948231 research-article20202020 MSJ0010.1177/1352458520948231Multiple Sclerosis JournalBP Moss, KR Mahajan MULTIPLE SCLEROSIS MSJ JOURNAL Original Research Paper Multiple sclerosis management during Multiple Sclerosis Journal 1­–9 the COVID-19 pandemic DOI: 10.1177/ https://doi.org/10.1177/1352458520948231 1352458520948231 https://doi.org/10.1177/1352458520948231 © The Author(s), 2020. Brandon P Moss , Kedar R Mahajan , Robert A Bermel, Kelsey Hellisz, Le H Hua , Article reuse guidelines: Timothy Hudec, Scott Husak, Marisa P McGinley, Daniel Ontaneda , Zhini Wang, sagepub.com/journals- Malory Weber, Paula Tagliani, Simón Cárdenas-Robledo, Ana Zabalza , permissions Georgina Arrambide , Pere Carbonell-Mirabent, Marta Rodríguez-Barranco, Jaume Sastre-Garriga , Mar Tintore , Xavier Montalban, Morgan Douglas, Esther Ogbuokiri, Berna Aravidis, Jeffrey A Cohen , Ellen M Mowry and Kathryn C Fitzgerald Abstract Correspondence to: Brandon Moss Background: People with multiple sclerosis (MS) may be at higher risk for complications from the Mellen Center for Multiple 2019 coronavirus (COVID-19) pandemic due to use of immunomodulatory disease modifying therapies Sclerosis, Cleveland Clinic, 9500 Euclid Ave, U-10, (DMTs) and greater need for medical services. Cleveland, OH 44195, USA. Objectives: To evaluate risk factors for COVID-19 susceptibility and describe the pandemic’s impact on mossb@ccf.org Brandon P Moss healthcare delivery. Kedar R Mahajan Methods: Surveys sent to MS patients at Cleveland Clinic, Johns Hopkins, and Vall d’Hebron-Centre Robert A Bermel Kelsey Hellisz d’Esclerosi Múltiple de Catalunya in April and May 2020 collected information about comorbidities, Timothy Hudec Scott Husak DMTs, exposures, COVID-19 testing/outcomes, health behaviors, and disruptions to MS care. Marisa P McGinley Results: There were 3028/10,816 responders. Suspected or confirmed COVID-19 cases were more likely Daniel Ontaneda Malory Weber to have a known COVID-19 contact (odds ratio (OR): 4.38; 95% confidence interval (CI): 1.04, 18.54). Jeffrey A Cohen In multivariable-adjusted models, people who were younger, had to work on site, had a lower education Mellen Center for Multiple Sclerosis, Cleveland Clinic, level, and resided in socioeconomically disadvantaged areas were less likely to follow social distancing Cleveland, OH, USA guidelines. 4.4% reported changes to therapy plans, primarily delays in infusions, and 15.5% a disruption Le H Hua Lou Ruvo Center for Brain to rehabilitative services. Health, Cleveland Clinic, Las Vegas, NV, USA Conclusion: Younger people with lower socioeconomic status required to work on site may be at higher Zhini Wang exposure risk and are potential targets for educational intervention and work restrictions to limit exposure. Department of Quantitative Providers should be mindful of potential infusion delays and MS care disruption. Health Sciences, Cleveland Clinic, Cleveland, OH, USA Paula Tagliani Simón Cárdenas-Robledo Keywords: COVID-19, SARS-CoV-2, multiple sclerosis, disease modifying therapies, health behaviors, Ana Zabalza healthcare delivery Georgina Arrambide Pere Carbonell-Mirabent Marta Rodríguez-Barranco Date received: 7 July 2020; accepted: 13 July 2020. Jaume Sastre-Garriga Mar Tintore Xavier Montalban Introduction the impact of DMTs on COVID-19 susceptibility and Servei de Neurologia- Neuroimmunologia, Centre Coronavirus disease 2019 (COVID-19), caused by severity, and the effects of SARS-CoV-2 on MS dis- d’Esclerosi Múltiple de severe acute respiratory syndrome coronavirus 2 ease activity. Moreover, many people with MS need Catalunya, (CEMCAT), Vall d’Hebron Institut de Recerca, (SARS-CoV-2), is a pandemic with a high case fatal- access to regular medical services (infusions, physical Vall d’Hebron Hospital ity rate (534,062 deaths out of 11,425,209 confirmed therapy, occupational therapy, botulinum toxin injec- Universitari, Universitat Autònoma de Barcelona, cases