If you have MS and think you are vulnerable to severe COVId-19 have you asked the obvious question? How long do I shield or self-isolate for?
The impact of Boris Johnson’s admission to ITU with severe COVID-19 on the collective mind of the UK will be substantial. I suspect pwMS who think they are vulnerable will now go into shielding mode in an attempt to never get exposed to SARS-CoV-2. Is this a feasible long-term strategy?
Yes, trying to never get infected with SARS-CoV-2 and waiting for a vaccine is one feasible option if this was in-line with the governments COVID-19 strategy. However, at the moment the government strategy is not clear. Without aggressive testing, case and contact finding and local quarantine programmes we have to assume their current strategy is still trying to flatten-the-curve and extending-the-tail of the epidemic until herd immunity does the job and the COVID-19 epidemic fizzles out. This strategy will take many many months to run its course during which vulnerable people will need to remain shielded. Shielding has social and mental-health consequences that most of us have yet to appreciate.
Active surveillance and contact tracing are what is being done in China, Korea and Singapore. The downside of the latter is that it takes hard work. Already in Singapore, we have seen a second flare, i.e. the peak appeared to come and gone, but once social distancing regulations were being lifted the epidemic flared-up again.
I think there is some disagreement between public health officials, epidemiologists and politicians which is the best approach to take. It would help if we had better data on how many of the population had already been infected with the virus, but we don’t. Current estimates on the proportion of the population who may have already been infected vary wildly. A major blow is a laboratory study from Oxford showing that the point-of-care finger-prick antibody tests to see if you have had SARS-CoV-2 don’t work very well. This means we will have to resort to the doing standard laboratory tests for antibodies on whole blood samples. This doesn’t matter; it is better to get reliable data that will allow the modellers to work-out what is best for the UK to quell this epidemic and to allow us to get back to business, which for me is treating pwMS and studying MS.
I reviewed a patient with MS in my telemedicine clinic yesterday. He has classified himself as being vulnerable, which I don’t agree with, and has put himself into shielding. He is quite disabled and hence has stopped his carers coming into his house. He is now having to battle with doing his own domestic chores, cooking his own food and doing his own on-line shopping without help. This is complicated by the fact that he is often incontinent, which creates an extra burden on personal hygiene. He has a dog that needs walking, which he is battling to do in his small back garden. His is clearly under a lot of stress. I am not convinced his position is tenable for much longer. He is just one example of how the COVID-19 epidemic is affecting individuals with MS.
This is why we need to start planning an exit strategy for pwMS. When do we start derisking patients, i.e. taking them off the vulnerable list and managing them face-2-face, encouraging them to reconnect with their families and friends, and eventually the wider community? Do we wait for herd immunity? Do we wait for a vaccine? Do we wait for a reliable antibody test and derisk/reintegrate those that are antibody positive? Do we tell our low-risk patients that it is okay to get COVID-19 because once you have had the infection you are then immune to reinfection? Or do we wait for the government to say now is the time to get back to normal? When do we start redosing alemtuzumab and other DMTs and restart our HSCT programme? When do we restart our clinical trials? Many questions and no answers.
If I was in charge of government policy I would hedge my bets and implement both strategies, i.e. (1) case and contact finding with quarantine and (2) flattening-the-peak and extending the tail of the epidemic until we have herd immunity. Once the seroprevalence data comes in; i.e. what proportion of the population has been infected asymptomatically and have early data from vaccine trials we can then definitively commit to one of the two paths based on data.
At the moment I am very frustrated; we are fighting a tactical war without a longterm strategy in place. Sadly, with Boris Johnson in ITU will there be anybody in government, with the power and chutzpah, to make a strategic decision?