Lessons learned from COVID-19 – 2021 in review

The ongoing COVID-19 pandemic has provided many lessons, all of them hard. The number of cases and lives lost continued to climb throughout 2021. By the end of 2020, there were about 85.1 million cases of COVID recorded; that number is now about 260 million. By January 2021, there had been about 1.9 million COVID-related deaths. Now over 5.2 million people have died worldwide.

The largest proportion of cases and deaths occurred in the U.S. There were 28 million new cases of COVID-19 in 2021, bringing the total to about 49 million – about 19% of the world total. The number of deaths in the war on COVID now stands at 798,520 – more than all the combat deaths combined that the country has suffered since the Revolutionary war. The high number of cases has also meant that the COVID death rate for Americans with MS (3.6%) is at least two-fold higher than for people with MS living in other countries (0.8% in Sweden, 1.6% in Italy, 1.7% in France (Sormani M. ECTRIMS 2021).

In Canada, this past year also saw another 1.2 million cases (total 1.77 million) and 13,983 additional deaths, bringing the total number of lives lost to 29,589.

The one bright spot was the remarkable development of effective vaccines early in the year – arguably the single most important factor contributing to the declining death rate from COVID. By the end of last year, the case-mortality rate in Canada was 2.67%. In 2021 it declined to 1.17%. That difference translates to 18,000 Canadians who might otherwise have died.

The pandemic and the development of vaccines raised important questions for the MS community. Since MS is an autoimmune disorder, were people more susceptible to infection? Was vaccination safe? Those answers came relatively quickly as databases started collecting information – and the news was generally good. People with MS did not have a higher risk of catching COVID or developing severe disease – unless they had the same risk factors as other people, such as other medical conditions, disability or obesity. And COVID infection did not appear to trigger relapses or worsen a person’s MS (Dreyer-Alster and colleagues. ECTRIMS 2021; P187. Chou and colleagues. ECTRIMS 2021; P133).

People with MS also did not appear to have a higher risk of vaccine-related side effects. However, vaccination did highlight that MS treatments are not all the same. Some acted to modulate the immune response but did not profoundly affect a person’s ability to fight infection (including COVID). In this category were the injectable drugs (Copaxone, Avonex, Betaseron, Rebif, Plegridy), some of the oral drugs (Tecfidera, Aubagio), and Tysabri. People on these medications were able to keep taking their medication as usual.

In contrast, other MS medications did profoundly affect a person’s immune response. These included Mavenclad, Lemtrada, Gilenya, Mayzent and Ocrevus. (Two late additions, Zeposia and Ponvory, fall into the same category as Gilenya and Mayzent. Kesimpta, which is in the same category as Ocrevus, is dosed differently so has been something of a question mark.) Mavenclad and Lemtrada are only dosed for brief periods. So for these drugs, the issue became one of timing – scheduling the vaccine a few months after the last course of treatment. (This requirement was dropped for Mavenclad in the most recent guidelines.)

A bigger concern emerged with Ocrevus and Gilenya. Ocrevus was flagged early on as increasing a person’s risk of developing severe COVID (Simpson-Yap M. ACTRIMS/ECTRIMS 2020; SS02.04), which prompted some doctors to consider other options such as Tysabri. Then as vaccinations began, it also became apparent that Ocrevus, as well as Gilenya, significantly impaired a person’s response to vaccination (Achiron and colleagues. Ther Adv Neurol Disord 2021;14:17562864211012835). This meant that a vaccine provided less protection against COVID. In practical terms, that meant that people taking these drugs needed to take extra precautions – washing hands, avoiding crowds indoors, wearing a mask – to guard against contracting COVID-19 even as restrictions eased. These precautions became even more important as the year saw the spread of the more infectious forms of COVID, such as the Delta and Delta-plus variants.

People taking Ocrevus or Gilenya do respond somewhat to vaccination – so getting the two shots is still worthwhile (Apostolidis and colleagues. Nat Med 2021;27:1990-2001). But their response is not as good as it could be. That is why the MS Society petitioned the government in August to allow booster shots for people with MS taking certain medications, such as Ocrevus, Kesimpta, Gilenya, Zeposia, Ponvory, Mavenclad and Lemtrada – the drugs known to have profound effects on the immune response (https://mssociety.ca/resources/news/article/ms-society-advocates-for-covid-19-vaccine-boosters-for-immunocompromised-individuals-with-ms).

The MS community to its credit has avoided much of the culture wars surrounding vaccination; few people have not gotten vaccinated. Unfortunately, as we close out the year, the pandemic shows little sign of easing and most people in the world (58%) have not been fully vaccinated (https://ourworldindata.org/covid-vaccinations?country=~OWID_WRL). So booster shots will likely be necessary for many people. The higher priority group will include people taking medications such as Ocrevus and Gilenya, but ultimately most people in the MS community will likely be candidates for a booster shot as they become more widely available in 2022.

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