as of 7 July 2020) and is associated with tions for spasticity, and homecare services), which Barcelona, Spain unprecedented changes to daily life and delivery of could be disrupted by changes to healthcare delivery Morgan Douglas Esther Ogbuokiri healthcare.1 People with multiple sclerosis (MS), an as a result of the COVID-19 pandemic. Berna Aravidis inflammatory demyelinating and neurodegenerative Ellen M Mowry Kathryn C Fitzgerald disorder treated with immunomodulatory disease To better understand the impact of COVID-19 on the Division of modifying therapies (DMTs), may be at higher risk MS population, three large MS centers in the United Neuroimmunology and Neurological Infections, than the general public due to neurologic disability,2 States (US) and Europe, the Cleveland Clinic Mellen journals.sagepub.com/home/msj 1 Multiple Sclerosis Journal 00(0) Johns Hopkins University, Center for MS Treatment and Research (CC), the Study assessments Baltimore, MA, USA Johns Hopkins MS Precision Medicine Center of Survey questionnaires sent in April and May of 2020 Excellence (JH), and the Vall d’Hebron Centre collected core information regarding living situation, d’Esclerosi Múltiple de Catalunya (CEMCAT), sent a comorbidities, current DMT use, smoking and drug comprehensive survey to their respective clinic popu- use, work and home exposure risks, travel, recent ill- lations. The goals of the survey and the current manu- ness and symptoms, SARS-CoV-2 testing, and script are to evaluate candidate risk factors for COVID-19 outcomes and treatments from all sites. COVID-19 susceptibility and describe the impact of Additional information about use of immunomodula- the pandemic on routine MS management in a large tory therapies for conditions other than MS, health international MS clinical population. Here we report behaviors (social distancing, mask use, and number of the results from the first 3028 participants. weekly contacts outside the home), and the presence of a relapse or worsening MS symptoms associated with COVID-19 illness were collected by CC and JH. The Materials and methods impact of the pandemic on routine clinical care (delay, discontinuation, or modification of DMT use, and Study design interruption of services) was collected by CC. A strict This is a multicenter observational study combining countrywide lockdown was in place for Spain at the survey data with detailed demographics, MS disease time of survey completion, only allowing people to characteristics, and a battery of patient-reported out- leave their homes to buy food and medicine, to work, come measures from clinical registries maintained at and to care for minors, the elderly, and other vulnerable each participating institution. Sites prospectively people. As a result, social distancing practices were not coordinated data collection to ensure that key survey expected to vary widely, and questions about health and registry data were consistent across institutions. behaviors were omitted from the CEMCAT survey. This study was conducted in accordance with the Clinical practice registries contained demographics International Conference on Harmonization Good (age, sex, race, ethnicity, and indicators of socioeco- Clinical Practice Guideline, the Declaration of nomic status (SES)), information about MS disease Helsinki, and local ethical and legal requirements. history and treatment (disease duration, disease Approval was obtained from the institutional review course, and current and prior DMTs), and measures of boards of each participating institution. disability. Disability was assessed by the Expanded Disability Status Scale (EDSS), the most commonly used measure of MS-related disability,5 or the Patient Study population Determined Disease Steps (PDDS), a validated self- Participants were recruited from the clinic popula- report measure of MS disability strongly correlated tions of CC, JH, and CEMCAT. Surveys were sent to