Article In Brief
An international group of women neurologists who treat multiple sclerosis discuss the impact that COVID-19 has had on research and care for patients with multiple sclerosis.
The inaugural meeting of the International Women in Multiple Sclerosis (iWiMS) was originally going to focus on the theme of women in leadership. But two days before the start of the meeting, it was clear that the number one concern on everyone's mind had shifted quickly to the public health crisis at hand—COVID-19.
Members from countries as distant as Australia, and over multiple time zones, convened instead on Zoom on March 18 to air concerns about care issues for multiple sclerosis (MS) patients and relay how their colleagues were faring. In interviews with Neurology Today, these neurologists spoke about how much the novel coronavirus had upended their lives over the past weeks and days.
A Rapidly Changing Environment
Fiona Costello, MD, FRCPC, associate professor in the departments of clinical neurosciences and surgery at the Cumming School of Medicine of the University of Calgary, and co-chair of the iWiMS Leadership Committee, works as a neurologist and neuro-ophthalmologist. A clinician-scientist, her area of research has been predominantly in the field of central nervous system (CNS) inflammatory disorders. At the time of the call, she was still seeing urgent new cases and follow-up patients in the clinic and handling non-urgent things by phone.
“I look after patients with diseases that are potentially life-threatening and blinding, so my personal challenge is to balance the risk of my patient contracting or spreading COVID-19 against the risk of suffering ill effects from their condition,” Dr. Costello said. Her institute has quickly responded to the COVID-19 crisis by implementing policies that limit patient exposure, cancelling elective procedures, and restricting hospital access to non-essential staff. Like many other institutions, they have a backup call schedule in place.
“Calgary is in lockdown, schools are out, businesses are closed, and there is no socializing,” Dr. Costello explained. Before entering the clinic, she gets temperature checks and must answer exposure-related questions, she added.
Labs Are Closing
Research facilities have also been shutting down. Soheila Karimi, PhD, professor of physiology and regenerative medicine at the Rady Faculty of Health Sciences of the University of Manitoba in Winnipeg, Canada, said, “We had major changes at our university this week, at both teaching and research fronts...it was really surreal.”
All in-person classes were cancelled suddenly, she explained, and they had to transition all graduate, medical, and undergraduate teaching courses to online format quickly and adjust to virtual teaching.
“I continue to conduct my weekly group meeting, teaching, university meetings virtually and in isolation at home,” she said. “At the research front, the impact was even bigger for us. I direct a research program and we had to quickly wrap up all ongoing experiments and shut down the lab until further notice; some planned research had to be cancelled.”
Dr. Karimi expects that there will be setbacks and interruptions in the experimental part of her research, and that these cancellations and closures of research labs may delay program completions of their graduate students. “Naturally, as a researcher, I am also concerned about future research funding given the global economic crisis, although my priority now is the safety and health of everyone across the globe,” she added.
Emmanuelle Waubant, MD, PhD, FAAN, professor of neurology at the University of California, San Francisco, (UCSF), director of the UCSF Regional Pediatric MS Center, and chair of the iWiMS Executive Committee, said, “I have spent hours daily on Zoom or on the phone working remotely with my research staff and students, whereas in the past most of my research interactions were in person,” she said.
She and her colleagues have postponed patients coming in for study visits as their research unit remains open only for crucial visits such as patient infusions.
Concerns About Patient Care
“My most immediate concern is that urgent patients with non-COVID-19 emergent or urgent health issues are going to get poor care, and suffer,” said Dr. Costello. “My long-range concern is that we will go the way of Italy, and not have the infrastructure to look after dying people,” she added.
“As more of us become ill and outpatient neurologists are moved to the inpatient setting, I fear the management of our MS patients will greatly suffer,” said Lauren B. Krupp, MD, FAAN, professor of neurology and director of the MS Division at NYU Langone Health, which as of March 19 had moved all MS outpatient visits to virtual visits.
Dr. Waubant and several others described the anxiety many MS patients are facing. She said that her clinic has been bombarded with emails and calls from patients regarding the safety of disease-modifying therapies (DMTs) in the COVID-19 era and how to best protect themselves.
“We have also been confronted with situations in which employers are refusing to allow employees—our patients—to work at home so our practice has been completing requests for short-term disability instead,” she explained.
Dr. Waubant, like many of her MS colleagues on the call, expressed concern about the lack of data regarding the safety of DMT for her MS patients during the epidemics, limiting what clinicians can tell them.
