23 October 2020

Global COVID-19 advice for people with MS
COVID-19 is a new illness that can affect your lungs, airways and other organs. It is caused by a novel
coronavirus (called SARS-CoV-2) that has spread around the world.
The advice below was developed by MS neurologists* and research experts from MSIF’s member
organisations**. It is based on the emerging evidence for how COVID-19 affects people with multiple
sclerosis (MS) and expert opinion. This advice will be reviewed and updated as further evidence about
COVID-19 becomes available.

Advice for people with MS
Current evidence shows that simply having MS does not make you more likely to develop COVID-19 or to
become severely ill or die from the infection than the general population. However, the following groups ofpeople with MS are more susceptible to having a severe case of COVID-19:
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People with progressive MS
People with MS over the age of 60
Men with MS
Black people with MS and possibly South Asian people with MS
People with higher levels of disability (for example, an EDSS score of 6 or above, which relates toneeding to use a walking stick)
People with MS and obesity, diabetes or diseases of the heart or lungs
People taking certain disease-modifying therapies for their MS (see below)

All people with MS are advised to follow World Health Organization guidelines for reducing the risk ofinfection with COVID-19. People in the higher risk groups should pay particular attention to thesemeasures. We recommend to:
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Practice social distancing by keeping at least 1.5 metre distance (6 feet) between yourself andothers, to reduce your risk of infection when they cough, sneeze or speak. This is particularly
important when indoors but applies to being outdoors as well.
Make wearing a mask a normal part of being around other people and ensure that you are using it
correctly by following these instructions
Avoid going to crowded places, especially indoors. Where this is not possible, ensure to wear amask and practice social distancing.
Wash your hands frequently with soap and water or an alcohol-based hand rub (70% alcohol
content is considered most effective)
Avoid touching your eyes, nose and mouth unless your hands are clean
When coughing and sneezing, cover your mouth and nose with a flexed elbow or tissue
Clean and disinfect surfaces frequently especially those which are regularly touched
Talk to your health care provider about optimal care plans, through video consultations or inperson visits where needed. Visits to health clinics and hospitals should not be avoided if they arerecommended based on your current health needs.
Stay active and try to take part in activities that will enhance your mental health and wellbeing.
Physical exercise and social activities that can take place outside and with social distancing areencouraged.
Get the seasonal flu vaccination where it is available and encourage your family to do the same1

Caregivers and family members who live with, or regularly visit, a person with MS in one of the higher risk
groups should also follow these recommendations to reduce the chance of bringing COVID-19 infection
into the home.
Advice regarding disease-modifying therapies for MS
Many disease modifying therapies (DMTs) for MS work by suppressing or modifying the immune system.
Some MS medications might increase the likelihood of developing complications from a COVID-19 but thisrisk needs to be balanced with the risks of stopping or delaying treatment.
We recommend that people with MS currently taking DMTs continue with their treatment, unless advised
to stop by their treating clinician.
People who develop symptoms of COVID-19 or test positive for the infection should discuss their MS
therapies with their MS care provider or another health care professional who is familiar with their care.
Before starting on any new DMT or changing an existing DMT, people with MS should discuss with theirhealthcare professional which therapy is the best choice for their individual circumstances. This decision
should consider the following information:●●●MS disease course and activity
The risks and benefits normally associated with different treatment options
Additional risks related to COVID-19, such as:
o The presence of other factors for a more severe case of COVID-19, such as older age,
obesity, pre-existing lung or cardiovascular disease, progressive MS, higher risk
race/ethnicity etc, as listed above
o The current and anticipated future COVID-19 risk in the local areao Risk of exposure to COVID-19 due to lifestyle, for example whether they are able to selfisolate or are working in a high-risk environmento Emerging evidence on the potential interaction between some treatments and COVID-19
severity

Evidence on the impact of DMTs on COVID-19 severity
Interferons and glatiramer acetate are unlikely to impact negatively on COVID-19 severity. There is somepreliminary evidence that interferons may reduce the need for hospitalisation due to COVID-19.
The evidence available suggests that people with MS taking dimethyl fumarate, teriflunomide, fingolimod,
siponimod and natalizumab do not have an increased risk of more severe COVID-19 symptoms.
There is some evidence that therapies that target CD20 – ocrelizumab and rituximab – may be linked to
an increased chance of having a more severe form of COVID-19. However, these therapies should still beconsidered as an option for treating MS during the pandemic. People with MS who are taking them (orofatumumab and ublituximab that work in the same way) should be particularly vigilant regarding theadvice above to reduce their risk of infection.
More data on the use of alemtuzumab and cladribine during the COVID-19 pandemic are required tomake any assessment of their safety. People with MS who are currently taking these therapies and areliving in a community with a COVID-19 outbreak should discuss their current lymphocyte counts with theirhealthcare professional. (Lymphocytes are a type of white blood cell that helps protect the body frominfection). If their counts are considered to be low they should isolate as much as possible to reduce theirrisk.

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Recommendations on delaying second or further doses of alemtuzumab, cladribine, ocrelizumab andrituximab due to the COVID-19 outbreak differ between countries. People who take these medications andare due for the next dose should consult their healthcare professional about the risks and benefits ofpostponing treatment. People are strongly encouraged not to stop treatment without the advice of theirclinician.