with the EDSS.6 Indicators of SES included years of adults age 18 and older, followed by a provider from education and the Area Deprivation Index (ADI) for one of the participating MS centers, with a clinical the US sites. The ADI is a composite measure that diagnosis of MS confirmed by chart review. Surveys incorporates 17 different measures of SES derived were sent by email or secure electronic medical record using geo-coded addresses; nationwide indices range communication. Survey data were collected and man- from 0 (least disadvantaged) to 100 (most aged using REDCap electronic data capture tools disadvantaged).7 hosted at each institution.3 Responders reported whether they had confirmed COVID-19 (viral symp- toms with a positive SARS-CoV-2 test result) or, if Statistical methods and data analysis untested, whether a healthcare provider suspected Baseline demographics, disease characteristics, and they had COVID-19. key comorbidities were reported with descriptive sta- tistics (mean and standard deviation for continuous All three MS centers are members of Multiple variables and frequency and percentage for categorical Sclerosis Partners Advancing Technology and Health variables). Differences between survey responders and Solutions (MS PATHS), a learning health system non-responders; participants with and without suspi- sponsored by Biogen in collaboration with 10 health- cion of having COVID-19; and SARS-CoV-2 positive care institutions in the United States and Europe.4 and negative cases were tested using logistic regression MS PATHS sites use a tablet-based application to models. Predictors of non-adherence to health behav- collect standardized patient data as part of routine iors were assessed using univariate and multivariable- clinical care. adjusted models performed with logistic regression 2 journals.sagepub.com/home/msj BP Moss, KR Mahajan et al. methods. Similar analyses evaluated potential differ- Suspected or confirmed COVID-19 was more preva- ences across sites via generalized linear models where lent for Spanish than the US residents (OR: 3.78; 95% appropriate. Statistical analysis was performed with the CI: 2.31, 6.17). R software, version 3.6.2.8 For the 2270 (75%) responders who were US resi- dents, the majority were strictly self-isolating, 1830 Results (81%), only leaving home to get basic necessities or to Of 10,816 people sent a questionnaire, 3028 (28%) go to work if they could not work from home; left finished the survey. Survey responders were predomi- home infrequently (mean 1.52 (standard deviation nantly female (75%) and white (90%) with relapsing (SD): 3.37)); and wore a mask when out in public, MS (72%). Across surveys, responders were older, 1329 (59%). We also conducted analyses assessing more likely to be female, more likely to be non-His- predictors of non-adherence to health behaviors (social panic whites, and had higher SES compared to distancing, mask use in public, and limiting number of non-responders. weekly contacts outside the home) (Table 3). In multi- variable-adjusted models, individuals having to work Table 1 summarizes characteristics of responders by on site, with lower education level, and residing in presence or absence of SARS-CoV-2 testing. For all more socioeconomically disadvantaged areas were responders, both tested and untested, 2334 (77%) less likely to be following social distancing guidelines. were on a DMT, 200 (7%) were taking an immu- Older individuals were more likely to follow social nomodulatory therapy for a condition other than MS, distancing guidelines. Predictors of social distancing 448 (15%) were current smokers or vapers, and 1376 were similar when stratified by site (CC vs. JH). (45%) had a medical comorbidity suspected to be a risk factor for more severe COVID-19 (obesity, Of the 90 suspected or confirmed COVID-19 cases, 5 hypertension, chronic obstructive pulmonary disease (5.6%) were hospitalized (1 from CC; 4 