“Equally worrisome is the likely disruption in MS patient care when the numbers with COVID-19 infection will be so high,” she said. “Infusion centers or MS clinics may have to close or limit their hours; some of the DMTs—which should not be discontinued without bridging to another treatment due to the risk of rebound relapse—may end up discontinued with possible irreversible disability incurred by patients,” she added. Finally, she said, she anticipates that there will be a decreased ability to send patients safely to do their laboratory tests or MRI monitoring.
Fears for Colleagues Abound
“This week one of our MS providers who was doing inpatient general neurology consult work has become sick, potentially with COVID-19, and we are all very concerned,” Dr. Krupp reported. “As protective gear and equipment becomes less available, I fear for the health of my fellow physicians and colleagues.”
“At the research front, the impact was even bigger for us. I direct a research program and we had to quickly wrap up all ongoing experiments and shut down the lab until further notice; some planned research had to be cancelled.”
—DR. SOHEILA KARIM
Dr. Krupp said she is also alarmed that her hospital is already experiencing shortages in equipment.
“In Canada, we are not suffering the way that our colleagues in Asia or Europe are suffering, and I hope it doesn't come to that; I believe we are in a state of anxious concern, waiting for the wave to hit,” Dr. Costello observed. She said the medical community is worried about exponential growth of cases, and lack of ventilators, but she takes comfort in the strong communication and policies put in place by their institutional and government leadership (a state of emergency has been declared).
“I believe that Alberta and Canada as a whole are leading the way in testing for COVID-19 per the population in North America, with over 20,000 people tested in Alberta (as of March 20) already, and we are all following the numbers,” she added.
Staying Safe and Protecting Others
Dr. Krupp believes that periodic virtual conferences for moral support as well as information sharing (as was done on the call) are extremely important. “We are all focused on the health of our patients, the well-being of our families, friends, and colleagues, and the stability of our health infrastructure and the socioeconomic underpinnings of our community,” she said. “I sincerely hope other areas in the USA and elsewhere will learn from the experiences we are having in New York City and throughout the world,” she cautioned.
Dr. Costello summed up the sentiment of many of the participants on the call. “My greatest concern is that I will infect my family, friends, and patients. Even now, given the asymptomatic spread of this condition, I see myself as a vector, and a potential threat to everyone.”
COVID-19: A Neurologist's View From the Front Lines in Spain
In Spain—which currently has one of the highestconfirmed cases of the 2019 novel coronavirus in the world, after China and Italy—many neurologists have been redeployed to care for COVID-19 patients. Georgina Arrambide, MD, PhD, neurologist and clinical researcher at the Multiple Sclerosis Centre of Catalonia (Cemcat), and professor of neurology-neuroimmunology at the Universitat Autònoma de Barcelona, who also participated in the iWiMS session, provided a glimpse into how life has changed in Spain where several of her colleagues have either tested positive or were under quarantine.
“Besides outpatient work at Cemcat, we provide inpatient consult work for suspected or confirmed neuroimmunological cases at Vall d'Hebron University Hospital in Barcelona, Spain, and some of my colleagues are doing night shifts, so we are spread thin,” she said. At Cemcat, they are doing phone visits in most cases, delaying long-lasting cell-depleting treatments as much as possible and, in more active cases, considering switching patients to other highly effective DMTs.
“We now have two suspected cases of COVID-19 in MS,” she said, adding that most neurological patients have been discharged from the hospital. “All residents, including neurology residents, are now doing COVID-19 night shifts, and neurologists have to do both the neurology night shifts and the inpatient care work.”
As of March 20, there were four neurologists in the COVID-19 teams: Two had started to see patients and the other two, including herself, were serving as back-ups.
Protective gear is becoming less available, although administration at Vall d'Hebron stated that they're working to solve this problem. “We are concerned that lack of protective gear will increase the risk of health care personnel becoming infected, thus straining the system even more—and we haven't reached the contagion peak, yet.”
The hospital intends to re-open an old ICU that had not been dismantled yet, so it will be put to use again. “But this might also mean that the hospital could become a COVID-19 hospital for several weeks and patients from other areas, including ours, may suffer the consequences,” Dr. Arramide said.
As for colleagues, some people are having difficulties adapting, Dr. Arramide noted. “One big problem is uncertainty: You never know when you'll be called to see COVID-19 patients and many individuals don't cope well with uncertainty.” She is trying to plan ahead but remain flexible.
“As a health care worker, you also have to cope with the fact that your chances of getting infected are greater than that of the general population,” she said. “There are also several colleagues whose partners are also physicians and/or have small children, so they have great difficulties balancing work and family life these days.”