On March 11, 2020, the World Health Organization (www.who.int) recognized COVID-19 as a pandemic.
COVID-19 spread much faster than both SARS, which infected 8000 people in eight months (https://www.cdc.gov), and MERS that took 12 months (https://www.cdc.gov) to infect 108 people. COVID-19 took only 8 weeks to infect 80,000 people worldwide.
The symptoms of COVID-19 are similar to those of influenza [1] and include fever, dry cough, hyposmia/anosmia, hypogeusia/ageusia, and shortness of breath. Eighty percent of those infected are asymptomatic or have a mild illness. Person-to-person transmission through airborne droplets has been established with a median incubation period of 5 days; the reproductive number is 2 to 3, and those who develop symptoms will do so within 11.5 days [2] . Case fatality rate is 1-4% (increasing with age > 50). So far, there is no specific treatment although remdesivir has been approved by FDA as an investigational new drug [3] . At the National Institutes of Health, a phase 1 study is ongoing for vaccine development.
Infection Prevention Practice includes the identification of potentially infected cases for isolation. At the same time, health care systems try to maintain the ability to provide essential health care while limiting the nosocomial spread of COVID-19 so that both non-COVID-19 patients and COVID-19-negative health care workers are protected from infection. Thus, responding to COVID-19 demands rapid adoption of new methods for triaging, educating, and monitoring patients.
During the COVID-19 pandemic, neurologists involved in the care of people with multiple sclerosis (pwMS) face a particular challenge since many of these patients (i) are on an immunotherapy, or (ii) belong-due to their disability and/or comorbidities-to the vulnerable proportion of the population, or both. While careful surveillance is required of pwMS who belong to these categories, they should be kept away from the hospital or outpatient clinics to minimize their risk of COVID-19 infection.
Approaches to reduce the risk for pwMS as well as the community may include the following steps:
1. Prior to engagement with the health system (outreach) (a) Ensure pwMS with scheduled appointments are screened in a non-face-to-face setting. (b) Pro-actively review population segments deemed high risk (e.g., immunocompromised).
During engagement with existing triage pathways (triage) 4. Approaches to decrease the burden for health care workers and mitigate their risk (a) Empower improved handling of inbound volume (b) Reduce unnecessary visits and increase efficiency of triage protocols by proactively engaging patients through customized digital programs and care pathways.
A possible way to pursue this objective is to use digital tools for surveillance and to triage patients through remote assessment of symptoms based on the US Center of Disease Control guidelines. In the COVID-19 context, as neurologists dedicated to pwMS, we found the management of immunocompromised patients particularly challenging. As a possible solution, we explored the use of a remote triage system to identify patients at risk for COVID-19. Based on the experience by colleagues at the Mount Sinai Hospital in New York, which leverages its existing digital tools to survey immunosuppressed patients with inflammatory bowel disease (Atreja A., personal communication), we developed a triage tool that can be sent to pwMS (see Table 1 ). The digital triage can be easily setup using Google Forms (https://docs.google.com/ forms/u/0/) which enables collection of responses almost in real time. The Google Forms platform may be used before checking for each specific country the General Data Protection Regulation (GDPR) compliance.
The use of digital triage could be personalized (in terms of frequency of invitation) according to the risk level and to the pandemic evolution.
Using digital triage during COVID-19 pandemic may have the following advantages. It may:
1. Limit unnecessary attendance of patients at the MS centers; 2. Reduce the disparities for patients living far from MS centers; and 3. Limit the economic impact of the disease.
In conclusion, patient-centric care using digital triage may decrease burden on health facilities, while enabling ongoing individualized surveillance and health care provision.
Conflict of interest The authors declare no conflict of interest in relation to this work.
Ethical approval The study protocol (questionnaire) was approved by the Ethics committee of University of Campania "Luigi Vanvitelli".