from CEMCAT). (COPD), diabetes, asthma, other chronic lung disease, 67 (74.4%) were recovering or fully recovered at the coronary artery disease, stroke, chronic kidney dis- time of the survey, while 3 (3.3%) had worsening symp- ease, cancer, other inflammatory disease, or HIV). Of toms or were recovering with complications. those with a medical comorbidity suspected to be a risk factor for more severe COVID-19, obesity Table 4 summarizes changes in MS management that (28.8%) and hypertension (19.1%) were most com- occurred as a result of the COVID-19 pandemic and mon. Contact with a known positive COVID-19 case incorporates results pooled from JH and CC (n = 2270). was relatively uncommon (1.8%). 100 (4.4%) survey responders reported changes to their therapy plans. By far, the most common type of Of 90 (3.0%) who reported having been tested for medication changes were delays in infusions (71.9%). SARS-CoV-2, 17 (18.8%) reported having a positive 94.6% cite preventing COVID-19 as the reason for test. Among those tested for SARS-CoV-2, there was a delay. Only half (51.2%) were advised to delay their lower proportion of men (14.4% vs. 25.2%), higher pro- infusion therapy by a healthcare provider. portion of people on immunomodulatory therapies for conditions other than MS (18.9% vs. 6.2%), and higher With respect to effects on MS care, 351 (15.5%) proportion of people with medical comorbidities (60.0% reported a disruption to rehabilitative therapy (physical vs. 45.0%) compared to untested individuals. therapy, occupational therapy, or botulinum toxin injec- tions), while 51 (2.2%) reported a disruption to home- There were 77 (2.5%) cases of suspected or confirmed care services. Those reporting disruption to rehabilitative COVID-19. Factors associated with suspected or con- therapy or homecare services were more likely to be firmed COVID-19 are summarized in Table 2. older (mean age 55.7 vs. 51.3 years; p < 0.001), have Suspected or confirmed cases were more likely to progressive MS (47.9% vs. 25.2%; p < 0.001), have a have contact with someone with known COVID-19 walking aid (46.4% vs. 18.9% cane use; p < 0.001), and (odds ratio (OR): 4.38; 95% confidence interval (CI): have a comorbid condition (65.2% vs. 58.8%; p = 0.04). 1.04, 18.54) or to live with someone with COVID-19 (OR: 13.94; 95% CI: 7.84, 24.80). For the US resi- dents, there was also a higher proportion of African Discussion Americans (15.6% vs. 6.8%) and people of lower SES The COVID-19 pandemic presents a unique challenge (ADI: 45.8 vs. 40.9), but these did not rise to the level to people with MS given the immune pathogenesis of of statistical significance (OR 2.56; 95% CI: 0.97, MS, use of treatments with immunomodulatory actions, 6.77 and OR 1.05; 95% CI: 0.90, 1.22, respectively). and need for access to regular medical services.9 In journals.sagepub.com/home/msj 3 Multiple Sclerosis Journal 00(0) Table 1. Survey population by COVID-19 testing status. COVID-19 testing status Not tested Tested p value n 2938 90 Age, mean (SD) 50.31 (12.09) 48.85 (12.42) 0.26 Male sex, n (%) 740 (25.2) 13 (14.4) 0.03 Race, n (%) White 2644 (90.0) 79 (87.8) 0.35 Black/African American 149 (5.1) 8 (8.9) Other 67 (2.3) 2 (2.2) Unknown 77 (2.6) 1 (1.1) Hispanic/Latino ethnicity 61 (2.1) 1 (1.1) 0.80 Area Deprivation Index, mean (SD)a 41.03 (25.14) 41.48 (25.21) 0.88 High school education or less, n (%)a 316 (14.4) 7 (9.2) 0.27 Disease duration, mean (SD) 16.40 (11.14) 17.50 (12.00) 0.21 RRMS, n (%) 2118 (72.1) 70 (77.8) 0.37 PDDS, mean (SD)a 2.07 (2.22) 1.68 (2.01) 0.56 EDSS, mean (SD)b 2.78 (2.00) 2.19 (2.43) 0.88 DMT, n (%) 0.76 Infusion 943 (33.3) 31 (34.4) Injectable 444 (15.7) 10 (11.1) None 669 (23.6) 25 (27.8) Oral 715 (25.3) 22 (24.4) Other 59 (2.1) 2 (2.2) Not reported 97 (3.3) 0 (0.0) Other immunotherapy, n (%)a 183 (6.2) 17 (18.9) <0.001 Any comorbidity, n (%)c 1322 (45.0) 54 (60.0) 0.007 Current smoker or vaper, n (%)a 433 (14.7) 15 (16.7) 