The following advice was prepared by the Australian and NZ - Neuroimmunology interested specialists in MS March 2020 in view of the COVID19 pandemic

Advice for patients with multiple sclerosis and related disorders regarding COVID-19 outbreak

Background
Since December 2019 following cases emerging in and around Wuhan, China most regions of the world have now experienced cases of a novel respiratory illness caused by a new coronavirus which has been identified as COVID-19.
The mortality of this infection amongst cases displaying symptoms and confirmed to have the virus is in the order of 1-3%, mainly in older persons with other health problems.
National and International measures to reduce the risk of transmission of the virus have been implemented in most jurisdictions. It is likely that these measures will slow the rate of transmission, but at this point it is unclear if further spread can be prevented and it is unclear how long the present outbreak will last.
At present there is no known effective treatment for COVID-19 and there is no vaccine. Older persons and those with pre-existing medical conditions (respiratory disease, heart disease, diabetes, cancer) have a higher risk of complications from COVID-19 infection.
At this stage, there is no evidence that being immunosuppressed increases a person’s risk of being infected with COVID-19, but there is a theoretical increased risk of developing complications if infected.
In New Zealand, we are currently at alert level  4. where it is hoped that the measures being implemented will limit the number of people infected and the present risk of being infected with COVID-19 is low. This situation may change. We will continue to monitor this and change our advice accordingly.

How can I protect myself from getting COVID-19?
In order to minimise the risk of being infected by COVID-19, you should follow the standard precautions advised by the Ministry of Health New Zealand (see https://www.health.govt.nz/our-work/diseases-and-conditions/covid-19-novel-coronavirus/covid-19-novel-coronavirus-health-advice-general-public#prevention). This is the best source of advice on how to keep yourself safe and will be updated daily.
What if I develop symptoms of COVID-19 infection or have a confirmed diagnosis of COVID-19 infection?
If you develop symptoms of COVID-19 infection (see https://www.health.govt.nz/our-work/diseases-and-conditions/covid-19-novel-coronavirus/covid-19-novel-coronavirus-health-advice-general-public#symptoms) or have a confirmed diagnosis of COVID-19 infection you should:
• Follow the standard self-isolation advice (see https://www.health.govt.nz/our... ).
• Follow the advice of the diagnosing doctor or health care facility.
• Seek the advice of your neurologist or ask the diagnosing health care team to discuss with them or the on-call neurologist.

Who should I contact if I have symptoms of COVID-19 infection?
If you are concerned that you are developing symptoms of COVID-19 you can:
1) Phone the Coronavirus Health Information Line 0800 358 5453
(or for international SIMs +64 9 358 5453).
2) Phone your General Practitioner for an appointment (please phone ahead to make an appointment).
Should I come to my outpatient clinic, infusion or MRI appointment?
If you have visited a high-risk area, have symptoms of COVID-19 infection or have had close contact with someone who has been diagnosed with COVID-19 please do not attend your outpatient appointment, infusion or MRI. Please contact your specialist clinic, MRI department, infusion centre or MS Nurse to advise of your need to cancel the appointment and make alternative arrangements.
Should I travel overseas?
Current travel advice is available on the New Zealand Safe Travel website (see https://www.safetravel.govt.nz/)
We also suggest if you are planning to travel you contact your travel insurance provider.
Should I have the flu and pneumonia vaccinations?
It is recommended that all persons with MS have the flu vaccination when it becomes available in April. The Pneumococcal vaccination is also recommended.

What should I do about my medication?
If you are on a regular medication for MS or a related condition then it is recommended that you should continue to take this medication because of the very real risk of relapse when medication is ceased.

With regards to specific therapies:
1) Glatiramer acetate [Copaxone], beta-interferon [Avonex, Betaferon, Plegridy, Rebif]):
• These medications are not immunosuppressive.
• You should continue these medications and follow the standard advice regarding prevention of COVID-19 infection.
2) Plasma exchange, intravenous gammaglobulin [IVIg]):
• These therapies have a minimal impact on immune function.
• You will require a blood test before your treatment
• You should continue these therapies and follow the standard advice regarding prevention of COVID-19 infection.
3) Dimethyl fumarate [Tecfidera], teriflunomide [Aubagio]):
• These therapies are mildly immunosuppressive, there is currently no evidence that they increase the risk of COVID-19 infection.
• Because of the very real risk of relapse on discontinuing these therapies compared to the currently low risk of COVID-19 infection our present advice is that these medications should be continued.
• Please ensure you are up to date with your blood safety monitoring
• You should follow the standard advice regarding prevention of COVID-19 infection.
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4) Fingolimod [Gilenya] and siponimod [Mayzent]):
• These therapies are moderately immunosuppressive. Because of this there is a possible increased risk of contracting the COVID-19 infection.
• However because of the very real risk of relapse on discontinuing these therapies compared to the current risk of COVID-19 infection our present advice is that these medications should be continued.
• Please ensure you are up to date with your blood safety monitoring.
• You should follow the standard advice regarding prevention of COVID-19 infection.
5) Natalizumab [Tysabri]:
• These therapies have a minimal impact on immune function.
• Because of the very real risk of relapse on discontinuing this therapy compared to the currently risk of COVID-19 infection our present advice is that these medications should be continued.
• You should follow the standard advice regarding prevention of COVID-19 infection.
6) Prednisolone, methotrexate [MTX], azathioprine [Imuran], mycophenolate mofetil [Cellcept], cyclophosphamide [Cytoxan]:
• The level of immunosuppression with these medications is variable and depends upon the dosage and combination of treatments.
• Because of the very real risk of relapse on discontinuing these therapies compared to the currently low risk of COVID-19 infection our present advice is that these medications should be continued.
• Please ensure you are up to date with your blood safety monitoring.
• You should follow the standard advice regarding prevention of COVID-19 infection.
7) Ocrelizumab [Ocrevus], Rrituximab [Rituxan]:
• These therapies are immunosuppressive to varying degrees and for variable times
• Decisions as to whether or not to delay a course of these therapies should be discussed with your neurologist.
• You may be asked to go into self-isolation for 14 day following an infusion.
• Please ensure you are up to date with your blood safety monitoring.
• You should follow the standard advice regarding prevention of COVID-19 infection.
8) Cladribine [Mavenclad]:
• These therapies are mildly-moderately immunosuppressive for a limited period.
• There is currently no evidence that they increase the risk of COVID-19 infection.
• Because of the very real risk of relapse on discontinuing this therapy compared to the current risk of COVID-19 infection our present advice is that these medications should be continued.
• Please ensure you are up to date with your blood safety monitoring
• You should follow the standard advice regarding prevention of COVID-19 infection.
9) Alemtuzumab [Lemtrada], AHSCT:
• These therapies are immunosuppressive to varying degrees and for variable periods of time.
• Decisions on whether or not to delay a course of these therapies should be discussed with your neurologist.
• Please ensure you are up to date with your blood safety monitoring.
• You should follow the standard advice regarding prevention of COVID-19 infection.



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