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Updated advice for persons with multiple sclerosis and related disorders regarding the COVID-19 pandemic

washing hands
9 November 2020

Background

Since December 2019 following cases emerging in and around Wuhan, China most regions of the world have now experienced cases of a novel respiratory illness (COVID-19) caused by a new coronavirus which has been identified as SARS-CoV-2. Globally, the mortality of this infection amongst cases displaying symptoms and confirmed to have the virus is in the order of 4%. National and International measures to reduce the risk of transmission of the virus have been implemented in most jurisdictions. As predicted these measures have slowed the rate of transmission, but at this point community spread of the virus continues in most regions of the world. The antiviral drug, Remdesivir, has been shown to shorten the duration of illness in those admitted to hospital. Corticosteroids, hydrocortisone and dexamethasone, have been shown to reduce the mortality risk in patients admitted to the intensive care unit. Phase III clinical trials of several potential vaccines have commenced and if successful, a vaccine could become available before the middle of 2021. However, initial vaccines may only be partially protective and the potential for ongoing community transmission may persist for several years. Older persons and those with pre-existing medical conditions (obesity, hypertension, respiratory disease, heart disease, diabetes, cancer) have a higher risk of complications from COVID-19 infection. Men are also at slightly increased risk. At this stage, there is no evidence that being immunosuppressed increases a person’s risk of being infected with COVID-19 or developing complications, but there is a theoretical risk of both. Preliminary evidence from the use of chemotherapy for the treatment of cancer has so far been reassuring.

Worldwide there have now been some 36 million people infected with SARS-CoV-2 and over 1 million have died. The number of daily new cases continues to grow steadily whilst the numbers of deaths have stabilised at 5,000 per day. In Australia, we remain in a containment phase with near eradication being achieved in several states and territories, where the only new cases have occurred in interstate or overseas arrivals and their immediate contacts. At present, the risk of contracting COVID-19 in Australia remains low and in many regions is effectively zero. In total, there have been 27,226 confirmed cases of COVID-19 in Australia with 897 deaths, giving a mortality rate of 3.3% which is slightly below the global average. The latest data indicate that the number of new cases is once again declining following a second wave that principally affected Victoria. Just over 90% of deaths have occurred in Victoria. This suggests that the present transmission prevention efforts have been effective, with some notable exceptions. This has been the result of two main factors. The first is that the population of Australia has largely followed the recommendations of social distancing and personal protection. The second is the outstanding work undertaken by our Public Health team who have successfully traced the source of 80-90% of cases and implemented testing, quarantine and self-isolation as necessary. This has been an amazing achievement and goes largely unnoticed. However, we need to remain vigilant as the situation may still change as was recently shown in Victoria. We will continue to monitor this and change our advice accordingly.

Preliminary studies looking at the incidence and impacts of COVID-19 in persons with MS (pwMS) have now been completed. Whilst further data collection and analysis is ongoing, what is clear at the present time is:

  1. The risk of a pwMS contracting COVID-19 appears to be no higher than the risk for the general population. If anything the risk is slightly lower. It has been speculated that this could be due to either stricter adherence to social distancing measures for those who consider themselves at risk or a protective effect of MS therapies (see below).
  2. The overall risk of developing complications of COVID-19 (requirement for ventilation or intensive care treatment, and death) are no greater for a pwMS than the general population.
  3. The same risk factors for a worse outcome from COVID-19 seen in the general population (age >60 years, male gender, comorbid conditions [diabetes, hypertension, obesity, cardiovascular disease, chronic respiratory disease and cancer]) have been confirmed in pwMS.
  4. The COVID-19 pandemic has affected the behaviour of pwMS. In one study, 40% of pwMS had postponed clinical appointments, laboratory tests and MRI scans. Treatment alterations were made in 14% and worryingly in 65% this decision had been self-determined and was not at the advice of their neurologist.
  5. Collectively, treatments for MS have not been associated with an increased risk of contracting COVID-19, developing complications of COVID-19 or death from COVID-19. Again, if anything the data points to a slight protective effect of MS therapies. As indicated above, the reduced risk of infection may relate to changed social distancing behaviour in those on therapy, but the reduction in complications and mortality suggests a beneficial effect on disease severity from these immunological agents,