0.72 Working on site, n (%)a 348 (15.9) 18 (23.7) 0.10 Positive COVID-19 test, n (%) – 17 Contact with positive case, n (%) 39 (1.7) 15 (16.7) <0.001 Positive household contact, n (%) 99 (3.4) 12 (13.3) <0.001 SD: standard deviation; RRMS: relapsing-remitting multiple sclerosis; PDDS: Patient Determined Disease Steps; EDSS: Expanded Disability Status Scale; DMT: disease modifying therapies. aData available in CC and JH surveys (n = 2270). bData available in CEMCAT survey (n = 758). cAny comorbidity denotes having obesity, hypertension, COPD, diabetes, asthma, other lung diseases, coronary artery disease, stroke, chronic kidney disease, cancer, other inflammatory diseases, or HIV. evaluating factors associated with suspected or con- distancing guidelines, whereas older individuals were firmed COVID-19 illness, only contact with someone more likely to report following social distancing guide- with known COVID-19 at home or in the community lines. Younger people with a lower education level may was significant, highlighting the importance of health be an important target for educational outreach regard- behaviors to prevent infection. ing health risks of COVID-19 and appropriate health behaviors. Because these individuals had fewer oppor- Overall, there was good compliance with reported tunities to work from home, clinician support for work social distancing measures, with 83% of participants restrictions may be important for people with MS who reporting strict self-isolation. However, individuals lack job flexibility, especially if they have risk factors required to work on site, with lower education level, for severe COVID-19 illness as defined in smaller and residing in more socioeconomically disadvantaged studies of MS populations2 and larger studies of non- areas were less likely to report following social MS populations.10–12 4 journals.sagepub.com/home/msj BP Moss, KR Mahajan et al. Table 2. Factors associated with suspected or confirmed COVID-19a in people with MS. No COVID-19 Suspected or confirmed OR (95% CI) for suspected COVID-19a or confirmed COVID-19b N 2951 77 Site, n (%) Cleveland Clinic 1557 (52.8) 26 (33.8) 1.00 (ref) Johns Hopkins 681 (23.1) 6 (7.8) 0.53 (0.22, 1.29) CEMCAT 713 (24.2) 45 (58.4) 3.78 (2.31, 6.17) Age, mean (SD)d 50.36 (12.12) 46.79 (10.84) 0.85 (0.63, 1.15) Male sex, n (%) 738 (25.5) 15 (19.7) 0.62 (0.35, 1.10) Race, n (%) White 2652 (89.9) 71 (92.2) 1.00 (ref) Black/African American 152 (5.2) 5 (6.5) 2.56 (0.97, 6.77) Other 68 (2.3) 1 (1.3) 1.16 (0.15, 8.75) Unknown 78 (2.6) 0 (0.0) – Hispanic/Latino ethnicity, n (%)c 62 (2.1) 0 (0.0) – Working on site, n (%)c 360 (16.1) 6 (18.8) 1.14 (0.46, 2.79) Area Deprivation Index, mean (SD)d,c 40.97 (25.13) 45.91 (25.75) 1.05 (0.90, 1.22) High school education or less, n (%)c 323 (14.4) 0 (0.0) RRMS, n (%) 2131 (72.2) 57 (74.0) 1.04 (0.62, 1.75) PDDS/EDSS, mean (SD) 2.24 (2.19) 2.30 (1.97) 0.95 (0.85, 1.07) Disease duration, mean (SD) 16.43 (11.19) 16.60 (10.15) 1.15 (0.93, 1.41) DMT, n (%) Injectable 438 (15.4) 16 (21.1) 1.00 (ref) Infusion 949 (33.4) 25 (32.9) 0.93 (0.49, 1.78) None 684 (24.1) 10 (13.2) 0.52 (0.23, 1.17) Oral 714 (25.1) 23 (30.3) 1.01 (0.52, 1.95) Other 59 (2.1) 2 (2.6) 0.79 (0.18, 3.58) Number of times leaving home per 1.52 (3.10) 2.47 (11.44) 1.07 (1.01, 1.14) week, mean (SD)c Number of times household contacts 1.42 (2.51) 1.25 (2.16) 0.97 (0.81, 1.15) leaving home per week, mean (SD)c Not adhering to social distancing 432 (19.3) 8 (25.0) 1.31 (0.58, 2.94) recommendations, n (%)c Viral symptoms, n (%) 782 (26.5) 71 (92.2) 66.09 (27.84, 156.88) Contact with positive case, n (%) 38 (1.7) 16 (20.8) 4.38 (1.04, 18.54) Positive household contact, n (%) 83 (2.8) 28 (36.4) 13.94 (7.84, 24.80) Any comorbidity, n (%)e 1339 (49.7) 37 (50.0) 1.83 (1.09, 3.07) Current smoker or vaper, n (%) 432 (15.7) 16 (21.1) 1.45 (0.82, 2.57) SD: standard deviation; CI: confidence interval; RRMS: relapsing-remitting