Impact of the first COVID-19 pandemic wave on the Scottish Multiple Sclerosis Register population

Potential beneficial effect of IFN-β1a and ocrelizumab in people with MS during the COVID-19 pandemic

BACKGROUND/AIM

Disease-modifying therapy (DMT) has led to added challenges in the management of people with multiple sclerosis (pwMS) during the COVID-19 era. It can reduce relapse in MS or slow down disease progression, but some DMTs can increased risk of infection. The aim of study was to evaluate risk and severity of COVID-19 in pwMS.

METHODS

The examined group of pwMS were divided in group treated with IFN-β1a, group treated with ocrelizumab and untreated group. The examination included impact of age, gender, duration of MS, type of MS, vaccination status and Expanded Disability Status Scale (EDSS) on the risk and severity of COVID-19 infection. A diagnosis of COVID-19 in pwMS was confirmed by positive polymerase-chain-reaction (PCR) or antigen test.

RESULTS

Out of 207 pwMS, 82 patients were treated with ocrelizumab, 63 with IFN-β1a, while 62 patients were untreated pwMS. The average duration of the MS was longer in the group of patients treated with ocrelizumab than in the group treated with IFN-β1a (p < 0.05). EDSS was higher in the ocrelizumab group compared to the other two groups (p < 0.001). Untreated (more often unvaccinated) had the same COVID frequency as ocrelizumab-treated (more vaccinated, but higher EDSS). The multivariate logistic regression model indicated that administration of IFN-β1a reduces the risk of COVID-19 infection (p = 0.001, OR = 0.381, 95% CI 0.602-0.160). The use of both DMTs, driven mainly by the IFN-β1a effect, reduces the risk of moderate and severe COVID-19 (p < 0.05, OR = 0.105, 95% CI 0.011-0.968).

CONCLUSION

This study provides evidence that IFN-β1a can reduce the frequency of COVID-19 infection and that two DMTs, driven mainly by the IFN-β1a effect, do not increase the risk of moderate/severe COVID-19.

Indirect impact of the COVID-19 pandemic on the care and outcomes of people with MS: A combined survey and insurance claims study

BACKGROUND

In the context of the COVID-19 pandemic, people with multiple sclerosis (pwMS) have been particularly vulnerable to adverse outcomes due to increased risk of severe infection and/or widespread disruptions in care. The CopeMS study led by The University of Texas at Austin and the MS Association of America investigates the long-term impact of the COVID-19 pandemic on healthcare access, disease modifying therapy (DMT) utilization and outcomes of pwMS.

METHODS

This retrospective cohort analysis used Optum's de-identified Clinformatics® Data Mart Database (CDM), a large de-identified administrative healthcare claims database to identify pwMS who were continuously enrolled from 01/01/2019 to 12/31/2020 and assessed changes in the utilization of DMTs and healthcare services during the COVID-19 pandemic compared to the year prior. Additionally, a national survey of pwMS and healthcare providers (HCPs) was conducted to further understand the indirect impact of the pandemic on healthcare resource utilization (HCRU), outcomes and prescription patterns.

RESULTS

Out of 529 pwMS in our national survey, over 47 % reported that their overall health and neurologic symptoms had deteriorated during the COVID-19 pandemic, with increased anxiety, and inability to maintain exercise habits as leading perceived causes for worsening. Survey respondents reported widespread disruption of MS-related services during the pandemic. In the Optum database, we identified 39,209 pwMS validating inclusion criteria. We observed a decrease in the utilization of MS-related services in 2020 compared to 2019. Significantly fewer pwMS had visits with their neurologist, primary care provider, physical or occupational therapist despite an increased utilization of telemedicine services. Fewer pwMS had magnetic resonance imaging (MRI) studies of the brain or spinal cord during the pandemic. Only 22.2 % of HCPs surveyed agreed that the perceived risk of more severe COVID-19 infection on a specific DMT influenced their therapeutic decisions. In the Optum database, individuals with an established diagnosis of MS prior to 2019 saw decreases in utilization of platform and moderate efficacy DMTs. In this group, those over the age of 55 saw a decrease in utilization of B-cell therapies (rate ratio 0.79, CI 0.75-0.83), whereas individuals under the age of 55 saw an increase in utilization of B-cell therapies (rate ratio 1.10, CI 1.03-1.17). We did not see any difference in rates of starting DMTs in persons diagnosed in 2019 prior to the pandemic and those diagnosed in 2020. Compared to 2019, B-cell therapies were prescribed more frequently in pwMS diagnosed in 2020 who were younger than 55 or commercially insured (rate ratio 1.35, CI 1.11-1.63).