One exception to the above is in relation to anti-CD20 therapies (ocrelizumab and rituximab). The evidence in relation to the risk of contracting any COVID-19 infection on these therapies is indeterminate with several studies showing no increased risk (and possibly reduced risk) over population expectations, but one large study showing an increased risk. However, the main determinant of contracting any infection is whether one is exposed to the virus, with only the secondary issues of whether, if exposed, it gets in and becomes a symptomatic infection likely to be altered by MS treatments. Several studies have now all shown a consistent effect of anti-CD20 therapies increasing the risk of serious infection (hospitalisation and/or requirement for ICU care) in pwMS. The risk of death shows a similar trend, but is not statistically significant, even when studies were combined. The larger studies looking at this did adjust for age, gender, disease course and MS disease severity and the association with worse outcomes from COVID-19 persisted for anti-CD20 therapies. However, it should be noted that the risk associated with anti-CD20 therapies was small compared to the established risk factors of age and comorbid disease.

 

How can I protect myself from getting COVID-19?

In order to minimise the risk of being infected by COVID-19, you should follow the standard precautions advised by the Australian Government (see https://www.health.gov.au/health-topics/novel-coronavirus-2019-ncov#prevention). This is the best source of advice on how to keep yourself safe and will be updated daily.

 

What if I develop symptoms of COVID-19 infection or have a confirmed diagnosis of COVID-19 infection?

If you develop symptoms of COVID-19 infection (see https://www.health.gov.au/health-topics/novel-coronavirus-2019-ncov#symptoms) or have a confirmed diagnosis of COVID-19 infection you should:

  • Follow the advice of the diagnosing doctor or health care facility.
  • Seek the advice of your neurologist or ask the diagnosing health care team to discuss with them or the on-call neurologist regarding any changes to your treatment.
  • It is extremely important that you advise your neurologist if you become infected with COVID-19 as we will be collectively monitoring the outcomes for people with MS and various therapies. This will assist in providing appropriate advice to all.

 

Who should I contact if I have symptoms of COVID-19 infection?

If you are concerned that you are developing symptoms of COVID-19 you can:

  1. Phone the Coronavirus Health Information Line 1800 020 080.
  2. Phone the Health Direct Hotline 1800 022 222.
  3. Phone your General Practitioner for an appointment (please phone ahead to make an appointment).
  4. Attend a coronavirus testing centre (these are listed for each state by the relevant health department, again please phone ahead to make an appointment).

 

Should I come to my outpatient clinic, infusion, blood test or MRI appointment?

If you have visited a high-risk area, have symptoms of COVID-19 infection or have had close contact with someone who has been diagnosed with COVID-19 please do not attend your outpatient, infusion, blood test or MRI appointment. Please contact your specialist clinic, MRI department, infusion centre or MS Nurse to advise of your need to cancel the appointment and make alternative arrangements. Most neurology clinics are now able to offer telephone or telehealth consultations.

It is important to remember that MRI scans and blood tests form an important part of the monitoring of your disease activity and potential side effects of medication. In some instances, there may be adverse consequences of delaying or cancelling these investigations. Please contact your neurologist before making any changes to your planned investigations. MRI departments in hospitals and private radiology practices have implemented measures to limit the risk of infection.

Some private pathology services offer a home collection service. Please contact your pathology service for details. This may require the approval of your neurologist.

 

Should I travel overseas?

Current travel advice is available on the Australian Smart Traveller website (see www.smartraveller.gov.au), but essentially all overseas travel is currently severely restricted.

 

Should I have the flu and pneumonia vaccinations?

It is recommended that all persons with MS and related disorders have the flu vaccination. The Pneumococcal vaccination is also recommended.

 

What if I am a healthcare worker?

At present we have no evidence of an increased risk of COVID-19 infection or its complications in pwMS or related conditions, even in those on treatment. However, as indicated below there are potential, theoretical risks with some medications and it would be sensible for healthcare workers on any of these therapies to avoid work environments that would bring them into direct contact with people either known to be or likely to be infected with COVID-19. If you require any documentation to this effect, please contact your neurologist who will be happy to assist.

