COVID-19 outcomes in MS: Observational study of early experience from NYU Multiple Sclerosis Comprehensive Care Center

Coronavirus disease 2019 infection among working-aged people with multiple sclerosis and the impact of disease-modifying therapies

Background

The risk of coronavirus disease 2019 among people with multiple sclerosis with different disease-modifying therapies is not well established.

Objective

To investigate the occurrence of coronavirus disease 2019 and the remaining symptoms among people with multiple sclerosis and the associations with different disease-modifying therapies.

Methods

Individuals aged 20-50 listed in the Swedish Multiple Sclerosis Registry were invited to participate in a survey in 2021. Information on reported coronavirus disease 2019 infection and remaining symptoms were linked to individual-level register data. The risks by disease-modifying therapy of having coronavirus disease 2019 or having remaining symptoms were estimated with logistic regression.

Results

Of the 4393 participants, 1030 (23.4%) self-reported coronavirus disease 2019 (749 confirmed and 281 suspected). The observed odds for coronavirus disease 2019 did not differ by disease-modifying therapy (p-values <0.05). The majority reporting coronavirus disease 2019 had fully recovered (68.5%), 4.2% were currently/recently sick, and 27.0% had symptoms remaining after 2 months. The most frequently reported remaining symptoms involved one's sense of smell or taste (37.0%), fatigue (20.0%), and breathing (12.0%). No statistically significant associations were observed between having remaining symptoms and the disease-modifying therapy.

Conclusion

Despite the initial concerns of differing infection risks by MS treatments, we observed no differences in coronavirus disease 2019 occurrence or remaining symptoms among those who had coronavirus disease 2019. Nonetheless, exercising caution in interpreting our findings, it remains implicit that people with multiple sclerosis are particularly susceptible to infection and that lingering symptoms may persist beyond the initial infection.

COVID-19 outcomes in patients with multiple sclerosis: Understanding changes from 2020 to 2022

BACKGROUND

Epidemiologic studies on coronavirus disease 2019 (COVID-19) in patients with multiple sclerosis (pwMS) have focused on the first waves of the pandemic until early 2021.

OBJECTIVES

We aimed to extend these data from the onset of the pandemic to the global coverage by vaccination in summer 2022.

METHODS

This retrospective, multicenter observational study analyzed COVISEP registry data on reported COVID-19 cases in pwMS between January 2020 and July 2022. Severe COVID-19 was defined as hospitalization or higher severity.

RESULTS

Among 2584 pwMS with confirmed/highly suspected COVID-19, severe infection rates declined from 14.6% preomicron wave to 5.7% during omicron wave (p < 0.001). Multivariate analysis identified age (odds ratio (OR) = 1.43, 95% confidence interval (CI) = [1.25-1.64] per 10 years), male sex (OR = 2.01, 95% CI = [1.51-2.67]), obesity (OR = 2.36, 95% CI = [1.52-3.68]), cardiac comorbidities (OR = 2.36, 95% CI = [1.46-3.83]), higher Expanded Disability Status Scale (EDSS) scores (OR = 2.09, 95% CI = [1.43-3.06] for EDSS 3-5.5 and OR = 4.53, 95% CI = [3.04-6.75] for EDSS ⩾6), and anti-CD20 therapies (OR = 2.67, 95% CI = [1.85-3.87]) as risk factors for COVID-19 severity. Vaccinated individuals experienced less severe COVID-19, whether on (risk ratio (RR) = 0.64, 95% CI = [0.60-0.69]) or off (RR = 0.32, 95% CI = [0.30-0.33]) anti-CD20.

DISCUSSION

In pwMS, consistent risk factors were anti-CD20 therapies and neurological disability, emerging as vital drivers of COVID-19 severity regardless of wave, period, or vaccination status.

Era of COVID-19 in Multiple Sclerosis Care

The unprecedented scope of the coronavirus disease 2019 (COVID-19) pandemic resulted in numerous disruptions to daily life, including for people with multiple sclerosis (PwMS). This article reviews how disruptions in multiple sclerosis (MS) care prompted innovations in delivery of care (eg, via telemedicine) and mobilized the global MS community to rapidly adopt safe and effective practices. We discuss how our understanding of the risks of COVID-19 in PwMS has evolved along with recommendations pertaining to disease-modifying therapies and vaccines. With lessons learned during the COVID-19 pandemic, we examine potential questions for future research in this new era of MS care.

Risk Factors and Clinical Outcomes of COVID-19 Infection in Multiple Sclerosis Patients: A Retrospective Study from a Single Center in Kosovo

BACKGROUND Multiple sclerosis (MS) is treated with disease-modifying therapies (DMTs) that can increase susceptibility to viral infections. This retrospective study aimed to evaluate the presentation, management, and outcomes of patients with MS on DMTs admitted with symptoms of COVID-19 to a single center in Prishtina, Kosovo between March 2020 and April 2022. MATERIAL AND METHODS In this observational, single-center study, we included 282 patients with MS (mean age 37.8±11, 64.9% females), of whom 272 (96.4%) had confirmed COVID-19 infection, either through the presence of antibodies in the serum or a positive PCR test. RESULTS Most patients with COVID-19 infection were either asymptomatic or mildly symptomatic, while 11 patients were hospitalized due to moderate to severe symptoms. Among those with severe infection, 2 patients have died. Patients with moderate and severe COVID-19 had more advanced MS disease (P=0.001) and higher disability scales (P<0.001). In a logistic regression analysis, advanced MS remained significantly associated with worse symptoms, even after adjusting for other risk factors, with a relative risk (RR) of 2.8 (95% CI=1.1-6.6, P=0.018). MS patients on anti-CD20 DMTs more frequently experienced moderate and severe symptoms (RR=2.1, 95% CI=1.1-4.0, P=0.012). Anti-SARS-CoV-2 IgG was also lower in patients treated with anti-CD20. Notably, patients receiving vitamin D supplementation experienced a lower frequency of moderate to severe symptoms (P=0.007). CONCLUSIONS Patients with advanced MS exhibiting higher disability scales and those on anti-CD20 therapy faced an increased risk of experiencing more pronounced symptoms after COVID-19 infection. Patients on vitamin D supplementation had better clinical outcomes.

COVID-19 Vaccination and Disease Course in People with Multiple Sclerosis in Greece

Over the past three years, humanity faced the abrupt spread of COVID-19, responsible for a worldwide health crisis. Initially, it was believed that individuals with chronic disorders, including multiple sclerosis, were more likely to be infected and suffer a worse degree of COVID-19 disease. Therefore, data with regard to COVID-19 disease outcomes in these populations may provide additional insight with regard to the management of chronic diseases during viral pandemics. The objective of this study is to evaluate COVID-19 disease course in people with multiple sclerosis (PwMS) during the COVID-19 pandemic in Greece and explore the impact of vaccination in the outcome of SARS-CoV-2 infection in this population. Anonymized data, extracted from nationwide administrative records between February 2020 and December 2021, were retrospectively analyzed in order to identify PwMS with SARS-CoV-2 infection. Demographic data, as well as data regarding COVID-19 infection and vaccination, were additionally collected. The study sample included 2351 PwMS (65.1% females, 51.2% unvaccinated at the time of infection). A total of 260 PwMS were hospitalized, while 25 PwMS died from COVID-19 disease and its complications. Older age, male sex and the presence of comorbidities were independently associated with a higher probability of hospitalization. The risk of hospitalization was decreased in PwMS receiving some disease-modifying treatments. Anti-CD20s demonstrated high odds ratios without reaching statistical significance. Regarding fatal outcome, only age reached statistical significance. Vaccination provided a significant protective effect against hospitalization but did not exhibit a statistically significant effect on mortality.

COVID-19: The Course, Vaccination and Immune Response in People with Multiple Sclerosis: Systematic Review

When the Coronavirus Disease 2019 (COVID-19) appeared, it was unknown what impact it would have on the condition of patients with autoimmunological disorders. Attention was focused on the course of infection in patients suffering from multiple sclerosis (MS), specially treated with disease-modifying therapies (DMTs) or glucocorticoids. The impact of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection on the occurrence of MS relapses or pseudo-relapses was important. This review focuses on the risk, symptoms, course, and mortality of COVID-19 as well as immune response to vaccinations against COVID-19 in patients with MS (PwMS). We searched the PubMed database according to specific criteria. PwMS have the risk of infection, hospitalization, symptoms, and mortality due to COVID-19, mostly similar to the general population. The presence of comorbidities, male sex, a higher degree of disability, and older age increase the frequency and severity of the COVID-19 course in PwMS. For example, it was reported that anti-CD20 therapy is probably associated with an increased risk of severe COVID-19 outcomes. After SARS-CoV-2 infection or vaccination, MS patients acquire humoral and cellular immunity, but the degree of immune response depends on applied DMTs. Additional studies are necessary to corroborate these findings. However, indisputably, some PwMS need special attention within the context of COVID-19.