Advice regarding aHSCT
Autologous Haematopoietic Stem Cell Treatment (aHSCT) includes intensive chemotherapy treatment.
This severely weakens the immune system for a period of time. People who have recently undergone
treatment should consider extending the period they remain in isolation during the COVID-19 outbreak toat least six months. People who are due to undergo treatment should consider postponing the procedurein consultation with their healthcare professional. If aHSCT treatment is given, chemotherapy should beadministered in rooms isolated from other hospital patients.

Seeking medical advice for relapses and other health concerns
People with MS should still seek medical advice if they experience changes in their health that may
suggest a relapse or another underlying issue such as an infection. This can be done using alternatives toin-person clinic visits (such as telephone or video consultations) if the option is available. In many cases, it
is possible to manage relapses at home.
The use of steroids for treating relapses should be carefully considered and only used for serious
relapses. There is some evidence that receiving high-dose steroids in the month prior to contracting
COVID-19 increases the risk of a more severe infection requiring a visit to hospital. Where possible, thedecision should be made by a neurologist experienced in the treatment of MS. People who receive steroid
treatment for a relapse should be extra vigilant and may want to consider self-isolation for at least a month
to reduce their risk from COVID-19.
People with MS should continue to participate in rehabilitation activities and stay active as much as
possible during the pandemic. This can be done through remote sessions where available or in clinics aslong as facilities are taking safety precautions to limit the spread of COVID-19. People with concerns
about their mental health should seek advice from their healthcare professional.

Flu vaccine
The flu vaccine is safe and recommended for people with MS. For countries entering flu season, werecommend people with MS receive the seasonal flu vaccine where it is available.

SARS-CoV-2 vaccine
At present there is not enough information available to comment on how the different SARS-CoV-2
vaccines in development would interact with MS or with disease-modifying therapies for MS. Advice will
be included in an updated version of this statement as soon as becomes available.

Advice for children or pregnant women with MS
At this time there is no specific advice for women with MS who are pregnant. There is general information
on COVID-19 and pregnancy from the World Health Organisation. There is no specific advice for children
with MS; they should follow the advice above for people with MS.

This statement was first agreed on 13 March 2020. The latest revisions were agreed on 21 October 2020
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The following individuals were consulted in the development of this advice:*MS neurologists and specialists
Professor Brenda Banwell, Chair of MSIF’s International Medical and Scientific Advisory Board (IMSB) –University of Pennsylvania, USA
Professor Simon Broadley - Griffith University and Gold Coast Hospital, Queensland, Australia
Professor Olga Ciccarelli - Institute of Neurology, UCL, UK
Dr Huang Dehui - Chinese PLA General Hospital, China
Dr Fernando Hamuy Diaz de Bedoya, President of LACTRIMS – Universidad Nacional de Asuncion,Paraguay
Professor Andrew Chan – Bern University Hospital, Switzerland
Professor Jeffrey Cohen, President of ACTRIMS – Cleveland Clinic Mellen Center for MS, USA
Dr Jorge Correale, Deputy Chair of MSIF’s IMSB – FLENI, Argentina
Professor Giancarlo Comi – IRCCS Ospedale San Raffaele, Italy
Professor Kazuo Fujihara, President of PACTRIMS – Fukushima Medical University School of Medicine,Japan
Professor Gavin Giovannoni, Barts and The London School of Medicine and Dentistry, Queen Mary
University of London, UK
Professor Bernhard Hemmer, President of ECTRIMS – Technische Universität München, Germany
Professor Joep Killestein, Amsterdam UMC, Netherlands
Professor Daphne Kos, President of RIMS - KU Leuven, National MS Center Melsbroek, Belgium
Dr Céline Louapre – Sorbonne Université, France
Professor Catherine Lubetzki – ICM, France
Professor Aaron Miller - Chairman, National Medical Advisory Committee, National MS Society (US);Icahn School of Medicine at Mount Sinai, USADr Mohammad Ali Sahraian- MS Research Center, Neuroscience Institute, Tehran University of MedicalSciences, Iran
Professor Marco Salvetti – Sapienza University, Italy
Dr Joost Smolders – ErasmusMC, Netherlands
Professor Per Soelberg Sørensen – University of Copenhagen, Denmark
Professor Maria-Pia Sormani, on behalf of the Italian MuSC-19 study – University of Genoa, Italy,
Professor Bassem Yamout, President of MENACTRIMS – American University of Beirut Medical Center,Lebanon
Professor Frauke Zipp, Johannes Gutenberg University Medical Center in Mainz, Germany**MSIF member organisations
Dr Clare Walton, Nick Rijke, Victoria Gilbert, Peer Baneke – MS International Federation
Phillip Anderson – MS Society (UK)
Pedro Carrascal – Esclerosis Múltiple España (Spain)
Dr Tim Coetzee, Dr Doug Landsman, Julie Fiol, Kathleen Costello – National MS Society (US)Professor Judith Haas – Deutsche Multiple Sklerose Gesellschaft Bundesverband e.V (Germany)
Dr Kirstin Heutinck – Stichting MS Research (Netherlands)
Dr Pam Kanellis – MS Society of Canada
Elisabeth Kasilingam – European MS Platform
Dr Marc Lutz – La Société suisse de la sclérose en plaques (Switzerland)Marie Lynning – Scleroseforeningen (Denmark)Dr Julia Morahan – MS Research Australia
Dr Emmanuelle Plassart-Schiess – ARSEP Fondation (France)
Dr Paola Zaratin – Associazione Italiana Sclerosi Multipla Onlus (Italy)
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