As I said last week please take up the offer of a booster vaccine and try and delay the next course of anti-CD20 therapy, until you have some peripheral B-cell reconstitution (CD19+ B-cell count of > 10/mm3) so that you are more likely to respond to the booster. If you are on an S1P modulator delaying or stopping your treatment for the booster is not really an option because of the potential for rebound activity. If developing vaccine immunity is a priority for you you may need to consider switching to another class of DMT that is not associated with blunted vaccine responses.
Finally, if you have not been vaccinated yet please do so as soon as possible; the benefits of COVID-19 vaccination far outweigh the risks of getting COVID-19. The delta variant vaccine breakthrough mentioned above is not a reason not to get vaccinated; vaccination is about preventing severe disease and hopefully protecting the vulnerable with herd immunity.
The following are recent MS-Selfie Newsletters that cover important information for pwMS on DMTs.
Are COVID-19 booster vaccines necessary? It is clear that the SARS-CoV-2 delta variant is a partial vaccine escape variant. This means that people with MS who have been vaccinated in the past are likely to need a booster.
COVID-19 vaccines and DMTs: What is happening to people with MS on DMTs getting vaccinated with the COVID-19 vaccines. Are they immune or not?
COVID-19 vaccination: Countering the misinformation and disinformation about vaccination in MS
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General Disclaimer: Please note that the opinions expressed here are those of Professor Giovannoni and do not necessarily reflect the positions of Barts and The London School of Medicine and Dentistry nor Barts Health NHS Trust. The advice is intended as general advice and should not be interpreted as being personal clinical advice. If you have problems please tell your own healthcare professional who will be able to help you.
I very much like the user friendly advice in the newsletter but in this instance that is somewhat tricky with school age children in the U.K. at this point in time! Particularly as my 11 year old is due to start secondary school and will be mixing with many more kids than before, and cannot access a vaccine on the current rules in the U.K.
Love the newsletter.
Question - have you heard of anyone or is there anyone here on an anti-CD20, who has been fully vaccinated but confirmed to not have had an antibody response (negative spike and nucleocapsid) who has then been infected (via a positive nucleocapsid test) asymptomatically? I know that’s a lot of conditions but I’m really curious to see if people like this exist, or does everyone without B cells and no antibodies (despite vaccination) get infected symptomatically, yet the majority of those avoid severe disease.