COVID-19 and Health Outcomes in People with Multiple Sclerosis: A Population-Based Study in Italy

People with multiple sclerosis (PWMS) are at high risk of being affected by the disruption of health services that occurred during the COVID-19 pandemic months. The aim of this study was to evaluate the effect of the pandemic on the health outcomes of PWMS. PWMS and MS-free residing in Piedmont (north-west of Italy) were identified from electronic health records and linked with the regional COVID-19 database, the hospital-discharge database, and the population registry. Both cohorts (9333 PWMS and 4,145,856 MS-free persons) were followed-up for access to swab testing, hospitalisation, access to the Intensive Care Unit (ICU), and death from 22 February 2020 to 30 April 2021. The relationship between the outcomes and MS was evaluated using a logistic model, which was adjusted for potential confounders. The rate of swab testing was higher in PWMS, but the positivity to infection was similar to that of MS-free subjects. PWMS had a higher risk of hospitalisation (OR = 1.74; 95% IC, 1.41-2.14), admission to ICU (OR = 1.79; 95% IC, 1.17-2.72), and a slight, albeit not statistically significant, increase in mortality (OR = 1.28; 95% IC, 0.79-2.06). Compared to the general population PWMS with COVID-19 had an increased risk of hospitalization and admission to the ICU; the mortality rate did not differ.

Prevalence and Mortality Risk of Neurological Disorders during the COVID-19 Pandemic: An Umbrella Review of the Current Evidence

INTRODUCTION

Coronavirus disease 2019 (COVID-19), a global pandemic, has infected approximately 10% of the world's population. This comprehensive review aimed to determine the prevalence of various neurological disorders in COVID-19 without overlapping meta-analysis errors.

METHODS

We searched for meta-analyses on neurological disorders following COVID-19 published up to March 14, 2023. We obtained 1,184 studies, of which 44 meta-analyses involving 9,228,588 COVID-19 patients were finally included. After confirming the forest plot of each study and removing overlapping individual studies, a re-meta-analysis was performed using the random-effects model.

RESULTS

The summarized combined prevalence of each neurological disorder is as follows: stroke 3.39% (95% confidence interval, 1.50-5.27), dementia 6.41% (1.36-11.46), multiple sclerosis 4.00% (2.50-5.00), epilepsy 5.36% (-0.60-11.32), Parkinson's disease 0.67% (-1.11-2.45), encephalitis 0.66% (-0.44-1.77), and Guillain-Barré syndrome 3.83% (-0.13-7.80). In addition, the mortality risk of patients with comorbidities of COVID-19 is as follows: stroke OR 1.63 (1.23-2.03), epilepsy OR 1.71 (1.00-2.42), dementia OR 1.90 (1.31-2.48), Parkinson's disease OR 3.94 (-2.12-10.01).

CONCLUSION

Our results show that the prevalence and mortality risk may increase in some neurological diseases during the COVID-19 pandemic. Future studies should elucidate the precise mechanisms for the link between COVID-19 and neurological diseases, determine which patient characteristics predispose them to neurological diseases, and consider potential global patient management.

Outcome of COVID-19 Infection in Patients With Multiple Sclerosis Who Received Disease-Modifying Therapies: A Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE

A systematic review and meta-analysis was performed of the outcome of Coronavirus disease 2019 (COVID-19) infection in patients with multiple sclerosis (MS) who received disease-modifying therapies (DMTs).

METHODS

Relevant studies published before November 2022 in the PubMed, Cochrane Library, Chinese National Knowledge Infrastructure, and Web of Science databases were retrieved using the following search expression: ("multiple sclerosis" OR "MS") AND ("DMT" OR "disease modifying therapies") AND ("COVID-19"). Two authors independently screened the articles and extracted the data. Qualitative analyses and a meta-analysis constituted 22 of the 794 retrieved articles. Differences in the hospitalization and mortality rates were used as the main measures of efficacy, and the meta-analysis was performed using RevMan software.

RESULTS

22 clinical trials were selected. The hospitalization rate was lower in the 3,216 patients who received DMTs than in the 774 patients who did not receive any treatment, with a moderate effect size of 0.43 (p<0.00001). The mortality rate was also lower among patients with MS treated using DMTs than in controls (odds ratio [OR]=0.19, 95% confidence interval [CI]=0.13-0.27, p<0.00001). The hospitalization rates for COVID-19 infection in patients with MS treated with anti-CD20 therapy also increased markedly (OR=3.32, 95% CI=2.63-4.20, p<0.00001). However, there was no significant difference between patients with MS who did and did not receive DMTs.

CONCLUSIONS

In summary, the application of DMTs was found to be valuable for patients with MS infected with COVID-19. However, more clinical studies are needed to determine the use of anti-CD20 drugs in patients with MS during the COVID-19 pandemic.

Humoral immune response following SARS-CoV-2 mRNA vaccination and infection in pediatric-onset multiple sclerosis

Objective

Currently, there is no data available on SARS-CoV-2 vaccine responses in pediatric-onset multiple sclerosis (POMS) and little is known about the course of SARS-CoV-2 infection in this age group. We therefore investigated humoral immune responses after Covid-19 vaccination and/or infection in POMS.

Methods

We retrospectively analyzed seroconversion rates and SARS-CoV-2 specific antibody levels in 30 POMS and 1 pediatric CIS patient treated with either no disease-modifying therapy (no DMT), immunomodulatory DMT (IM-DMT), or immunosuppressive DMT (IS-DMT) from two Austrian MS centers.

Results

Median age at MS onset was 15.39 years (IQR 1.97). Median age at first COVID-19 vaccination was 17.43 years (IQR 2.76). After two vaccine doses, seroconversion (≥0.8 BAU/ml) was reached in 25/28 patients (89.3%). All patients with no DMT or IM-DMT generated robust immune responses to vaccination (seroconversion: no DMT: 6/6, IM-DMT: 7/7 (100%); median titers: no DMT: 2075 BAU (IQR 1268.50), IM-DMT: 2500 BAU (IQR 0)). In the IS-DMT group seroconversion was achieved in 12/14 patients (80%), median titers were 50.8 BAU (IQR 254.63). Titers were significantly higher in no DMT versus IS-DMT (p=0.012) and in IM-DMT versus IS-DMT (p=0.001). Infection with SARS-CoV-2 occurred in 11 of 31 patients and symptoms were mild in all cases. One relapse occurred after infection, but no relapses were documented after vaccination.

Conclusions

Generally, mRNA vaccinations were well tolerated in POMS patients with and without DMT. Immune response was significantly reduced in patients treated with IS-DMT. No unexpected adverse events or relapses related to vaccinations were observed.

Serology results after COVID vaccine in multiple sclerosis patients treated with fingolimod

INTRODUCTION

While it is recommended that patients with multiple sclerosis (MS) be vaccinated against COVID-19, it is unknown what the vaccine response is in MS patients treated with fingolimod, an agent which modulates the humoral response. We aimed to characterize the immune response to the COVID-19 vaccine in MS patients treated with fingolimod and to explore which factors influenced response.

METHOD

We collected the following data from 59 MS patients treated with fingolimod and vaccinated against COVID-19: age, sex, duration of treatment, number of vaccine doses, date of last vaccination, type of vaccine, lymphocyte count, history of COVID-19, and serology to measure the vaccine response. We used Student's t-test and Chi² test to see whether there was a relationship between these variables and seropositivity. A multivariate logistic regression model was used to identify factors influencing the serology result. A multivariate linear regression model was used to identify factors influencing the antibody titer.

RESULTS

Twenty-eight participants (47%) developed a positive serology. Age (P<0.001) and the duration of treatment (P=0.002) were significantly related to seropositivity. Gender (P=0.73), number of vaccinations (P=0.78), lymphocyte count (P=0.46), and the time between the last vaccine dose and blood sampling (P=0.84) were not significant variables. Multivariate analysis using logistic regression (n=59) showed that age (P=0.003, RR = 2.28, 95%CI = 1.28, 4.07) and duration of treatment (P=0.04, RR=1.91, 95%CI=1.04, 3.50) were significantly and independently correlated with COVID serology. Multivariate linear regression analysis of the antibody titer (n=59) found the duration of treatment to be significant (P = 0.015), but not age (P = 0.53). After removing three outliers, age (P = 0.005, RR=6.82, 95%CI=1.66, 27.98) and duration of treatment (P = 0.008, RR=5.12, 95%CI=1.24, 21.03) were significantly correlated with the antibody titer.

CONCLUSION

COVID-19 seropositivity was present in 47% of our sample of 59 MS patients on fingolimod. A strong relationship was found between antibody development, age, and duration of treatment, as well as between antibody titer and age and duration of treatment.

Multiple Sclerosis Patients’ COVID-19 Catching Ratios and Disease Profiles

Objective: For a long time ımmunomodulatory / immunosuppressive drugs are used to slow the progression of multiple sclerosis (MS). These treatments are known to suppress the immune system and create susceptibility to infections. In our study, it was aimed to evaluate whether MS patients who received immunomodulatory / immunosuppressive treatments in the current coronavirus disease 2019 (COVID-19) pandemic, negatively affect them in terms of disease severity, frequency and psychological outcomes. Methods: Participants consist of MS patients who acquired COVID-19 (group 1) aged 18-65, using disease modifying treatments (DMT) with follow-up in neurology outpatient clinic, and the other two groups consist of similar age and gender. One of the other two groups is MS patients who have not had COVID-19 (group 2), the other group consisted of patients who had COVID-19 and did not have MS (group 3). MS profile, coronavirus anxiety scale (CAS) and Beck depression inventory (BDI) scales between groups 1 and 2; COVID-19 profile between groups 1 and 3 compared. Results: As a result of comparing the MS disease profile of the 1st and 2nd groups and in terms of the COVID-19 disease profile of the 1st and 3rd groups, there was no statistically significant difference in these paired comparison groups (p> 0.05). Conclusion: İt was concluded that DMT use does not increase the severity of COVID-19 and acquiring COVID-19 did not affect the psychiatric outcomes in MS patients, since no statistically significant difference was observed in 2 MS group and 2 COVID-19 group comparison

Multiple sclerosis and COVID-19: Assessing risk perception, patient behaviors and access to disease-modifying therapies

BACKGROUND

Following the outbreak of COVID-19, global healthcare systems have had to rapidly adapt. People with multiple sclerosis (pwMS) were required to make decisions about their individual risk and consequent work and social behaviors. This study aimed to evaluate risk perception and patterns of shielding behavior amongst pwMS at the onset of the COVID-19 pandemic and the subsequent impact on patients' employment and access to disease modifying therapies (DMTs).