CONCLUSION

The COVID-19 pandemic was associated with perceived worsening of neurological symptoms in pwMS. Despite the expansion of telemedicine, we observed decreased access to healthcare services important to the comprehensive care of pwMS. Additionally, we observed changes in DMT utilization in pwMS during the pandemic, particularly in older adults with an established diagnosis of MS.

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.

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.

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.

Evidence of extensive cellular immune response after SARS-CoV-2 vaccination in ocrelizumab-treated patients with multiple sclerosis

BACKGROUND

Patients with multiple sclerosis receiving ocrelizumab-treatment are in desperate need of a protection against SARS-CoV-2 infection.

METHODS

In this study, Euroimmun semi-quantitative Anti-SARS-CoV-2 IgG for detection of humoral response and ELISpot assays for detection of SARS-CoV-2-specific T-cell-response were used in 10 ocrelizumab-treated patients with multiple sclerosis twice vaccinated with Comirnaty® mRNA vaccine. This data was compared with a control group of 20 age- and sex-matched healthy volunteers, who had all previously received a full SARS-CoV-2 mRNA vaccination with Comirnaty® or Spikevax®.

RESULTS

While all subjects in the control group had high humoral response to the vaccination, in B-cell-depleted individuals a significantly reduced antibody response to vaccination against SARS-CoV-2 was observed. SARS-CoV-2 specific T-cell-response, however, did not differ significantly between both cohorts.

CONCLUSIONS

T-cell-mediated response to Comirnaty® vaccination is observable despite attenuated humoral response in B-cell-depleted patients. This might enable partial protection against COVID-19. Trial registration Retrospectively registered.

Deaths involving COVID-19 by self-reported disability status during the first two waves of the COVID-19 pandemic in England: a retrospective, population-based cohort study

Background

People with learning disabilities are at substantially increased risk of COVID-19 mortality, but evidence on risks of COVID-19 mortality for disabled people more generally is limited. We aimed to use population-level data to estimate the association between self-reported disability and death involving COVID-19 during the first two waves of the COVID-19 pandemic in England.

Methods

We conducted a retrospective, population-based cohort study of adults aged 30–100 years living in private households or communal establishments in England, using data from the Office for National Statistics Public Health Data Asset. Participants were present at the 2011 Census and alive on Jan 24, 2020. Participants reported being limited a lot in their daily activities, limited a little, or not limited at all, in response to a question from the 2011 Census. The outcome was death involving COVID-19, occurring between Jan 24, 2020, and Feb 28, 2021. We used Cox proportional hazards regression to calculate hazard ratios (HRs) for the association between disability and death involving COVID-19, sequentially adjusting for age, residence type (private household, care home, or other communal establishment), geographical characteristics (local authority district and population density), sociodemographic characteristics (ethnicity, highest qualification, Index of Multiple Deprivation decile, household characteristics [National Statistics Socio-economic Classification of the household reference person, tenure of household, household size, family status, household composition, and key worker in household], key worker type, individual and household exposure to disease, and individual and household proximity to others), and health status (pre-existing health conditions, body-mass index, and number of admissions to hospital and days spent in hospital over the previous 3 years).