multiple sclerosis; PDDS: Patient Determined Disease Steps; EDSS: Expanded Disability Status Scale; DMT: disease modifying therapies. aDenotes individuals who were confirmed positive cases and those who were suspected by a healthcare professional of ever having COVID-19 but were never tested. bOR are adjusted for location of suspected or confirmed COVID-19 case. Because of the relatively limited number of cases and cases were not distributed with equal frequency across centers, we did not perform extensive multivariable-adjusted analyses. cData for these variables were pooled from JH and CC surveys only (n = 2270, 32 with suspected or confirmed COVID-19). dOR for age represents a per 15-year increase; OR for ADI represents a per 10 percentile increase in deprivation. eAny comorbidity denotes having obesity, hypertension, COPD, diabetes, asthma, other lung diseases, coronary artery disease, stroke, chronic kidney disease, cancer, other inflammatory diseases, or HIV. With regard to practice management, most individu- Society and MS International Federation guidelines.13,14 als continued DMT dosing without intentional delays However, 5% of survey responders reported changes or discontinuations, consistent with National MS to their therapy plans, most commonly delays in journals.sagepub.com/home/msj 5 Multiple Sclerosis Journal 00(0) Table 3. Factors associated with differences in social distancing behavior. Strictly At least some OR (95% CI) for at least some in- self-isolating in-person socializing person socializing Univariate model Multivariable- adjusted modela N 1830 440 Age, mean (SD)b 52.44 (12.06) 50.01 (11.85) 0.78 (0.68, 0.89) 0.80 (0.65, 1.00) Male sex 405 (22.6) 115 (26.9) 1.26 (0.99, 1.60) 1.33 (0.99, 1.79) Race White 1584 (86.6) 385 (87.5) 1.00 (ref) 1.00 (ref) Black/African American 127 (6.9) 30 (6.8) 0.97 (0.64, 1.47) 1.06 (0.65, 1.74) Other 53 (2.9) 13 (3.0) 1.01 (0.54, 1.87) 0.99 (0.43, 2.28) Unknown 66 (3.6) 12 (2.7) 0.75 (0.40, 1.40) 1.35 (0.60, 3.01) Hispanic/Latino ethnicity 53 (3.0) 9 (2.0) 0.70 (0.34, 1.43) 0.62 (0.25, 1.57) Working on site 239 (13.1) 127 (28.7) 2.70 (2.11, 3.46) 1.92 (1.41, 2.64) Area Deprivation Index, mean 39.56 (24.92) 47.17 (25.13) 1.13 (1.08, 1.17) 1.13 (1.07, 1.20) (SD)b High school education or less 238 (13.0) 85 (19.3) 1.60 (1.22, 2.10) 1.54 (1.10, 2.17) RRMS 1272 (71.0) 309 (72.5) 1.07 (0.85, 1.36) 1.08 (0.78, 1.50) PDDS 2.09 (2.23) 1.91 (2.14) 0.96 (0.92, 1.01) 1.02 (0.94, 1.10) Disease duration 17.86 (11.52) 16.32 (10.97) 0.88 (0.80, 0.97) 1.02 (0.89, 1.18) DMT Injectable 242 (14.0) 40 (9.1) 1.00 (ref) 1.00 (ref) Infusion 609 (35.1) 162 (36.9) 1.61 (1.10, 2.35) 1.30 (0.82, 2.06) None 451 (26.0) 94 (21.4) 1.26 (0.84, 1.88) 1.47 (0.91, 2.36) Oral 408 (23.5) 134 (30.5) 1.99 (1.35, 2.93) 1.75 (1.10, 2.77) Other 24 (1.4) 9 (2.1) 2.27 (0.98, 5.23) 2.86 (1.02, 8.01) Wearing a mask when leaving the 1086 (59.3) 243 (55.2) 0.85 (0.69, 1.04) 0.64 (0.49, 0.85) house Number of times leaving the 1.26 (2.76) 2.58 (4.93) 1.11 (1.07, 1.14) 1.12 (1.08, 1.17) house per week Any comorbidityc 967 (59.8) 242 (60.2) 1.02 (0.81, 1.27) 1.03 (0.78, 1.35) Current smoker or vaper 255 (15.4) 87 (20.7) 1.44 (1.09, 1.88) 1.09 (0.78, 1.53) SD: standard deviation; CI: confidence interval; RRMS: relapsing-remitting multiple sclerosis; PDDS: Patient Determined Disease Steps; EDSS: Expanded Disability Status Scale; DMT: Disease Modifying Therapies. aMultivariable OR is adjusted for all factors included in the table. bOR for age represents a per 15-year increase; OR for ADI represents a per 10 percentile increase in deprivation. cAny comorbidity denotes having obesity, hypertension, COPD, diabetes, asthma, other lung diseases, coronary artery disease, stroke, chronic kidney disease, cancer, other inflammatory diseases, or HIV. Table 4. Changes in MS management occurring as a result infusions. While most of these individuals were of COVID-19. advised to delay their infusions, a large