METHODS

Postal surveys were sent to 1690 people within a UK population-based MS cohort during the first wave of the COVID-19 pandemic. Patients were surveyed on: (i) perceived vulnerability to COVID-19; (ii) isolation behavior; (iii) interruption to DMT; (iv) employment status; (v) level of satisfaction with their current working arrangement.

RESULTS

Responses were received from 1000 pwMS. Two thirds of patients reported isolating at home during the first wave of the pandemic. This behavior was associated with increased age (p<0.0001), higher disability (p<0.0001) and use of high-efficacy DMTs (p = 0.02). The majority of patients reported feeling vulnerable (82%) with perceived vulnerability associated with higher EDSS (p<0.0001) and receiving a high-efficacy DMT (p = 0.04). Clinician-defined risk was associated with shielding behavior, with those at high-risk more likely to self-isolate/shield (p<0.0001). Patients on high-efficacy DMTs were more likely to have an interruption to their treatment (50%) during the first wave of the pandemic. Most pwMS experienced a change to their working environment, and most were satisfied with the adjustments.

CONCLUSION

This study highlights the risk perception, social behavioral practices and changes to treatment experienced by pwMS during the first wave of the COVID-19 pandemic in a large, well-described UK cohort. The results may help inform management of pwMS during future pandemic waves.

Multiple sclerosis patients’ response to COVID-19 pandemic and vaccination in Egypt

Background

On 11 March 2020, WHO declared COVID-19 has become a pandemic. This had an impact on everyday activity for every person. For special groups such as multiple sclerosis patients, the situation is a little bit confusing. In this study, COVID-19 infection impact on MS patients, willingness for vaccination, percentage of vaccinated patients and adverse effects of different vaccines were investigated. This cross-sectional descriptive study included 160 Egyptian MS patients. Demographic and clinical characteristics of all patients were extracted from their files MS unit archives. All these patients were contacted either by telephone and an oral informed consent was taken or in-person on their scheduled follow-up and informed written consent was taken to join this study. Patients were asked about: COVID-19 infection, severity of infection, and vaccination using a special questionnaire developed by the authors.

Results

Only 39 (24.3%) patients have had COVID-19 infection with confirmed diagnosis. Most of infected patients (84.6%) were treated at home with no need for hospital admission. Five patients (12.8%) reported symptom suggestive of relapses after COVID-19 infection. Sixty-five patients (40.6%) were vaccinated against COVID-19. Out of these vaccinated patients, 22 patients (33%) developed adverse events from vaccine. These adverse events were self-limiting and related to local injection site and general manifestations. MS relapse after vaccination was reported in 7.7% of the vaccinated group.

Conclusion

Prevalence of COVID-19 infection and severity of infection were equal to general population. Risk of relapse is low either with infection or vaccination. No severe adverse events were reported after vaccination.

Risk and prognostic factors for SARS-CoV-2 infection in Spanish population with multiple sclerosis during the first five waves

Background

Data on coronavirus disease 2019 (COVID-19) incidence in patients with multiple sclerosis (MS) during the first wave have been published but are scarce for the remaining waves. Factors associated with COVID-19 infection of any grade are also poorly known. The aim of this study was to analyze the incidence, clinical features, and risk factors for COVID-19 infection of any grade in patients with MS (pwMS) during waves 1–5.

Methods

This study prospectively analyzes the cumulative incidence of COVID-19 from the first to the fifth waves by periodic case ascertainment in pwMS followed at the University Hospital of Getafe (UHG). Global and stratified cumulative incidence was calculated. Logistic regression models were used to estimate the weight of selected variables as risk and prognostic factors.

Results

We included 431 pwMS, of whom 86 (20%) were infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The overall cumulative incidence of confirmed cases was similar to that of Madrid (13,689 vs. 13,307 per 100,000 habitants) but 3 times higher during the first wave and slightly lower from the second to the fifth waves. The majority (86%) of pwMS developed mild forms of COVID-19. Smoking was the only factor associated with a decreased risk of SARS-CoV2 infection of any grade [odds ratio (OR) 0.491; 95% CI 0.275–0.878; p = 0.017]. Risk factors associated with severe forms were Expanded Disability Severity Scale (EDSS) ≥3.5 (OR 7.569; 95% CI 1.234–46.440) and pulmonary disease (OR 10.763; 95% CI 1.27–91.254).

Conclusion

The incidence of COVID-19 was similar in this MS cohort to the general population. Smoking halved the risk of being infected. Higher EDSS and pulmonary comorbidity were associated with an increased risk of severe forms.

Exacerbation of Pre-existing Neurological Symptoms With COVID-19 in Patients With Chronic Neurological Diseases: An Updated Systematic Review

The neurotropism of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can potentially explain the worsening of symptoms in patients with a history of neurological conditions such as stroke, Parkinson's disease, Alzheimer's, and epilepsy. Several studies have reported that these pre-existing conditions may worsen with a higher frequency of flare-ups, thus resulting in a more significant risk of patient mortality. In this review, we sought to provide an overview of the relationship between pre-existing neurological disorders and COVID-19, focusing on whether the initial infection directly influenced the severity of symptoms. We systematically searched the electronic database PubMed (MEDLINE) and used specific keywords related to our aims from January 2020 to July 2022. All articles published on COVID-19 with keywords pertaining to pre-existing neurological diseases were retrieved and subsequently analyzed. After independent review, the data from 107 articles were selected and evaluated. After analyzing the data from selected articles reviewing the effect of COVID-19 on neurological conditions, we have documented the relationship between said pre-existing neurological diseases, showing an increased risk of hospitalization, admission length, worsening of symptoms, and even mortality in COVID-19 patients.

Impact of Covid-19 emergency on rehabilitation services for Multiple Sclerosis: An international RIMS survey

Background

Covid-19 pandemic greatly impacted on the healthcare systems worldwide with negative consequences on several aspects of clinical populations. For neurological chronic conditions such as Multiple Sclerosis (MS), rehabilitation activities have been suspended or postponed during the pandemic. Rehabilitation is crucial for people with MS (PwMS) because it promotes recovery from relapses and maximizes opportunities for social participation. To better understand the impact of Covid-19 emergency on rehabilitation services for MS, the European network for rehabilitation in MS (RIMS) disseminated a survey to healthcare professionals (HPs) and representatives of the MS rehabilitation services (RSs), to explore the two different perspectives on the delivery of rehabilitation in usual circumstances and during the Covid-19 emergency.

Methods

The online survey was distributed from July 9th to September 20th, 2020. Besides general information on the responders (e.g. location of center, and memebership to RIMS), information was collected on usual service delivery (e.g. settings, specialities, and types of treatment), the impact of Covid-19 circumstances (e.g. restrictions, use of personal protective equipment, and impact on work), and the use of technologiesin rehabilitation.

Results

Twenty-two representatives of MS rehabilitation services (RSs)and 143 health care professionals (HPs) responded. Most of RSs and HPs worked in services specialized for MS including a mixture of all usual rehabilitation settings (i.e. inpatient, outpatient and community setting). The majority of services adopted a multidisciplinary framework, including physical therapy, occupational therapy, social service, speech and language therapy, psychological support, dietary interventions, medical management, vocational rehabilitation and cognitive rehabilitaton. Overall, most of responders indicated they did not use technologies in their practice (e.g. for treatment or assessment). However, depending on the type of technology a low-to-medium percentage of responders declared to use some technologies before Covid-19 crisis (5-55% for RSs and 12-53% for HPs) and a low percentage planned the use after pandemic (0-14% for RSs and 1-10% for HPs). Moreover, for the responders the most feasible interventions deliverable through tele-rehabilitation were psychological support and dietary interventions, with psychological support considered the most necessary intervention to be remotely implemented. Moderate feasibility (30-60%) was reported for hands-off interventions (e.g. aerobic exercise and cognitive rehabilitation) whereas low feasibility (<30%) was reported for hands-on interventions. Feasibility was especially low when tools were used that are not adaptable at-home (e.g. hyperbaric oxygen therapy).

Conclusion

The Covid-19 pandemic has stimulated the MS healthcare professionals to find new solutions to deliver alternative interventions to PwMS. In this context, the role of telemedicine is crucial to continue rehabilitation services at home, and limit exposure to infection. However, most of healthcare professionals have not incorporated the use of technologies. Therefore, the implementation of digital health solutions in the clinical practice needs more attention towards education on the potentials of technologies for rehabilitation and simplification of the national healthcare system reimbursement procedures for the rehabilitation technologies use.

The Outcome of COVID-19 in Pediatric-Onset Multiple Sclerosis Patients

BACKGROUND

The pathogenesis of multiple sclerosis (MS) involves immune-mediated mechanisms, and disease-modifying therapies (DMTs) administered in MS have immunomodulatory effects. The concern about MS patients' susceptibility to coronavirus disease 2019 (COVID-19) has prompted several studies based on clinical observations and questionnaires. Information about COVID-19 in pediatric-onset multiple sclerosis (POMS) is scarce. The objective of this study was to collect information on the experience of POMS patients with COVID-19 during the pandemic.

