Greater MS disability reported in patients with COVID-19 infection

Infection with the virus that causes COVID-19 significantly accelerates neurological disability in people with multiple sclerosis (MS), at least in the first months after infection, a study from Belgium reported.

A more severe case of COVID-19, one requiring hospitalization, also significantly associated with a faster worsening of MS symptoms, its researchers noted. While being vaccinated against COVID-19 protected patients from a more severe infection, it did not prevent a faster accumulation of disability.

The study, “Occurrence and Severity of Coronavirus Disease 2019 Are Associated With Clinical Disability Worsening in Patients With Multiple Sclerosis,” was published in the journal Neurology: Neuroimmunology and Neuroinflammation.

Recommended Reading

March 17, 2023 Columns by Ed Tobias

3 tools to help you choose the right MS disease-modifying therapy

Changes in disability measured using the Expanded Disability Status Scale

A neurodegenerative disease, MS is marked by excessive inflammation in the brain and spinal cord. Infections are known to exacerbate disease symptoms and to increase the number of lesions evident on MRI scans. Studies also have pointed to a significant worsening of neurological MS symptoms after hospitalization for any cause.

Most research to date has focused on patients’ risk of severe infection with SARS-CoV-2, the virus causing COVID-19, and their immune responses to infection or vaccination. Few studies have examined how COVID-19 and its severity affect MS progression.

Researchers with Universitair Ziekenhuis Brussel and the Nationaal Multiple Sclerose Centrum (NMSC) Melsbroek opened an observational clinical study (NCT05403463) to examine disease progression in 234 patients, being followed at that center, who tested positive for COVID-19 from March 2020 through February 2022.

Patients’ mean age was 54, and they had been living with MS for an average of 23 years. About half (47.4%) had relapsing-remitting MS, 35.9% had secondary progressive MS, and 16.7% had primary progressive disease.

Of this group, 31 people or 13.2%  were hospitalized to treat COVID-19, and five patients or 2.1% died, mostly of complications following infection.

To examine changes in the rate of disease progression, as measured with the Expanded Disability Status Scale (EDSS), the researchers used the last two EDSS assessments before COVID-19 — called T0 and T1 — and the first assessment after the infection, called T2.

The mean interval between all three assessments was 13.7 months; the T1 measure was taken about eight months before COVID-19, and T2 about five months after testing positive for the virus.

Disease progression after COVID-19 infection — as seen in EDSS changes from T1 to T2 — was significantly higher than before infection, or from T0 to T1, results showed. Specifically, mean EDSS scores increased by 0.1 points before infection, moving from a mean of 5.5 to 5.6 on that scale, and by 0.3 points after COVID-19.

No differences in the progression of other measures of MS clinical disability, including walking ability, hand and finger dexterity, or cognition were evident.

Greater worsening seen in progressive patients, severe COVID-19 cases

Additional analyses found that the worsening in disease progression after infection was particularly evident in people with progressive MS and in those hospitalized due to more severe COVID-19 infection. Among progressive patients, mean EDSS score changes were 0.06 over the time prior to infection and 0.33 in the months after a positive test.

“We observed that the occurrence and severity of COVID-19 were both associated with worsening of global disability, as measured with the EDSS, over time in the individual patient trajectory,” the researchers wrote. “Mathematically expressed, a more aggressive course of COVID-19 resulted in a more than 2.5-fold increase of the risk of subsequent clinically relevant EDSS deterioration.”

At the time of a positive COVID-19 test, 53.8% of the patients were either fully vaccinated or had tested positive for COVID-19 within six months of their last vaccine dose.

Not surprisingly, more severe COVID-19 outcomes, including hospitalization and death, were seen among unvaccinated MS patients, particularly over the months prior to the vaccine becoming available in Belgium in March 2021.

However, both unvaccinated and vaccinated patients experienced faster MS progression after infection, indicating that vaccination did not protect against a worsening of MS-related disability.

“In our total cohort (N = 234), there were 17 patients (7.3%) with a neurologist-reported relapse and 96 (41.0%) with self-reported worsening of neurologic symptoms during the T1-T2 interval,” the researchers wrote.

While the mechanisms through which COVID-19 exacerbates MS progression remain unknown, the researchers noted that the infection can cause neurological symptoms, indicating the virus affects the nervous system.

COVID-19 also has been associated with a transient loss of myelin in the brain and spinal cord, and people with MS may have more difficulty recovering the lost myelin.

“Hesitancy and/or unwillingness to receive vaccination against SARS-CoV-2 ranges between 15% and 30% in patients with MS and is often instilled by safety concerns,” the researchers noted. “At present, COVID-19 vaccination is strongly advised for most people with MS, as it is the general view that potential benefits outweigh any possible risks in the vast majority of cases.”