Findings

29 293 845 adults were included in the study (13 806 623 [47%] men, 15 487 222 [53%] women), of whom 3 038 772 (10%) reported being limited a little and 2 011 576 (7%) reported being limited a lot. During follow-up, 105 213 people died from causes involving COVID-19 in England, 61 416 (58%) of whom were disabled. Age-adjusted analyses showed higher mortality involving COVID-19 among disabled people who were limited a lot (HR 3·05 [95% CI 2·98–3·11] for men; 3·48 [3·41–3·56] for women) and disabled people who were limited a little (HR 1·88 [1·84–1·92] for men; 2·03 [1·98–2·08] for women) than among non-disabled people. Adjustment for residence type, geography, sociodemographics, and health conditions reduced but did not eliminate the associations between disability and death involving COVID-19 (HR 1·35 [1·32–1·38] for men who were limited a lot; 1·21 [1·18–1·23] for men who were limited a little; 1·55 [1·51–1·59] for women who were limited a lot; and 1·28 [1·25–1·31] for women who were limited a little).

Interpretation

Given the association between disability and mortality involving COVID-19, verification of these findings and consideration of recommendations for protective measures are now required.

Funding

None.

COVID-19 in Multiple Sclerosis: Clinically reported outcomes from the UK Multiple Sclerosis Register

BACKGROUND

In March 2020, the United Kingdom Multiple Sclerosis Register (UKMSR) established an electronic case return form, designed collaboratively by MS neurologists, to record data about COVID-19 infections in people with MS (pwMS).

OBJECTIVES

Examine how hospital admission and mortality are affected by disability, age and disease modifying treatments (DMTs) in people with Multiple Sclerosis with COVID-19.

METHODS

Anonymised data were submitted by clinical teams. Regression models were tested for predictors of hospitalisation and mortality outcomes. Separate analyzes compared the first and second 'waves' of the pandemic.

RESULTS

Univariable analysis found hospitalisation and mortality were associated with increasing age, male gender, comorbidities, severe disability, and progressive MS; severe disability showed the highest magnitude of association. Being on a DMT was associated with a small, lower risk. Multivariable analysis found only age and male gender were significant. Post hoc analysis demonstrated that factors were significant for hospitalisation but not mortality. In the second wave, hospitalisation and mortality were lower. Separate models of the first and second wave using age and gender found they had a more important role in the second wave.

CONCLUSIONS

Features associated with poor outcome in COVID-19 are similar to other populations and being on a DMT was not found to be associated with adverse outcomes, consistent with smaller studies. Once in hospital, no factors were predictive of mortality. Reassuringly, mortality appears lower in the second wave.

Multiple sclerosis and COVID-19: The Swedish experience

The COVID-19 pandemic has brought challenges for healthcare management of patients with multiple sclerosis (MS). Concerns regarding vulnerability to infections and disease-modifying therapies (DMTs) and their complications have been raised. Recent published guidelines on the use of DMTs in relation to COVID-19 in MS patients have been diverse between countries with lack of evidence-based facts. In Sweden, there exists a particular interest in anti-CD20 therapy as a possible risk factor for severe COVID-19 due to the large number of rituximab-treated patients off-label in the country. Rapid responses from the Swedish MS Association (SMSS) and the Swedish MS registry (SMSreg) have resulted in national guidelines on DMT use for MS patients and implementation of a COVID-19 module in the SMSreg. Recently updated guidelines also included recommendations on COVID-19 vaccination with regard to the different DMTs. Social distancing policies forced implementation of telemedicine consultation to replace in-person consultations as part of regular MS health care. Patient-reported outcome measures (PROMs) in SMSreg have been useful in this respect. This paper reports our experiences on the progress of national MS health care during the COVID-19 pandemic, in addition to offering an overview of the present scientific context.

The prevalence of COVID-19 infection in patients with multiple sclerosis (MS): a systematic review and meta-analysis

BACKGROUND

The prevalence of COVID-19 is different in studies conducted in different countries. The aim of this systematic review and meta-analysis is to estimate the pooled prevalence of COVID-19 in patients with MS.

METHODS

Two independent researchers independently searched PubMed, Scopus, EMBASE, Web of Science, and google scholar along with gray literature up to April 2021. The search strategy included the MeSH and text words as (((coronavirus OR Wuhan coronavirus OR novel coronavirus OR coronavirus disease OR COVID-19 OR 2019 novel coronavirus infection OR 2019-nCOV OR severe acute respiratory syndrome coronavirus 2 OR SARS-CoV-2) AND (Multiple Sclerosis OR Sclerosis, Multiple) OR Sclerosis, Disseminated) OR Disseminated Sclerosis) OR MS (Multiple Sclerosis)) OR Multiple Sclerosis, Acute Fulminating).