METHODS

This cross-sectional study was conducted with POMS patients diagnosed at Hacettepe University Pediatric Neurology Department and under 23 years of age between October 1 and December 31, 2021. Those who experienced COVID-19 or had a history of contact and were found seropositive for COVID-19 were evaluated for the severity of COVID-19, disability, treatment status, and comorbidities.

RESULTS

Among the 101 POMS patients, 13 reported having had COVID-19 and five were exposed and seropositive but clinically asymptomatic. Of these 18 patients, 14 were ≤18 years of age at the time of the study. All 13 patients (72%) reported mild symptoms without hospitalization or respiratory support. Four of 18 had a neurological disability (Expanded Disability Status Scale [EDSS] scores ranging between 1 and 7.5), while the remaining had a score of 0. The outcome of COVID-19 was not affected by DMTs, neurological disabilities, and comorbidities.

CONCLUSIONS

In this single-center POMS series, the small subgroup of patients who had contacted the SARS-CoV-2 virus or developed COVID-19 had reported no or mild symptoms. This may be partly related to the infrequent use of rituximab in this group. Our results corroborate those in adult-onset MS where no increased risk is reported for patients whose EDSS scores are <6 and who are not on B cell-depleting DMTs. Although less frequently than in adult MS, immunosuppressive DMTs may be needed in POMS; therefore, the importance of appropriate vaccination is to be underlined.

Immune response to SARS-CoV-2 vaccination in relation to peripheral immune cell profiles among patients with multiple sclerosis receiving ocrelizumab

BACKGROUND

Vaccination has proven to be effective in preventing SARS-CoV-2 transmission and severe disease courses. However, immunocompromised patients have not been included in clinical trials and real-world clinical data point to an attenuated immune response to SARS-CoV-2 vaccines among patients with multiple sclerosis (MS) receiving immunomodulatory therapies.

METHODS

We performed a retrospective study including 59 ocrelizumab (OCR)-treated patients with MS who received SARS-CoV-2 vaccination. Anti-SARS-CoV-2-antibody titres, routine blood parameters and peripheral immune cell profiles were measured prior to the first (baseline) and at a median of 4 weeks after the second vaccine dose (follow-up). Moreover, the SARS-CoV-2-specific T cell response and peripheral B cell subsets were analysed at follow-up. Finally, vaccination-related adverse events were assessed.

RESULTS

After vaccination, we found anti-SARS-CoV-2(S) antibodies in 27.1% and a SARS-CoV-2-specific T cell response in 92.7% of MS cases. T cell-mediated interferon (IFN)-γ release was more pronounced in patients without anti-SARS-CoV-2(S) antibodies. Antibody titres positively correlated with peripheral B cell counts, time since last infusion and total IgM levels. They negatively correlated with the number of previous infusion cycles. Peripheral plasma cells were increased in antibody-positive patients. A positive correlation between T cell response and peripheral lymphocyte counts was observed. Moreover, IFN-γ release was negatively correlated with the time since the last infusion.

CONCLUSION

In OCR-treated patients with MS, the humoral immune response to SARS-CoV-2 vaccination is attenuated while the T cell response is preserved. However, it is still unclear whether T or B cell-mediated immunity is required for effective clinical protection. Nonetheless, given the long-lasting clinical effects of OCR, monitoring of peripheral B cell counts could facilitate individualised treatment regimens and might be used to identify the optimal time to vaccinate.

SARS-CoV-2 infection in multiple sclerosis patients: interaction with treatments, adjuvant therapies, and vaccines against COVID-19

The SARS-CoV-2 pandemic has raised particular concern for people with Multiple Sclerosis, as these people are believed to be at increased risk of infection, especially those being treated with disease-modifying therapies. Therefore, the objective of this review was to describe how COVID-19 affects people who suffer from Multiple Sclerosis, evaluating the risk they have of suffering an infection by this virus, according to the therapy to which they are subjected as well as the immune response of these patients both to infection and vaccines and the neurological consequences that the virus can have in the long term. The results regarding the increased risk of infection due to treatment are contradictory. B-cell depletion therapies may cause patients to have a lower probability of generating a detectable neutralizing antibody titer. However, more studies are needed to help understand how this virus works, paying special attention to long COVID and the neurological symptoms that it causes.

Multiple sclerosis and the risk of infection: Association of British Neurologists consensus guideline

Infection in people with multiple sclerosis (MS) is of major concern, particularly for those receiving disease-modifying therapies. This article explores the risk of infection in people with MS and provides guidance-developed by Delphi consensus by specialists involved in their management-on how to screen for, prevent and manage infection in this population.

SARS-CoV-2 infection in patients with neuroimmunological disorders in a tertiary referral centre from the north of Portugal

Introduction

The impact of COVID-19 in patients with neuroimmunological disorders is not fully established. There is some evidence suggesting an increased risk of more severe infection associated with the use of immunosuppressors in this population.

Objective

To characterize SARS-CoV-2 infection in patients followed in the neuroimmunology outpatient clinic of a tertiary centre from the north of Portugal.

Methods

Retrospective analysis of neuroimmunological patients with PCR-proven SARS-CoV-2 infection during the observational period of 20 months.

Results

Ninety-one patients were infected, 68.1% female, with a mean age of 48.9±16.7 years. The median disease duration was 11.0 (IQR 6.0-19.0) years. Sixty-one patients (67.0%) had Multiple Sclerosis, of which 50 with relapsing-remitting course, 12 (13.2%) Myasthenia Gravis (MG), 6 (6.6%) Autoimmune Encephalitis and 6 (6.6%) Chronic Inflammatory Demyelinating Polyneuropathy. Seventy-six patients (83.5%) were taking disease-modifying therapy, 77.6% of which were on immunosuppressants, including anti-CD20 in 12 (13.2%). Most patients had mild COVID-19 (84.6%), with 3 cases (3.3%) of severe disease and, 7 cases (7.7%) of critical disease being reported. In total, 13 patients were hospitalized and 4 died. Patients with severe to critical disease were significantly older than patients with milder forms (69.4±21.0 versus 46.5±14.4 years, p<0.01). MG was also associated with more severe disease (p=0.02). There was no association between comorbidities or use of immunosuppressors (including anti-CD20) and COVID-19 severity.

Conclusions

Greater age and MG were associated with severe or critical COVID-19. We found no association between a specific DMT, including anti-CD20, and outcome. Clinical recovery was achieved by 93.4%.

COVID-19 infection and vaccination against COVID- 19: Impact on managing demyelinating CNS disorders in Southern India- Experience from a demyelinating disease registry

Background and objective

The impact of COVID-19 infection and the effect of COVID-19 vaccinations on patients with demyelinating central nervous system disease in low middle income countries (LMIC's) have not been reported in detail earlier. We sought to identify risk factors associated with COVID-19 infection and the role of vaccination in order to develop management guidelines relevant to our patients.

Methods

A total of 621 patients from our registry that included 297 MS and 324 non MS disorders (Aquaporin- 4 antibody positive [50], Myelin oligodendrocyte glycoprotein antibody positive [81], seronegative [162] and clinically isolated syndrome [31]) were contacted. COVID-19 infection and vaccination status were queried. Patients who self reported COVID-19 infection based on a positive RT PCR report were compared with non infected patients to identify factors associated with susceptibility for COVID-19 infection. Univariate and multivariate analysis of potential risk factors included demographic and clinical features, body mass index (BMI), presence of comorbidities, absolute lymphocyte count, treatment types and vaccination status.

Results

Sixty seven patients with MS and 27 with non MS disorders developed COVID-19 infection. Among them 81 patients had mild infection and remained quarantined at home. All 13 patients who needed hospitalization recovered. Vaccination status was known in 582 patients among whom 69.8% had completed or taken one dose of vaccine at the time of inquiry. Majority of treated patients (61.3%) were on nonspecific immunosuppressants. In univariate analysis, presence of ≥1 comorbidity was significantly associated with COVID-19 infection in both MS (p value 0.01, OR-2.28, 95%CI- 1.18–4.4) and non MS patients (p- 0.001, OR-4.4, 95% CI-1.88–10.24). In the latter, BMI ≥ 30 (p-0.04, OR-3.27, 95% CI- 0.98–10.87) and EDSS score ≥ 3 (p-0.02, OR- 2.59,95% CI- 1.08–6.23) were other significant associations. History of prior COVID-19 vaccination was associated with reduced frequency of COVID-19 infection among MS (p- 0.001,OR- 0.24,95% CI- 0.13–0.43) and non MS patients (p- 0.0001,OR-0.14, 95% CI- 0.058–0.35). In multivariate analysis presence of comorbidities significantly increased and prior vaccination significantly reduced frequency of COVID-19 infection for both MS and related disorders. Concurrent disease modifying treatments showed a trend for association with infection. In the unvaccinated group, patients on disease modifying treatment were significantly at risk of infection, 81.5% unvaccinated and treated versus 18.5% who were unvaccinated and untreated (p- 0.0001, OR-10.1, 95% CI-0.56–2.11).

Conclusion

Frequency and severity of COVID-19 infection was low among our patient cohort. Higher rate of infection in the treated group was significantly seen among unvaccinated patients. Our preliminary results suggests that in LMIC's, where “off label therapies” with inexpensive immunosuppressives are the main disease modifying drugs, mRNA vaccinations appear safe and effective against severe COVID-19 infection.