portion Characteristic N (%) delayed their infusions for other reasons, possibly due to their own concerns about treatment during the Disruption to rehabilitative therapy 355 (15.5) COVID-19 pandemic and possibly due to interrup- Disruption to homecare services 51 (2.2) tions of care. There was also a notable disruption of Changed or adjusted MS therapy 100 (4.4) rehabilitative therapy and homecare services among Type of medication change survey responders. These findings are consistent with Changed 8 (8.2) reports of disruptions in health services for other non- Delay 71 (73.2) communicable diseases.15 Interruptions to these ser- Stopped 18 (18.6) vices could have downstream consequences for MS-related outcomes and other aspects of health- MS: multiple sclerosis. related quality of life. 6 journals.sagepub.com/home/msj BP Moss, KR Mahajan et al. The relatively low proportion of tested individuals, honoraria from Sanofi and Merck; and is a member of potential for false negative polymerase chain reaction the International Women in Multiple Sclerosis (iWiMS) (PCR), and small number of cases makes estimation of network executive committee. https://orcid.org/0000- COVID-19 prevalence and prevalence of adverse dis- 0002-2657-5510. Dr R.A.B. has served as a consultant ease-related outcomes difficult, and, most likely, our for Biogen, EMD Serono, Genzyme/Sanofi, Genentech/ survey missed those with the most severe outcomes. Roche, Novartis, and Viela Bio. He receives ongoing Nevertheless, of the 90 suspected or confirmed research support directed to his institution from Biogen, COVID-19 cases, there were few hospitalizations, and Genentech, and Novartis. Mr P.C.-M.’s yearly salary is most reported having recovered or being fully recov- supported by a grant from Biogen to Fundació privada ered at the time of the survey. Larger ongoing registry CEMCAT toward statistical analysis, and he has studies will evaluate predictors of COVID-19 out- received travel expenses from Biogen. Dr S.C.-R. is an comes in people with MS. ECTRIMS clinical fellowship awardee; he has received travel expenses for scientific meetings from Biogen Our study has certain limitations. As with any obser- Idec and Genzyme, compensation for consulting ser- vational study, our survey is subject to ascertainment vices or participation in advisory boards from Roche bias. Differences in the demographic characteristics and Novartis, and speaking honoraria from Novartis. of responders versus non-responders demonstrate https://orcid.org/0000-0002-7612-3985. Dr J.A.C. some degree of ascertainment bias. In addition, more received personal compensation for consulting for severe illness or hospitalization could have prevented Adamas, Convelo, MedDay, and Mylan; and serving as prospective participants from responding. Even so, an editor of Multiple Sclerosis Journal. Ms M.D. has our findings were similar to a registry study of 11,672 nothing to disclose. Dr K.C.F. is supported by NIMH individuals in the CC population at large, where men, K01 MH121582 and a Career Transition Fellowship African Americans, older individuals, and those with from the National MS Society. Ms K.H. has nothing to known COVID-19 exposure were at higher risk of disclose. Dr L.H.H. has received speaking and consult- testing positive for COVID-19.16 ing fees from Biogen, Genzyme, Genentech, Novartis, Bristol Myers Squibb, and EMD Serono. Mr T.H. has Ongoing surveys will facilitate case ascertainment and nothing to disclose. Mr S.H. has nothing to disclose. Dr serve as a vehicle for future studies of change in behav- K.R.M. is funded by NIH NINDS K23 Career iors over time and effects of the pandemic on patient- Development Award 1K23NS109328. Dr M.P.M. has reported outcomes and MS disease management. served on scientific advisory boards for Genzyme and Longitudinal follow-up will also allow assessment of Genentech, research support from Novartis, and the degree to which