RESULTS

We found 1466 articles by literature search, and after deleting duplicates, 1029 remained. Twelve articles remained for meta-analysis. Totally, 101,462 patients were evaluated and the total number of possible/confirmed cases was 1394. Mean age ranged from 35 to 54 years. Totally, 49 patients died. The pooled prevalence of suspected COVID-19 in MS patients was 4% (95% CI: 3-4%) (I2 = 98.5%, P < 0.001). The pooled prevalence of hospitalization in infected cases was 10% (95% CI: 7-12%) (I2 = 95.6%, P < 0.001). The pooled prevalence of death in hospitalized cases was 4% (95% CI: 1-6%) (I2 = 82.4%, P < 0.001).

CONCLUSION

Hospitalization rate is higher among MS patients based on COVID-19 infection while the pooled infection rate is estimated as 4%.

Understanding and managing the impact of the Covid-19 pandemic and lockdown on patients with multiple sclerosis

INTRODUCTION

Covid-19 has been sweeping over the world for more than a year. People with Multiple Sclerosis (MS) might be particularly vulnerable either for the disease iteself or for the ongoing immune treatment. The aim of this review is to understand the impact of the Covid-19 pandemic and lockdown on patients with MS and to provide evidence-based advice to ensure them a high standard of care even during the pandemic.

AREAS COVERED

Literature search was conducted in the Scopus, Web of Science, Pubmed electronic databases, and articles reference lists to investigate the effect of Covid-19 on MS patients' treatment, access to health-care services and mental-health.The search terms 'multiple sclerosis' AND 'Covid-19' were combined with each of the following term 'disease modifying treatment,' 'steroids,' 'vaccination,' 'mental health,' 'stress,' 'quality of life,' 'management,' 'impact,' 'recommendations,'.

EXPERT OPINION

To ensure MS control during the pandemic, minimizing the risk of Covid-19 contagion, face-to-face visits may be implemented with televisits. Management of relapses and DMTs schedule should be adapted based on the specific benefit/risk ratio for each patient, considering disease activity, disability, comorbidities. Vaccination should be strongly recommended. Telerehabilitation and online psychological support programs should be encouraged to preserve motor performances and mental health.

Expert Consensus and Narrative Review on the Management of Multiple Sclerosis in the Arabian Gulf in the COVID-19 Era: Focus on Disease-Modifying Therapies and Vaccination Against COVID-19

This article describes consensus recommendations from an expert group of neurologists from the Arabian Gulf region on the management of relapsing multiple sclerosis (RMS) in the COVID-19 era. MS appears not to be a risk factor for severe adverse COVID-19 outcomes (though patients with advanced disability or a progressive phenotype are at higher risk). Disease-modifying therapy (DMT)-based care appears generally safe for patients with MS who develop COVID-19 (although there may be an increased risk of adverse outcomes with anti-CD20 therapy). Interferon-β, teriflunomide, dimethyl fumarate, glatiramer acetate, natalizumab and cladribine tablets are unlikely to increase the risk of infection; fingolimod, anti-CD20 agents and alemtuzumab may confer an intermediate risk. Existing DMT therapy should be continued at this time. For patients requiring initiation of a DMT, all currently available DMTs except alemtuzumab can be started safely at this time; initiate alemtuzumab subject to careful individual risk-benefit considerations. Patients should receive vaccination against COVID-19 where possible, with no interruption of existing DMT-based care. There is no need to alter the administration of interferon-β, teriflunomide, dimethyl fumarate, glatiramer acetate, natalizumab, fingolimod or cladribine tablets for vaccination; new starts on other DMTs should be delayed for up to 6 weeks after completion of vaccination to allow the immune response to develop. Doses of the Oxford University/AstraZeneca vaccine may be scheduled around doses of anti-CD20 or alemtuzumab. Where white cell counts are suppressed by treatment, these should be allowed to recover before vaccination.