Implementing education: Personal communication with a healthcare professional is a critical step to address vaccine hesitancy for people with multiple sclerosis

Background

People with Multiple Sclerosis (PwMS) were first able to access COVID-19 vaccines in Australia from March 2021, when vaccine hesitancy in the general population was high (14–43%). High uptake of vaccination is important globally and critical to protect this vulnerable population. We conducted an on-line survey to examine factors influencing COVID-19 vaccination willingness among PwMS in Australia.

Methods

149 PwMS living in Australia completed the on-line survey (April-September 2021) examining demographic, environmental and clinical factors with respect to vaccine willingness, including attitudes towards COVID-19 illness and vaccines. Additional items explored the influence of different information sources on vaccination decisions. Continuous and ordinal data were compared using the Mann-Whitney U test. All tests were two-tailed, with alpha set at 0.5.

Results

A majority of the respondents were female (87.2%) with relapsing-remitting MS (77.5%) treated by a neurologist (94.0%). A majority were on high efficacy disease-modifying therapies (DMTs) (64.9%), while 19.9% were on no DMTs. About one third of respondents (32.9%) had had two doses, 20.8% had received their first dose, and 22.1% were unvaccinated, while 24.2% of responses were missing. When asked about vaccine intentions, 60.6% of the unvaccinated indicated they were likely to extremely likely to get vaccinated, while 15.2% were very unlikely or extremely unlikely to do so and 24.2% were undecided. Unvaccinated people were significantly more concerned about vaccine side effects (mean 5.3 versus 3.1/10; p < .001). Only 53.3% of people on DMTs were vaccinated, compared to 75% of those who were not. People on ocrelizumab therapy (n = 35) had a lower vaccination rate (39%) than those on other medications (n = 86, 59%). Vaccine willingness in the unvaccinated was most highly correlated with knowledge regarding the vaccine (r_s²=.709), agreement with the statement that COVID-19 vaccination is “too new for me to be confident about getting vaccinated” (r_s²= -.709), anticipation of regret due to side effects of vaccination (r_s²= -.642), and lack of knowledge regarding interactions between COVID-19 vaccines and DMTs (r_s²= -.570).

Almost two thirds had read MS-specific information about COVID-19 vaccinations and found it easy to understand (67.6%) and applicable to their situation (53.6%). However, less than half (47.8%) reported the information helped them make a personal vaccination decision. Over two-thirds (64.9%) had discussed vaccinations with their healthcare professional and 31.1% had not. Those who had not, were significantly more uninformed about the interactions of the vaccine with MS medications (mean 3.9 versus 2.9/10; p = .044) and significantly lower intention of vaccine uptake than those who had (mean 5.8 versus 7.9/10; p = .009).

Conclusion

Our study highlights that vaccination efforts should be delivered by healthcare professionals, focus on educating those who are managed with DMTs, and include individual recommendations related to specific DMTs, how the vaccines work, expectations regarding potential side-effects, potential exacerbation of MS symptoms, likelihood of recovery from any exacerbation, and the relative risks of side effects versus COVID-19 infection. Specific recommendations are provided.

COVID-19-Related Burden and Risk Perception in Individuals with Chronic Inflammatory Demyelinating Polyneuropathy and Multifocal Motor Neuropathy: A Cross-Sectional Study

Introduction

This study investigated the mental health burden of patients with chronic inflammatory demyelinating polyneuropathy (CIDP) or multifocal motor neuropathy (MMN) during the COVID-19 pandemic in comparison to matched healthy controls.

Methods

The cross-sectional study included 59 patients with a diagnosis of either CIDP or MMN and 59 propensity score matched healthy controls. All participants completed a survey including demographics, distress (distress thermometer), depressive symptoms (PHQ-2), generalized anxiety (GAD-7), COVID-19-related fear, and risk perception. Additionally, patients with CIDP or MMN were asked about the frequency and type of infections since treatment initiation.

Results

Patients with either CIDP or MMN reported experiencing reduced frequency or no differences in infection frequency since immune medication was initiated. Regarding COVID-19, patients with CIDP or MMN rated their risk of infection similar to healthy controls, while they expected a higher probability of the occurrence of symptoms, severe course, and dying of COVID-19. They reported increased depressive symptoms, generalized anxiety, and COVID-19-related fear in comparison to healthy controls.

Conclusion

Despite their personal experience of reduced frequency of infection since immune medication was initiated, patients with CIDP or MMN reported increased risk perception and prevalence of depressive symptoms, generalized anxiety, and COVID-19-related fear in comparison to healthy controls. This highlights the need for evidence-driven strategies to protect the mental health of this vulnerable group.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40120-022-00359-3.

Seroprevalence of SARS-CoV-2 in a Cohort of Patients with Multiple Sclerosis under Disease-Modifying Therapies

Background: Disease-modifying therapies (DMTs) used to treat multiple sclerosis (MS) alter the immune system and therefore increase the risk of infection. There is growing concern about the impact of COVID-19 on patients with MS (pwMS), especially those treated with DMTs. Methods: This is a single-center prospective observational study based on data from the Esclerosis Múltiple y COVID-19 (EMCOVID-19) study. Demographic characteristics, MS history, laboratory data and SARS-CoV-2 serology, and symptoms of COVID-19 in pwMS treated with any DTM were extracted. The relationship among demographics, MS status, DMT, and COVID-19 was evaluated. Results: A total of 259 pwMS were included. The administration of interferon was significantly associated with the presence of SARS-CoV-2 antibodies (26.4% vs. 10.7%, p = 0.006). Although patients taking interferon were significantly older (49.1 vs. 43.5, p = 0.003), the association of interferon with the presence of SARS-CoV-2 antibodies was still significant in the multivariate analysis (OR 2.99 (1.38; 6.36), p = 0.006). Conclusions: According to our data, pwMS present a higher risk of COVID-19 infection compared with results obtained from the general population. There is no evidence of a worse COVID-19 outcome in pwMS. DMTs did not significantly change the frequency of COVID-19, except for interferon; however, these findings must be interpreted with caution given the small sample of pwMS taking each DMT.

Perspectives and experiences with COVID-19 vaccines in people with MS

Background

People with MS may have unique perspectives on COVID-19 vaccines due to their condition and/or medications.

Objective

Assess perspectives and experiences with COVID-19 vaccination, and quantify variables impacting COVID-19 vaccine willingness in people with MS.

Methods

A survey captured demographics, MS characteristics, and COVID-19 infection and exposures data; opinions on COVID-19 vaccine safety, side effects, and efficacy; and experiences following vaccination. Chi-square tests and a logistic regression model were used to denote between-group differences and variables predicting vaccine willingness, respectively.

Results

Most (87.8%) of the 237 participants were willing to receive the vaccine. Fifteen percent held or delayed a DMT dose for vaccination. MS symptoms worsened in a minority (7.6% first/only dose; 14.7% second dose), and most side effects were mild (80.0%; 55.3%). Those not planning to receive the vaccine were primarily concerned with long-term safety (70.4%). Medical comorbidities (adjusted odds ratio [aOR]=5.222; p=0.04) and following infection prevention precautions (aOR=6.330; p=0.008) were associated with vaccine willingness.

Conclusion

Most individuals with MS surveyed plan to receive the COVID-19 vaccine. People with MS experience similar side effects to the general population, and few experience transient MS symptom worsening. These results can inform conversations on vaccination between providers and people with MS.

Prevalence, severity, outcomes, and risk factors of COVID-19 in multiple sclerosis: An observational study in the Middle East

A cross-sectional hospital records-based study was conducted to evaluate the prevalence, severity, outcomes, and identify demographic and clinical risk factors of coronavirus disease (COVID-19) in patients with MS. The study was conducted at multiple clinics in Oman, Kuwait, and the United Arab Emirates (UAE) from March 2020 to February 2021. The association of patient demographics, MS disease characteristics, and use of disease-modifying therapies with outcomes of COVID-19 illness were evaluated using odds ratio. A total of 134 MS patients with COVID-19 (prevalence rate of 3.7%) having a median age of 35.5 years were analyzed in the study. A majority (126 [94.0%]) of patients had mild COVID-19 illness and 122 (91.0%) made a full recovery, while 1 (0.7%) patient died. The median EDSS score reported in the study was low (1.0). Univariate regression analysis showed high EDSS scores, progressive MS disease, and use of anti-CD20 therapy such as rituximab as risk factors for moderate to severe COVID-19 requiring hospitalization. Comorbidities were associated with a higher risk of non-recovery from COVID-19 in both univariate and multivariate analyses. Age, sex, smoking history, and duration of MS did not show a significant association with severity or adverse COVID-19 disease outcome. Identification of risk factors can aid in improving the treatment and monitoring of pwMS and COVID-19.

COVID-19 Outcomes in Hospitalized Patients With Neurodegenerative Disease: A Retrospective Cohort Study

Background and Objectives

COVID-19 outcomes in patients with neurodegenerative disorders (NDs) are not well understood, and we hypothesize that there may be increased morbidity and mortality in this group.

Methods

This was a retrospective cohort study performed at 3 hospitals in the Chicagoland area. All patients hospitalized with COVID-19 infection with ND during a 3-month period (March 15, 2020-June 15, 2020) were included and compared with age-matched controls (CL) at 1:1 ratio. Primary outcomes were death, intensive care unit (ICU) admission, and invasive ventilation. Secondary outcomes included presenting COVID-19 symptoms, development of encephalopathy, supplementary oxygen use, discharge disposition, and risk factors for mortality.

