2 March 2020

Update on MS and Coronavirus - 2 March

Because people with pre-existing conditions are widely perceived to be more at risk from coronavirus, we have had many questions from members of the Overcoming MS community about the possible impact of Covid-19 on people with MS. The situation continues to change but hand hygiene, social distancing and PPE remain effective measures, and doctors are unlikely to recommend stopping DMTs (disease-modifying therapies) given that the immunosuppression associated with them is relatively low.

COVID-19

Whether or not the current global Coronavirus outbreak is technically a “pandemic” or not is largely arbitrary, it has involved enough people in enough countries, and there is no doubt that it causes significant cause for concern. This is a virus never before seen in humans, and therefore there is no herd immunity against it. It also appears to be extremely infective, and at latest count there are an estimated 84,000 cases with almost 3,000 deaths worldwide.

The symptoms of coronavirus to look out for:

Cough
High temperature
Shortness of breath

But these symptoms do not necessarily mean you have the illness, the symptoms are similar to other more common conditions, such as cold and flu.

It must also be kept in perspective. Seasonal influenza (“the flu”) kills between 50,000 – 60,000 people globally each year, and gets nowhere near the same media coverage, let alone a stock market crash! The flu is also potentially a new virus every winter, and whilst there is a vaccine, the evidence for its effectiveness is not always that promising. COVID-19 is in many ways simply another flu.

So far, the epidemiological data tells us that this a condition with a rule of fifths:

4 in every 5 sufferers recover quickly with minimal to moderate symptoms only, requiring no treatment
1 in every 5 sufferers are more severely affected, requiring medical assessment and possible hospital care
A further 1 in 5 of this 1 in 5 group become very unwell, requiring more intensive supportive treatment
The current mortality risk is between 1 and 2 for every 100 people infected.

How to reduce risk

The best general prevention strategy seems to be through simple hygiene measures:

Cover your mouth and nose with a tissue or your sleeve (not your hands) when you cough or sneeze
Put used tissues in the bin immediately
Wash your hands with soap and water frequently – use hand sanitiser gel if soap and water are not available
Try to avoid close contact with people who are unwell
Do not touch your eyes, nose or mouth if your hands are not clean

Like with influenza, we know that the elderly and people with other serious health conditions are at increased risk of complications and death from Coronavirus, so there is a natural anxiety amongst the MS community as to what Coronavirus might mean for us, especially when many are also taking immunosuppressive drugs.

There is obviously a degree of uncertainty with COVID-19 specifically, but if you apply the basic principles from what we already know about other infective diseases and those undergoing chemotherapy or taking MS treatments, the news is generally reassuring.

Changes to treatment

Doctors are very unlikely to recommend stopping your disease-modifying therapy (DMT) at present. The immunosuppression associated with DMTs is relatively mild and therefore most people with MS (pwMS) can combat infections relatively well. The exceptions are alemtuzumab (Lemtrada), and potentially cladribine (Mavenclad), during the early stages of treatment, when the lymphocyte (a type of white blood cell that fights viruses and bacteria) count is low. Once the immune system has rebuilt itself, there should be no issue in dealing with infections.

Fingolimod (Gilenya)

Although fingolimod (Gilenya) causes a low lymphocyte count, they are simply trapped in lymph nodes rather than circulating in the blood. Therefore, pwMS on fingolimod can generally combat viral infections, although they tend to have more frequent and possibly more severe infections. This also applies to the other drugs in the same class (siponimod, ponesimod, ozanimod).

Anti-CD20 therapies

The immune response to viruses whilst talking the anti-CD20 therapies (rituximab, ocrelizumab and ofatumumab) should also be almost normal, but may be slightly slower than in the general population.

Natalizumab (Tysabri)

In those taking natalizumab (Tysabri), there is a potential concern over COVID-19 and a brain infection called encephalitis. This is similar to the infection PML, and due to the drug preventing the immune system from “patrolling” the brain. But, at present, we don’t know if this particular type of Coronavirus has that potential, and even if it does, it generally only happens in those who are severely immunocompromised. If you are concerned, we would suggest discussing this with your MS team.

Tecfidera (BG-12, dimethyl fumarate)

Tecfidera has only a mild immunosuppressive effect, so it is unlikely to cause a significant issue with COVID-19, unless your lymphocyte count is very low, e.g. less than 0.8 x 109/L.

Other DMTs

Teriflunomide (Aubagio), glatiramer acetate (Copaxone) and interferon beta (Betaferon, Avonex, Rebif, Plegridy) are not immunosuppressive and should not increase your risk of COVID-19.

As the situation now stands, the risk of COVID-19 infection to the general public, and hence pwMS is low, outside of certain areas (mainland China, South Korea, Iran and Italy). It would therefore not be routinely recommended to change your DMT or delay a planned infusion at this stage.

If however you are currently immunosuppressed, it is very important to be extremely vigilant about hygiene (handwashing, etc.) and to avoid travel to high-risk areas.

The benefit of using a face mask to protect against COVID-19 is largely unknown, as this is a new pathogen to humans. At present, it also appears the virus is spread by droplets, rather than being aerosolised, and therefore sits on surfaces rather in the air. For that reason, rigorous hand hygiene is likely to be more effective at preventing spread. It is also very dependent on the quality of the mask you are wearing, as to whether it provides any meaningful protection.

Advice

For more information on the current situation in your area and for travel advice and restrictions, please refer to your local Public Health Authority and Government information sources.