To get a booster or not

Barts-MS rose-tinted-odometer: ★★★ (a red-eyed Tuesday #FF0000)

I was doing a Q&A webinar with some US clinicians last night and they were asking whether or not pwMS should have a booster COVID-19 vaccine or not. The answer is simple, YES. The study below in 60+-year-old Israelis shows that people who had a booster or third dose of the Pfizer-BionTech RNA vaccine were 11.3x less likely to be infected with SARS-CoV-2 compared to people who had been double vaccinated. The more impressive finding is that severe COVID-19 was reduced by a factor of 19.5 in the boosted group compared to the non-boosted group.

The question is whether or not this study’s findings are relevant to pwMS. Of course, they are. Older people have immunosenescence which is a form of immunosuppression and hence if you have MS and are on immunosuppressive therapy you need to boost your immunity. The principles are very similar.

In the UK pwMS on immunosuppressive therapies are being called up for a third dose. Please go ahead with the booster. People on anti-CD20 therapy should be aware that if they have no B-cells in their peripheral blood they are unlikely to make an antibody response, but the booster should theoretically improve their anti-SARS-CoV-2 T-cell responses. If they want to make an antibody response they can ask their team if they can delay their next infusion to allow some B-cell reconstitution before being vaccinated. The question is whether or not this is necessary is a moot point.

Hopefully, real-life data will emerge comparing COVID-19 outcomes in pwMS who are seropositive post-vaccine with those who are seronegative. 

If you are on an S1P-modulator, such as fingolimod, you don’t really have the luxury of delaying dosing. Therefore I suggest going ahead with the booster in the hope that it works. Stopping fingolimod, and or other S1P modulators, for a vaccine is risky because of rebound disease activity.

Booster responses for all other DMTs should be fine.

Bar-On et al. Protection of BNT162b2 Vaccine Booster against Covid-19 in Israel. NEJM September 15, 2021 DOI: 10.1056/NEJMoa2114255

BACKGROUND: On July 30, 2021, the administration of a third (booster) dose of the BNT162b2 messenger RNA vaccine (Pfizer–BioNTech) was approved in Israel for persons who were 60 years of age or older and who had received a second dose of vaccine at least 5 months earlier. Data are needed regarding the effect of the booster dose on the rate of confirmed coronavirus 2019 disease (Covid-19) and the rate of severe illness.

METHODS: We extracted data for the period from July 30 through August 31, 2021, from the Israeli Ministry of Health database regarding 1,137,804 persons who were 60 years of age or older and had been fully vaccinated (i.e., had received two doses of BNT162b2) at least 5 months earlier. In the primary analysis, we compared the rate of confirmed Covid-19 and the rate of severe illness between those who had received a booster injection at least 12 days earlier (booster group) and those who had not received a booster injection (non-booster group). In a secondary analysis, we evaluated the rate of infection 4 to 6 days after the booster dose as compared with the rate at least 12 days after the booster. In all the analyses, we used Poisson regression after adjusting for possible confounding factors.

RESULTS: At least 12 days after the booster dose, the rate of confirmed infection was lower in the booster group than in the non-booster group by a factor of 11.3 (95% confidence interval [CI], 10.4 to 12.3); the rate of severe illness was lower by a factor of 19.5 (95% CI, 12.9 to 29.5). In a secondary analysis, the rate of confirmed infection at least 12 days after vaccination was lower than the rate after 4 to 6 days by a factor of 5.4 (95% CI, 4.8 to 6.1).

CONCLUSIONS: In this study involving participants who were 60 years of age or older and had received two doses of the BNT162b2 vaccine at least 5 months earlier, we found that the rates of confirmed Covid-19 and severe illness were substantially lower among those who received a booster (third) dose of the BNT162b2 vaccine.

Conflicts of Interest

MS-Selfie Newsletter  /  MS-Selfie Microsite

Preventive Neurology

Twitter   /  LinkedIn  /  Medium

General Disclaimer: Please note that the opinions expressed here are those of Professor Giovannoni and do not necessarily reflect the positions of the Barts and The London School of Medicine and Dentistry nor Barts Health NHS Trust and are not meant to be interpreted as personal clinical advice.