Results

The study included 132 patients with neurodegenerative disorders and 132 age-matched CL. Ninety-day mortality (ND 19.7% vs CL 23.5%, p = 0.45) and ICU admission (ND 31.5% vs CL 35.9%, p = 0.43) rates were not significantly different between the 2 groups. Patients with ND had a lower rate of invasive ventilation (ND 11.4% vs CL 23.2%, p = 0.0075) and supplementary oxygen use (ND 83.2% vs CL 95.1%, p = 0.0012). Patients with ND were also more likely to have altered mental status or confusion as their presenting COVID-19 symptom and less likely to present with respiratory symptoms. Patients with ND were discharged to nursing home or hospice at higher rates compared with CL.

Discussion

We found that there was no difference in short-term mortality of patients with ND hospitalized for COVID-19 compared with CL, but they may have higher rates of neurologic complications and disability. Future studies should address long-term outcomes.

Mental Health in Multiple Sclerosis During the COVID-19 Outbreak: A Delicate Balance between Fear of Contagion and Resilience

The current study aimed at exploring the relationship between objective disability, illness perceptions, resilience, fear of COVID-19, and psychological distress (i.e., anxiety, depression, and stress) in people with multiple sclerosis (pwMS) during the second wave of the COVID-19 outbreak. A group of 122 pwMS recruited in an Italian university hospital took part in this cross-sectional monocentric study. Hierarchical multiple linear regression analyses were performed to assess the strength of the hypothesized associations. Results indicated that, differently from cognitive impairment, motor disability was positively associated with anxiety. However, accounting for subjective illness perception, such association was no longer significant. Moreover, accounting for both protective and risk factors in the models, even illness perception was no longer significant, highlighting the central role of resilience and fear of COVID-19 in explaining the negative emotional outcomes. Implications for clinical interventions and psychoeducational trainings are discussed.

Determinants of COVID-19-related lethality in multiple sclerosis: a meta-regression of observational studies

Objective

To identify risk factors for an increased lethality of COVID-19 in patients with multiple sclerosis (MS).

Methods

We searched scientific databases to identify cohort studies with the number of deaths in patients with MS. We fitted inverse-variance weighted meta-regressions with random-effects models to identify potential moderators (determinants) of COVID-19-related lethality (outcome).

Results

After an independent screening, 18 articles satisfied the eligibility criteria; all data were collected before anti-SARS-COV-2 vaccination was available. Out of 5,634 patients, 111 died, yielding a pooled death rate of 1.97% (95% confidence intervals 1.61–2.33). There was a substantial heterogeneity between the included studies (Q₁₇ = 66.9, p < 0.001; I² = 77.5%), but no relevant publication bias (p = 0.085). Higher lethality was observed in studies including older patients (β = 0.80, p = 0.025) and in studies with higher proportions of patients with comorbidity (β = 0.17, p = 0.046), progressive disease course (β = 0.15, p = 0.027), and current treatment with anti-CD20 agents (β = 0.18, p < 0.001). Otherwise, higher proportions of patients treated with interferon beta (β = – 0.16, p < 0.001) and teriflunomide (β = – 0.11, p = 0.035) were associated with lower lethality. These estimates did not change even in both multivariable meta-regressions including adjustment variables and leave-one-out sensitivity analyses.

Conclusion

Except for age and comorbidities, risk factors in common with the general population, we identified MS-specific determinants influencing the lethality of COVID-19. Our findings suggest the implementation of a risk mitigation plan for patients with progressive MS and for those treated with anti-CD20 agents.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00415-021-10951-6.

The social and occupational consequences of the COVID-19 pandemic among patients with multiple sclerosis in three distinct populations: A web-based cross-sectional survey

Background

The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes the disease COVID-19, has caused a pandemic that has rapidly affected the whole world and caused a significant threat to public health. The aim of this study was to investigate and analyze the social and occupational effects of the COVID-19 pandemic on patients with multiple sclerosis (MS) in three different countries: China, Spain, and Cuba.

Methods

A cross-sectional survey was designed to assess the social and occupational effects of the COVID-19 pandemic in MS patients in these three countries, using a 25-item anonymous online questionnaire, structured into three sections. Quantitative data are expressed as mean (standard deviation), and quantitative data as absolute frequency and percentage.

Results

A total of 361 participants responded to the questionnaire: 194 from China, 104 from Spain, and 63 from Cuba. We found no cases of COVID-19 among Chinese patients with MS, and few cases in Spain and Cuba. Respondents reported different levels of impact on relationships with friends, family, and colleagues, and patients in all three countries described increased use of digital or social media platforms. Spanish patients reported a significantly less negative impact than those in Cuba and China. Mental and cognitive effects were similar in all three countries, although China seemed to have a better situation. We also found that the time spent exercising decreased at specific points during the pandemic, but with few changes in dietary habits. Patients reported little or no change in their means of transport in all three countries. Most patients in all three countries reported little or no physical deterioration, especially in Chinese patients (82.47%), compared to the Spanish (70.20%) and Cuban respondents (73.02%). In general, patients from all three countries demonstrated confidence in overcoming the COVID-19 pandemic, although to a lesser extent among Spanish respondents.

Conclusions

During the pandemic, family support was more effective in China than in Cuba and Spain. Neither COVID-19 infections nor the number of MS relapses increased significantly during lockdown in any of the three countries. Regarding their economic situation, Spanish MS patients reported a significantly less severe negative impact than those in Cuba and China. Patients from all three countries used digital or social media platforms more frequently, probably to maintain personal relationships. Chinese and Cuban respondents were more confident of the control of the pandemic than the Spanish, who were more pessimistic.

Analysis of neurology consultations in hospitalized patients with COVID-19

OBJECTIVE

The aim of this study was to evaluate patients who were hospitalized with a diagnosis of COVID-19 and were consulted by neurology during their hospital stay.

METHODS

All files of patients with COVID-19 who were admitted to Cerrahpasa Medical Faculty Hospital between March 11th and December 31st, 2020 were retrospectively reviewed, and files of patients who consulted by neurology during their stay were included. Demographic and clinical characteristics, neurologic diagnosis, outcome and related laboratory data were extracted from electronic medical records and analyzed. Patients were categorized into the first wave and second wave according to the date of hospitalization.

RESULTS

A total of 2257 patients were hospitalized for COVID-19; among them, 127 were consulted by a neurologist during their hospital stay. Fifteen patients received a consultation for possible drug interactions. Among the remaining 112 patients, the reason for neurology consultation was i. exacerbation of a neurological comorbidity vs ii. new-onset neurological manifestations. The median age was 68.5 ± 14.2 years, and 60.7% were men. Dementia and stroke were the leading neurological comorbidities. COVID-19 disease was more severe in the patients with the new-onset neurological comorbidity than in patients with exacerbation of a neurological comorbidity (p = 0.07). Serum creatinine kinase levels were higher in the new-onset patient group (p < 0.05). Exacerbation of previous neurological disease or new neurological impairment were jointly and severely related to high mortality (overall 35/112 vs 275/2145, p < 0.001; exacerbation 12/45 vs 275/2145 p < 0.01; new-onset 23/67 vs 275/2145, p < 0.001).

CONCLUSION

Serious neurological involvement is relatively uncommon in hospitalized patients with COVID-19 and is associated with increased mortality.

COVID-19 susceptibility and outcomes among patients with neuromyelitis optica spectrum disorder (NMOSD): A systematic review and meta-analysis

BACKGROUND

We conducted this systematic review and meta-analysis to assess the risk of coronavirus disease (COVID-19), clinical features and outcome among patients with neuromyelitis optica spectrum disorder (NMOSD).

METHODS

We systematically searched PubMed, Scopus, Web of Science, and Embase from December 1, 2019, to July 2, 2021. The gray literature including the references of original studies, review studies, conference abstracts, and WHO COVID-19 database was also searched. We included any type of studies that reported NMOSD patients with COVID-19, prevalence of COVID-19 among NMOSD patients or the infection outcome (hospitalization, intensive care unit [ICU] admission, or mortality).

RESULTS

Out of 540 records, a total of 23 studies (19 published articles and 4 conference abstracts) including 112 NMOSD patients with COVID-19 met the inclusion criteria. Nine studies reporting risk of COVID-19 and nine studies on outcome were included in a quantitative synthesis. The pooled prevalence of COVID-19 was 1.2% (95% CI: 0.001%-0.030%; I2 = 92%, p< 0.001), with hospitalization of 33.7% (95% CI: 23.3-44.8%; I2 = 9.1%, p = 0.360) with 52.9% on rituximab treatment. ICU admission was 15.4% (95% CI: 7.6%-24.7%; I2 = 20.7%, p = 0.272) and mortality was 3.3% (95% CI: 0-9.7%; I2 = 21.3%, p = 0.253). Thirty-eight patients (48.7%) reported at least one comorbidity. The mean age of the included patients was 40.8 (10.63) years, female/male ratio was 3.35:1. The most common COVID-19 symptom was fever (54.5%), followed by fatigue/asthenia (42.9%), headache (41.6%), and cough (40.3%). Four patients developed neurological worsening. The Begg's and Egger's tests showed no evidence of publication bias.

CONCLUSION

The analysis suggests that comorbidity and treatment with rituximab may be risk factors for COVID-19 infection in NMOSD patients.