disruptions of care affect disease receives funding from a KL2 (KL2TR002547) grant activity or severity independent of COVID-19. from Clinical and Translational Science Collaborative of Cleveland, from the National Center for Advancing Translational Sciences (NCATS) component of the Conclusion NIH. Dr X.M. received speaking honoraria and travel Our findings suggest that exposure risks are the driver expenses for scientific meetings, has been a steering of COVID-19 infection in the MS population. committee member of clinical trials or participated in Younger people with lower SES required to work on advisory boards of clinical trials in the past 3 years with site may be at higher risk for exposure and are poten- Actelion, Alexion, Bayer, Biogen, Celgene, EMD tial targets for educational intervention and clinician Serono, EXCEMED, Genzyme, MedDay, Merck, support for work restrictions to limit exposure. MSIF, Nervgen, NMSS, Novartis, Roche, Sanofi- Providers should be mindful of potential delays of Genzyme, Teva Pharmaceuticals, and TG Therapeutics. infusion therapies and disruption of MS care more https://orcid.org/0000-0002-0098-9918. Dr B.P.M. generally. reports research funding for investigator-initiated stud- ies from Roche and is site PI for studies sponsored by Declaration of Conflicting Interests Roche; he received speaking fees from Genzyme, con- The author(s) declared the following potential conflicts sulting fees for Roche, and has stock in Pfizer. Dr of interest with respect to the research, authorship, and/ E.L.M. reports research funding for investigator-initi- or publication of this article: Ms B.A. has nothing to ated studies from Biogen, Sanofi-Genzyme, and Teva, disclose. Dr G.A. has received compensation for con- and is site PI for studies sponsored by Biogen. She sulting services or participation in advisory boards received royalties for editorial duties for UpToDate. from Sanofi, Merck, and Roche; research support from Ms E.O. has nothing to disclose. Dr D.O. has received Novartis; travel expenses for scientific meetings from research support from the National Institutes of Health, Novartis, Roche, Stendhal, and ECTRIMS; speaking National Multiple Sclerosis Society, Patient Centered journals.sagepub.com/home/msj 7 Multiple Sclerosis Journal 00(0) Outcomes Research Institute, Race to Erase MS Jaume Sastre-Garriga https://orcid.org/0000-0002 Foundation, Genentech, Genzyme, and Novartis. He -1589-2254 has also received consulting fees from Biogen Idec, Mar Tintore https://orcid.org/0000-0001-9999-5359 Genentech/Roche, Genzyme, Novartis, and Merck. Ms Jeffrey A Cohen https://orcid.org/0000-0001-9245 M.R.-B. has nothing to disclose. Dr J.S.-G. has received -9772 compensation for participating on Advisory Boards, speaking honoraria and travel expenses for scientific meetings, consulting services or research support from Celgene, Novartis, Biogen, Teva, Merck, Almirall, and References Genzyme. https://orcid.org/0000-0002-1589-2254. Dr 1. World Health Organization. WHO Coronavirus P.T. is an ECTRIMS clinical fellowship awardee and Disease (COVID-19) Dashboard, covid19.who.int/ has received travel expenses for scientific meetings (2020, accessed 7 July 2020). from Roche. https://orcid.org/0000-0002-4048-7314. 2. Louapre C, Collongues N, Stankoff B, et al. Clinical Dr M.T. has received compensation for consulting ser- characteristics and outcomes in patients with vices and speaking honoraria from Almirall, Bayer coronavirus disease 2019 and multiple sclerosis. Schering Pharma, Biogen Idec, Genzyme, Merck- JAMA Neurol. Epub ahead of print 26 June 2020. Serono, Novartis, Roche, Sanofi-Aventis, and Teva DOI: 10.1001/jamaneurol.2020.2581. Pharmaceuticals. Dr M.T. is coeditor of Multiple Sclerosis Journal—Experimental, Translational and 3. Harris PA, Taylor R, Thielke R, et al. Research Clinical. https://orcid.org/0000-0001-9999-5359. 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