 

What should I do about my medication?

If you are on a regular medication for MS or a related condition, it is recommended that you should continue to take this because of the very real risk of relapse when the medication is ceased. This is in view of the very low risk of contracting COVID-19 in Australia, the lack of evidence for any increased risk of COVID-19 infection or its complications in pwMS on immunomodulatory therapies, and only a marginal increase in the risk of a more severe course of COVID-19 on rituximab and ocrelizumab. 

 

With regards to specific therapies:

  1. Self-injected therapies (glatiramer acetate [Copaxone], beta-interferon [Avonex, Betaferon, Plegridy, Rebif]):
    • These medications are not immunosuppressive.
    • You should continue these medications and follow the standard advice regarding prevention of COVID-19 infection.
  2. Intermittent immunotherapies (plasma exchange, intravenous immunoglobulin [IVIg]):
    • These therapies have a minimal impact on immune function.
    • You should continue these therapies and follow the standard advice regarding prevention of COVID-19 infection.
  3. Regular potentially immunosuppressive MS therapies (natalizumab [Tysabri], fingolimod [Gilenya], siponimod [Mayzent], dimethyl fumarate [Tecfidera], teriflunomide [Aubagio]):
    • These therapies are mildly immunosuppressive, there is currently no evidence that they increase the risk or consequences of COVID-19 infection. Specifically, studies of natalizumab, dimethyl fumarate and teriflunomide have not shown any cause for concern.
    • Because of the very real risk of relapse on discontinuing these therapies compared to the currently low risk of COVID-19 infection, the present advice is that these medications should be continued.
    • Your neurologist may wish to monitor your immune cell counts more frequently.
    • You should follow the standard advice regarding prevention of COVID-19 infection.
  4. Immunosuppressive therapies (prednisolone, methotrexate [MTX], azathioprine [Imuran], mycophenolate mofetil [Cellcept], cyclophosphamide [Cytoxan]):
    • The level of immunosuppression with these medications is variable and depends upon the dosage and combination of therapies.
    • Because of the very real risk of relapse on discontinuing these therapies compared to the currently low risk of COVID-19 infection the present advice is that these medications should be continued.
    • Your neurologist may wish to monitor your immune cell counts more frequently.
    • You should follow the standard advice regarding prevention of COVID-19 infection.
  5. Pulsed immunosuppressive therapies (rituximab [Rituxan], ocrelizumab [Ocrevus], alemtuzumab [Lemtrada], cladribine [Mavenclad], autologous haematopoietic stem cell therapy [AHSCT]):
    • These therapies are immunosuppressive to varying degrees and for variable periods of time.
    • Because of the pulsed nature of these therapies there are options to delay courses of treatment.
    • Decisions on whether or not to delay a course of these therapies should be discussed with your neurologist.
    • Because of the very low risk of COVID-19 in many states and territories the use of alemtuzumab has resumed sometimes with additional precautions of self-isolation immediately before and after therapy.
    • A study of cladribine has not shown any cause for concern.
    • The risk/benefit profile of rituximab and ocrelizumab in those with additional risk factors for worse outcomes from COVID-19 (age >60 years, male gender, comorbidities, higher levels of disability) needs to be considered carefully on a case-by-case basis.
    • You should follow the standard advice regarding prevention of COVID-19 infection, in some situations, on the advice of your neurologist, it may be appropriate to take additional precautions.

 

 

Signatories

 

Simon Broadley

Bill Carrol

Natasha Gerbis

Deborah Mason

Mike Boggild

Heidi Beadnall

Anneke van der Walt

Jeannette Lechner-Scott

Jane Frith

Suzanne Hodgkinson

Stephen Reddel

Richard Macdonell

Michael Barnett

Mark Marriott

Pamela McCombe

Trevor Kilpatrick

Bruce Taylor

Allan Kermode

Ernie Willoughby

Simon Hawke

Mahtab Ghadiri

Tomas Kalincik

Steve Vucic

Ian Sutton

Todd Hardy

Ann French

Mastura Monif

Helmut Butzkueven

John Parratt

Olga Skabina

Caron Chapman

Patrick Aouad

Judy Spies

Nicholas Crump