COVID-19 infection and hospitalization rate in Iranian multiple sclerosis patients: What we know by May 2021

BACKGROUND

Despite investigations on the effect of disease modifying therapies (DMTs) used in multiple sclerosis (MS) on coronavirus disease 2019 (COVID-19); there are still controversies.

OBJECTIVE

We designed this study to evaluate the epidemiological features of covid-19 in a large sample of people with MS (pwMS) in Isfahan, Iran, as well as the association between DMTs, risk of COVID-19 infection and hospitalization.

METHODS

In an observational pwMS, we interviewed subjects on their MS and COVID-19 history.

RESULTS

3050 subjects were included (74% female) with a mean age of 41.36. 423 (13.8%) had confirmed COVID-19 which shows that pwMS are at a higher risk of infection compared to the general population, No significant relationship was observed in COVID-19 infection when individual drugs. Dimethyl fumarate and rituximab had the lowest and the highest relative risks for hospitalization rate compared to other drugs, respectively.

CONCLUSION

We found no evidence supporting a higher prevalence of COVID-19 in pwMS compared to the general population. However, our results show pwMS to be more prone to hospitalization compared to the general population, Therefore, it is advised to use safer treatment if possible until complete vaccination, and to postpone the use of rituximab.

Impact of COVID-19 on multiple sclerosis care and management: Results from the European Committee for Treatment and Research in Multiple Sclerosis survey

BACKGROUND

The spread of Coronavirus disease-19 (COVID-19) poses unique challenges in the management of people with multiple sclerosis (PwMS).

OBJECTIVES

To collect data about the impact of COVID-19 emergency on access to care for PwMS and on MS treatment practices.

METHODS

Between March and July 2020, the European Committee for Treatment and Research in Multiple Sclerosis (ECTRIMS) promoted an online survey covering patient access to care, management of relapses and visits, disease-modifying therapy (DMT) and experience with COVID-19.

RESULTS

Three-hundred and sixty neurologists from 52 countries (68% from Europe) completed the survey. 98% reported COVID-19-related restrictions. Telemedicine was adopted to overcome the limited access to care and was newly activated (73%) or widely implemented (17%). 70% reported changes in DMT management. Interferons and glatiramer were considered safe. Dimethyl fumarate, teriflunomide and fingolimod were considered safe except for patients developing lymphopenia. No modifications were considered for natalizumab in 64%, cladribine in 24%, anti-CD20 in 22% and alemtuzumab in 17%; 18% (for alemtuzumab and cladribine) and 43% (for anti-CD20) considered postponing treatment.

CONCLUSION

The ECTRIMS survey highlighted the challenges in keeping standards of care in clinical practice. Telemedicine clearly needs to be implemented. Gathering data on DMT safety will remain crucial to inform treatment decisions.

Characteristics of COVID-19 in patients with multiple sclerosis

Background

Regarding the high prevalence of multiple sclerosis (MS) and COVID-19 in Iran, a multicenter study of COVID-19 in Iranian MS patients with is carried out to address the concerns of this population.

Methods

Data on MS patients with COVID-19 from nine provinces of Iran were entered in a web-based registry system, between July 2020 and March 2021. Among the COVID-19 symptoms, dyspnea, altered mental status, or those resulting in hospital admission were considered severe.

Results

A total of 397 eligible patients were identified. In addition, 310 (78%) were female. The mean age was 36.5 ± 9.5. 294 (74%) patients had relapsing- remitting form. Also, four patients (1%) expired due to COVID-19 infection. The mean duration of admission in hospitalized patients was 9 (± 5.3) days. MRI was performed on 111 (28%) patients after developing COVID-19. MRI changes were observed in 27 (24%) of these cases. MS drug was changed in 26 (6%) patients. Steroid use in the past three months (OR: 2.43, 95% CI: 1.003–5.88) (p value: 0.049) and antiCD20s (OR: 4.03, 95% CI: 2.41–6.68) (p value < 0.001) showed significant association with severe COVID-19 symptoms.

Conclusion

The death rate of COVID-19 among MS patients (1%) is lower than the overall death rate of the pandemic in Iran (3%). Those who received steroid in the past three months may be at increased risk of more severe forms of COVID-19. There are still doubts about the effect of anti CD20s on COVID-19 severity.

Risk factors of severe COVID-19 in people with multiple sclerosis : A systematic review and meta-analysis

Objectives

To gather, synthesize, and meta-analyze data regarding the risk factors associated with a severe course of COVID-19 among patients with multiple sclerosis (pwMS).

Methods

MEDLINE, Embase, Scopus, and WoS were searched in May 2021. Briefly, the eligibility criteria included: 1) studies assessing COVID-19 severity among adult pwMS; 2) definitive diagnoses or high clinical suspicion of COVID-19; 3) a categorization of COVID-19 severity into at least two categories; 4) quantitative effect size and precision measurements; and 5) English language; and 6) clear effect size/precision measures. internal validity of studies was assessed using the NIH Quality Assessment Tools. A list of possible risk factors was created based on the search results and was later used in extraction, synthesis, and meta-analysis of the data.

Results

Thirteen studies were included in the syntheses. Outcome measures were either extracted from the papers, obtained from the primary researchers or calculated manually. The meta-analyses showed a significantly (P < 0.05) increased odds of a severe COVID-19 in pwMS with all of the assessed risk factors, except smoking and most DMTs.

Conclusion

This study facilitates evidence-based risk/benefit assessments in practice. Older men with progressive MS on anti-CD20 therapies are more at risk of an unfortunate COVID-19 outcome.

The Turkish experience of COVID-19 infection in people with NMOSD and MOGAD: A milder course?

Background

COVID-19 is a multisystemic infection with variables consequences depending on individual and comorbid conditions. The course and outcomes of COVID-19 during neuromyelitis optica spectrum disorders (NMOSD) and myelin oligodendrocyte glycoprotein antibody-associated disorders (MOGAD) are not clearly known.

Objective/methods

The aim of this study was to examine the features and outcomes of COVID-19 infection in NMOSD and MOGAD patients. The patients' demographic and clinical factors, disease modifying treatment (DMT) used and disease information of COVID-19 infection were recorded. Conditions leading to hospitalization and severe exposure to COVID-19 infection were also analyzed.

Results

The study included 63 patients from 25 centers. Thirty-two patients (50.8%) belong to AQP-4 seropositive group, 13 (20.6%) and 18 (28.6%) were in MOG-positive and double-seronegative groups, respectively. Risk factors for severe COVID-19 infection and hospitalization were advanced age, high disability level and the presence of comorbid disease. Disease severity was found to be high in double-seronegative NMOSD and low in MOGAD patients. No statistically significant effect of DMTs on disease severity and hospitalization was found.

Conclusion

In NMOSD and MOGAD patients, advanced age, high disability and presence of comorbid disease pose risks for severe COVID-19 infection. There was no direct significant effect of DMTs for COVID-19 infection.

The Outcome of COVID-19 in Patients with a History of Taking Rituximab: A Narrative Review

Coronavirus disease 2019 (COVID-19) is a recently emerging disease caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Notably, the safety of immunosuppressive medications is a major concern during an infectious disease pandemic. Rituximab (RTX), as a monoclonal antibody against CD20 molecule, is widely used for the treatment of various diseases, mostly autoimmune diseases and some malignancies. Previous studies indicated that RTX, as an immunosuppressive medication, may be associated with the increased risk of infections. Moreover, given the wide use of RTX, a necessity of determining the different aspects of RTX use in the COVID-19 era is strongly felt. We reviewed current studies on the clinical courses of patients with SARS-CoV-2 infection. It appears that the use of RTX does not increase morbidity and mortality in most patients. However, underlying diseases and other concomitant medications may play a role in the disease course, while the concerns of vaccine efficacy in patients receiving RTX still need to be addressed. Therefore, more controlled studies are needed for a better conclusion.

Current international trends in the treatment of multiple sclerosis in children-Impact of the COVID-19 pandemic

BACKGROUND

Only recently has the first disease-modifying therapy been approved for children with multiple sclerosis (MS) and practice patterns including substantial off-label use have evolved. Understanding attitudes towards treatment of paediatric MS and whether this has changed due to the ongoing COVID-19 pandemic is vital to guide future therapeutic trials and for developing guidelines that reflect practice.

METHODS

We performed an online survey within the International Paediatric Multiple Sclerosis Study Group between July and September 2020. The survey was sent to 130 members from 25 countries and consisted of five sections: demographic data, treatment, disease modifying therapies and COVID-19, outcome and three patient cases.

RESULTS

The survey was completed by 66 members (51%), both paediatric neurologists and adult neurologists. Fingolimod and β-interferons were the most frequently used disease-modifying therapies, especially among paediatric neurologists. Almost a third (31%) of respondents had altered their prescribing practice due to COVID-19, in particular at the beginning of the pandemic.

CONCLUSIONS

The survey results indicate a tendency of moving from the traditional escalation therapy starting with injectables towards an early start with newer, highly effective disease modifying therapies. The COVID-19 pandemic only slightly affected prescribing patterns and treatment choices in paediatric MS.

Multiple Sclerosis and SARS-CoV-2: Has the Interplay Started?

Current knowledge on Multiple Sclerosis (MS) etiopathogenesis encompasses complex interactions between the host's genetic background and several environmental factors that result in dysimmunity against the central nervous system. An old-aged association exists between MS and viral infections, capable of triggering and sustaining neuroinflammation through direct and indirect mechanisms. The novel Coronavirus, SARS-CoV-2, has a remarkable, and still not fully understood, impact on the immune system: the occurrence and severity of both acute COVID-19 and post-infectious chronic illness (long COVID-19) largely depends on the host's response to the infection, that echoes several aspects of MS pathobiology. Furthermore, other MS-associated viruses, such as the Epstein-Barr Virus (EBV) and Human Endogenous Retroviruses (HERVs), may enhance a mechanistic interplay with the novel Coronavirus, with the potential to interfere in MS natural history. Studies on COVID-19 in people with MS have helped clinicians in adjusting therapeutic strategies during the pandemic; similar efforts are being made for SARS-CoV-2 vaccination campaigns. In this Review, we look over 18 months of SARS-CoV-2 pandemic from the perspective of MS: we dissect neuroinflammatory and demyelinating mechanisms associated with COVID-19, summarize pathophysiological crossroads between MS and SARS-CoV-2 infection, and discuss present evidence on COVID-19 and its vaccination in people with MS.

Increased risk of death from COVID-19 in multiple sclerosis: a pooled analysis of observational studies

Objective

To estimate whether the risk of death from COVID-19 in patients with multiple sclerosis (MS) exceeds that of the general population.

Methods

We conducted a pooled analysis of cohort studies on COVID-19 in patients with MS published until July 31, 2021. We calculated the pooled crude death rate (CDR) and estimated the indirectly-adjusted age-standardized lethality ratio (SLR) to assess the risk of death from COVID-19 in patients with MS as compared to general population.

Results

Out of 520 articles, 18 fulfilled criteria for pooled analysis, with a total of 5634 patients (28.6% males, mean age 41.8 years). Of them, 111 died, yielding a CDR of 1.97% (95% confidence intervals [CIs] 1.61–2.33). The estimated SLR was 1.24 (95% CIs 1.01–1.48) after indirect age-standardization using case-fatality rates obtained from the detailed surveillance data available at the World Health Organization (WHO) website. A leave-one-out sensitivity analysis and the analysis of temporal trends of SLR from March 2020 to July 2021 provided consistent findings.

Conclusions

Our pooled analysis suggests a 24%-increased risk of death from COVID-19 in patients with MS. These findings must be interpreted with caution, mainly because of the difficulties in COVID-19 case detection (especially in the first pandemic wave) and heterogeneity of the analyzed cohorts. Confirmation in larger population-based studies is warranted.

Myasthenia gravis and COVID-19: A case series and comparison with literature

Objective

To describe presenting symptoms, clinical outcomes, and therapeutic management of concurrent Coronavirus disease 2019 (COVID‐19) infections in patients with a pre‐existing myasthenia gravis (MG).

Methods

We conducted a retrospective study in patients with preexisting MG presenting with concurrent COVID‐19 between September 21st and November 4th, 2020 when attending the emergency department or routine neurology consultation at the National Institute Mongi Ben Hamida of Neurology of Tunis, Tunisia.

Results

Five patients were identified. The Myasthenia Gravis Foundation of America scores (MGFA) prior to COVID‐19 infection were class I in one patient, class II (IIa, IIb) in two patients, and class IIIb in one patient.

Four patients had mild to moderate courses of COVID‐19 infection. One patient presented a critical infection with acute respiratory disease syndrome (ARDS) requiring mechanical ventilation. Two of them also demonstrated signs of MG exacerbation requiring the use of intravenous immunoglobulin in one case.

We maintained immunosuppressant therapy to MG in all our patients. All our patients received Azithromycin (AZM) as a part of specific drug treatment of COVID‐19 infection. Outcome was favorable in 4 patients and rapidly fatal evolution was observed in the patient with ADRS.

Discussions and conclusion

The results from our study suggest that prior MG activity could partially influence the subsequent clinical outcomes. It emerged also that ongoing long‐term immunosuppressive immunotherapy to MG should be maintained during the COVID‐19 pandemic and that AZM can be used safely in MG patients and concurrent COVID‐19 infection.

Clinical Features of COVID-19 on Patients With Neuromyelitis Optica Spectrum Disorders

Background and Objectives

To describe the clinical features and disease outcomes of coronavirus disease 2019 (COVID-19) in patients with neuromyelitis optica spectrum disorder (NMOSD).

Methods

The Neuroimmunology Brazilian Study Group has set up the report of severe acute respiratory syndrome (SARS-CoV2) cases in patients with NMOSD (pwNMOSD) using a designed web-based case report form. All neuroimmunology outpatient centers and individual neurologists were invited to register their patients across the country. Data collected between March 19 and July 25, 2020, were uploaded at the REDONE.br platform. Inclusion criteria were as follows: (1) NMOSD diagnosis according to the 2015 International Panel Criteria and (2) confirmed SARS-CoV2 infection (reverse transcription-polymerase chain reaction or serology) or clinical suspicion of COVID-19, diagnosed according to Center for Disease Control / Council of State and Territorial Epidemiologists (CDC/CSTE) case definition. Demographic and NMOSD-related clinical data, comorbidities, disease-modifying therapy (DMT), COVID-19 clinical features, and severity were described.

Results

Among the 2,061 pwNMOSD followed up by Brazilian neurologists involved on the registry of COVID-19 in pwNMOSD at the REDONE.br platform, 34 patients (29 women) aged 37 years (range 8–77), with disease onset at 31 years (range 4–69) and disease duration of 6 years (range 0.2–20.5), developed COVID-19 (18 confirmed and 16 probable cases). Most patients exhibited mild disease, being treated at home (77%); 4 patients required admission at intensive care units (severe cases); and 1 patient died. Five of 34 (15%) presented neurologic manifestations (relapse or pseudoexacerbation) during or after SARS-CoV2 infection.

Discussion

Most NMOSD patients with COVID-19 presented mild disease forms. However, pwNMOSD had much higher odds of hospitalization and intensive care unit admission comparing with the general Brazilian population. The frequency of death was not clearly different. NMOSD disability, DMT type, and comorbidities were not associated with COVID-19 outcome. SARS-CoV2 infection was demonstrated as a risk factor for NMOSD relapses. Collaborative studies using shared NMOSD data are needed to suitably define factors related to COVID-19 severity and neurologic manifestations.

COVID-19 severity and outcome in multiple sclerosis: Results of a national, registry-based, matched cohort study

Background

Risk factors associated with coronavirus disease 2019 (COVID-19) severity in patients with multiple sclerosis (MS) have been described. Recent improvements in supportive care measures and increased testing capacity may modify the risk of severe COVID-19 outcome in MS patients. This retrospective study evaluates the severity and outcome of COVID-19 in MS and characterizes temporal trends over the course of the pandemic in the United States.

Methods

We conducted a comparative cohort study using de-identified electronic health record (EHR) claims-based data. MS patients diagnosed with COVID-19 between February 2, 2020 and October 13, 2020 were matched (1:2) to a control group using propensity score analysis. The primary outcome was a composite of intensive care unit (ICU) admission, mechanical ventilation, and/or death.

Results

A total of 2,529 patients (843 MS and 1,686 matched controls) were included. Non-ambulatory and pre-existing comorbidities were independent risk factors for COVID-19 severity. The risk for the severe composite outcome was lower in the late cohorts compared with the early cohorts.

Conclusions

The majority of MS patients actively treated with a disease-modifying therapy (DMT) had mild disease. The observed trend toward a reduction in severity risk in recent months suggests an improvement in COVID-19 outcome.

Multiple sclerosis is not associated with an increased risk for severe COVID-19: a nationwide retrospective cross-sectional study from Germany

Background

Since the coronavirus disease 2019 (COVID-19) has risen, several risk factors have been identified, predicting a worse outcome. It has been speculated that patients with Multiple sclerosis (MS) have an increased risk for a severe course of COVID-19 due to a suspected higher vulnerability. Therefore, we aimed to analyze the impact of comorbid MS on the outcome of patients with COVID-19 in Germany.

Methods

We conducted a retrospective cross-sectional study using the administrative database of all hospitalized patients diagnosed with PCR-confirmed COVID-19 (n = 157,524) in Germany during 2020. The cohort was stratified according to the presence (n = 551) or absence (n = 156,973) of comorbid MS, including discrimination of MS subtypes. Primary outcome measures were admission to the intensive care unit (ICU), use of invasive or non-invasive ventilation, and in-hospital mortality. Differences were investigated using rates and odds ratios as estimates. Pooled overall estimates, sex-stratified estimates, age-group stratified estimates, and MS subtype stratified estimates were calculated for all outcomes under the random-effects model.

Results

Among 157,524 patients hospitalized with COVID-19, 551 had a concurrent MS diagnosis (0.3%). Overall, univariate analysis showed lower rates of ICU admission (17.1% versus 22.7%, p < 0.001), lower use of ventilation (9.8% versus 14.5%, p < 0.001) and lower in-hospital mortality (11.1% versus 19.3%, p < 0.001) among COVID-19 patients with comorbid MS. This finding was stable across the subgroup analysis of sex and MS subtype but was attenuated by age-stratification, confirming equal odds of in-hospital mortality between COVID-19 patients with and without MS (log OR: 0.09 [95% CI: − 0.40, 0.59]).

Conclusions

Although there might be differences in risk within the MS patients’ population, this large-scale nationwide analysis found no evidence for a worse outcome of COVID-19 in patients with comorbid MS compared to non-MS individuals.

Supplementary Information

The online version contains supplementary material available at 10.1186/s42466-021-00143-y.