28 thoughts on “To get a booster or not”

  1. Now I get you can’t advise me but I am booked in for booster this Thursday
    I have grade 3 lymphopenia as lymphs at 0.25 (as at bloods July)
    Cladribine Y2 last dose in May
    (Pfizer Vaccine February )
    I am told covid antibodies have a long half life but then read elsewhere antibodies drop significantly at 6-7 months ?
    I’m gonna get the booster anyway as long as can find petrol!
    Appreciate all the support

  2. Great news thanks.
    I have advanced MS have had no Ms treatment since alemtuzumab in 2014 and have been called for my third vaccination.
    MD said that if there was a choice between Pfizer and Moderna while both very good Moderna may have a slight advantage. Apparently some centres are offering either
    I previously had two pfizer vaccinations so does it matter which I have?

    1. Not really I had three Pfizer but would have selected Moderna for the boost as it gives slightly higher antibody titre

      1. Ok MD thanks as always. Without this blog and with neurologists being on the whole impossible to contact other than during an appointment every 6-months if you’re lucky people with MS would be completely in the dark about all of this without you!

      2. Yes, thank you for posting information to help me understand this evolving life challenging situation. I am not able to get elsewhere and it allows me to have an informed consult with my Neuro.

  3. Morning, many thanks for your really informative blogs they are so helpful.

    With the booster only being given 6 months after your 2nd Covid vaccine but the 3rd dose stated by the JCVI to be given at a minimum of 8 weeks, what would you recommend is the best timing to get a 3rd dose if you’re on Ocrevus and didn’t make any antibodies to the initial vaccine course please? I had 2x Pfizer vaccines 3 weeks apart to time it with my infusion and waited 16 weeks post Ocrevus to get my 1st vaccine as recommended, but unfortunately my antibody test was negative. So I’m now wondering whether to wait the same 16 weeks post-treatment again? I don’t want to go down the route of delaying my next infusion if that’s avoidable. And also wondering whether to try & request Moderna in the hope it may increase my chances of producing antibodies?

    Is there any information at all as yet as to whether Ronapreve will potentially be offered as a preventative as well as a treatment or is this not looking likely please?

    Many thanks for your time.

    1. No idea if they will offer Ronapreve.
      Best timing looks like 9-12 months but if you dont want to delay then I would say at 5 months offers the best chance of a response

  4. Hello, will people on all DMT be called up for a booster or just those that more actively surprises the immune system.

  5. I have “PPMS”, have never been on any medication and had a very normal response to vaccination according to the temporary side effects. I don’t think I’ll be getting the booster.

    1. That is your choice…but you could get a visit from Mister COVID-19 and if you have disability you are more at risk from a more severe course

  6. Are people on fingolimod likely to make a response after the booster if they haven’t seroconverted after the first 2 vaccinations? Does it make sense for them to pause their DMT for 3-4 days only before/after the booster? Such a short period of time wouldn’t cause rebound activity, would it?

    1. This is a fantastic question and one that I dont have an answer for
      A pause of 3-4 days is not going to cause rebound, but it may not make much of a difference with fingolimod because it has a half life of 6-9 days and can take months to leave the system.

  7. RESULTS: At least 12 days after the booster dose, the rate of confirmed infection was lower in the booster group

    Would the results old up 6 ,months 7 months or one 1 year after the booster?

    Should we boost every year?

    I remmeber Shane Crotty saying that those t cell need a break from antigen exposure


  8. Moderne is working on a flu/COVID vaccine in one shot. It seems logical to combine an annual flu shot with a COVID booster. What do you think?

  9. I’m not currently on any DMT.

    I do have Graves disease following alemtuzumab which I know can affect liver enzymes and my endocrinologist is not too concerned about the levels however I have never had liver enzyme issues before the vaccination and I’m now concerned about having the booster

  10. Good afternoon, i was hoping you can help. I am taking beta interferon avonex and need some help re the third vaccination or booster…I understand that anyone on any meds for MS needs 3 vaccines and a top u booster, is that correct?
    Secondly is there a difference between the booster and third vaccination, ie the amount of vaccination being administered? Speculation is that the booster is a smaller dose so I’m confused as what to have as my GP doesn’t know and the MS team aren’t being clear….
    Lastly how do I get my 4th vaccination/booster after having a third, do I advise the practice or do they write to me??? What is the protocol from MS clinics …. Also is there a way of testing antibody response because I can’t work without some understanding of how the vaccination has worked for me due to the nature of my job…

    Thank you in advance for your assistance

    1. iFN are not immunosuppressive although an argument can be made.The booster is given 6 months after dose 2 the third dose it is addressed number of weeks after dose 2. The amount given will be same for Pfizer not sure about moderna they have a smaller booster dose.
      .no mention of Forth booster dose but would be more than 6 months after dose 3

      If offered third dose booster take it as it means your protection will be better

Leave a Reply

%d bloggers like this: