COVID-19 vaccine acceptance and hesitancy in N'Djamena, Chad: A cross-sectional study of patients, community members, and healthcare workers

As of March 2022, the COVID-19 vaccination rate in Chad approximated 1%. There are no published reports of COVID-19 vaccine hesitancy or beliefs in Chad. We aimed to study COVID-19 vaccine acceptance and hesitancy among community members, patients, and health care workers in urban Chad. We recruited a prospective convenience sample of adult patients, community members, and healthcare workers from N'Djamena, Chad between August-October 2021. Participants completed a 15-minute, 25-question survey instrument exploring demographic, social, and clinical variables related to COVID-19 and an adapted WHO SAGE Vaccine Hesitancy Survey. Primary outcomes were vaccine acceptance and vaccine hesitancy. Regression models were fit to assess associations between Vaccine Hesitancy Scale (VHS) scores, ranging from 10 (least hesitant) to 50 (most hesitant) points, and pre-selected variables of interest. An inductive thematic analysis was used to analyze the qualitative vaccine hesitancy responses. Of 508 participants (32% female; mean age 32 years), 162 were patients, 153 were community members, and 193 were healthcare workers. COVID-19 vaccine acceptance was significantly higher among patients (67%) than community members (44%) or healthcare workers (47%), p < .001. The average VHS score was 29 points (patients = 27.0, community members = 28.9, healthcare workers = 29.4), and more than one-third of participants were classified as highly vaccine hesitant (score >30 points). Knowing someone who died from COVID-19, believing local healthcare workers support vaccination, trusting the government, having a higher socioeconomic status (i.e. having electricity), and reporting medical comorbidities were each associated with less vaccine hesitancy (all p < .05). The vaccine concerns most frequently endorsed were: vaccine side effects (48%), efficacy (38%), safety (34%), concerns about the pharmaceutical industry (27%), and lack of government trust (21%). Four main themes arose from qualitative vaccine hesitancy responses (n = 116): education, trust, clinical concerns, and misinformation and false beliefs. Overall, COVID-19 vaccine acceptance was low, including among health care workers, and reasons for vaccine hesitancy were broad. We detail the most commonly reported concerns of urban Chadians for receiving the COVID-19 vaccine; we also identify subgroups most likely to endorse vaccine hesitancy. These analyses may inform future vaccination outreach campaigns in N'Djamena.

Positive Predictive Value of MOG-IgG for Clinically Defined MOG-AD Within a Real-World Cohort

Myelin oligodendrocyte glycoprotein antibody associated disease (MOG-AD) is a CNS demyelinating disease, typically presenting with optic neuritis, transverse myelitis, and/or ADEM-like syndromes. The positive predictive value (PPV) of MOG-IgG testing by live cell-based assay was reported to be 72% in a study performed at the Mayo Clinic using a cut-off of 1:20. PPV may vary depending upon the tested population, thus supporting further investigation of MOG-IgG testing at other centers. In this real-world institutional cohort study, we determined the PPV of serum MOG-IgG for clinically defined MOG-AD in our patient population. The Massachusetts General Brigham Research Patient Data Registry database was queried for patients with positive serum MOG-IgG detection, at least once, between January 1, 2017 and March 25, 2021. All were tested via the MOG-IgG1 fluorescence-activated cell sorting assay (Mayo Laboratories, Rochester, MN). MOG-IgG positive cases were reviewed for fulfillment of typical MOG-AD clinical features, determined by treating neurologists and study authors. Of 1,877 patients tested, 78 (4.2%) patients tested positive for MOG-IgG with titer ≥1:20, and of these, 67 had validated MOG-AD yielding a PPV of 85.9%. Using a ≥1:40 titer cutoff, 65 (3.5%) tested positive and PPV was 93.8%. Three MOG positive cases had a prototypical multiple sclerosis diagnosis (RRMS n = 2, titers 1:20 and 1:40; PPMS n = 1; 1:100). The treating diagnosis for one RRMS patient with a 1:40 titer was subsequently modified to MOG-AD by treating neurologists. Validated diagnoses of the remaining positive patients without MOG-AD included: migraine (n = 2, titers 1:20, 1:100), inclusion body myositis (n = 1, titer 1:100), autoimmune encephalitis (n = 2, titers 1:20, 1:20), hypoxic ischemic brain injury (n = 1, titer 1:20), IgG4-related disease (n = 1, titer 1:20), and idiopathic hypertrophic pachymeningitis (n = 1, titer 1:20). In our cohort, the PPV for MOG-IgG improved utilizing a titer cut-off of ≥1:40. The presence of positive cases with and without demyelinating features, emphasizes a need for testing in the appropriate clinical context, analysis of titer value and clinical interpretation.

How Should Relief Organizations Fund Care of Patient-Asylees Who Have Cancer?

Several clinical and ethical dilemmas arise when caring for refugees with complex, costly, and chronic conditions in low- and middle-income countries where they often first seek asylum. This commentary responds to a case involving a patient asylee with a malignant brain tumor and considers these questions: (1) Should refugee care costs be allocated as a specific amount per refugee or designated to fund only specific interventions? (2) Should interventions not available to host population members with low incomes be available to refugees? (3) Should refugee cancer care focus on cure, rehabilitation, and palliation or on just one or two of these areas? This commentary responds to these questions by considering how to approach trade-offs between numbers of patients treated and per patient expenditures.

Anti-SARS-CoV-2 monoclonal antibodies for the treatment of active COVID-19 in multiple sclerosis: An observational study

Monoclonal antibodies (mAbs) against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) received emergency use authorization for the acute treatment of COVID-19. We are not aware of published data on their use in immunosuppressed people with multiple sclerosis (pwMS). We report 23 pwMS (mean age = 49 years, ocrelizumab (n = 19), fingolimod (n = 2), vaccinated with at least an initial series (n = 19)) who received mAb for acute COVID-19. Following mAb receipt, approximately half recovered in <7 days (48%). There were no adverse events or deaths. Use of mAb for pwMS treated with fingolimod or ocrelizumab was not observed to be harmful and is likely helpful for treatment of acute COVID-19.

Measuring Ambulation, Motor, and Behavioral Outcomes with Post-stroke Fluoxetine in Tanzania: The Phase II MAMBO Trial

We test the safety of fluoxetine post-ischemic stroke in sub-Saharan Africa. Adults with acute ischemic stroke, seen <14 days since new-onset motor deficits, were enrolled from November 2019 to October 2020 in a single-arm, open-label phase II trial of daily fluoxetine 20 mg for 90 days at Muhimbili National Hospital, Dar es Salaam, Tanzania. The primary outcome was safety with secondary outcomes of medication adherence and tolerability. Thirty-four patients were enrolled (11 were female; mean age 52.2 years, 65% < 60 years old; mean 3.3 days since symptom onset). Participants had hypertension (74%), diabetes (18%), and smoked cigarettes (18%). The median National Institutes of Health Stroke Scale score at enrollment was 10.5. The median Fugl-Meyer Motor Scale score was 28.5 (upper extremity 8, lower extremity 17.5). 32/34 participants (91%) survived to 90 days. There were eight serious and two nonserious adverse events. Deaths occurred due to gastrointestinal illness with low serum sodium (nadir 120 mmol/L) with seizure and gastrointestinal bleed from gastric cancer. The average sodium level at 90 days was 139 mmol/L (range 133-146) and alanine transaminase was 28 U/L (range 10-134). Fluoxetine adherence was 96%. The median modified Rankin Scale score among survivors at 90 days was 2 and Fugl-Meyer Motor Scale score was 66 (upper extremity 40, lower extremity 27). Median 90-day Patient Health Questionnaire-9 and Montgomery-Åsberg scores were 3.5 and 4 (minimal depression). Fluoxetine administration for 90 days poststroke in sub-Saharan Africa was generally safe and well-tolerated, but comorbid illness presentations were fatal in 2/34 cases, even after careful participant selection.

A point-of-care diagnostic test for aquaporin-4 antibody seropositive neuromyelitis optica

BACKGROUND

Given the need for specialized laboratory techniques, diagnostic testing for serum antibodies to aquaporin-4, a protein associated with neuromyelitis optica spectrum disorder (NMOSD), is not globally accessible. We aimed to evaluate a novel point-of-care, filter paper-based test for serum AQP4 antibodies (AQP4-Ab).

METHODS

Adults with AQP4-Ab seropositive NMOSD and seronegative controls (with other central nervous system demyelinating diagnoses) used lancets to place blood drops (∼1 mL) on filter paper cards. Samples were analyzed after an average of 9.4 days using transfected AQP4-GFP HEK293 cells, and results were compared to participants' prior serum AQP4-Ab test results by blinded laboratory staff.

RESULTS

Of 40 participants (mean age 53.7 years; 83% female), 25 were cases and 15 were controls. The most common diagnosis of controls was multiple sclerosis (73%). The average NMOSD disease duration was 6.3 years. All AQP4-Ab seropositive participants were on disease modifying therapies at the time of participation. The point-of-care test yielded a sensitivity of 80% and specificity of 93% (positive and negative predictive values 95% and 74%).

CONCLUSION

This point-of-care AQP4-Ab testing method may become a pragmatic option to diagnose AQP4-Ab seropositive NMOSD in difficult-to-reach settings. This method should be confirmed with other testing parameters and field tested in new populations.

Efficacy of Fluoxetine for Post-Ischemic Stroke Depression in Tanzania

OBJECTIVE

Post-stroke fluoxetine trials are primarily conducted in high-income countries. We characterize post-ischemic stroke depression in fluoxetine-treated and -untreated study participants in urban Tanzania.

METHODS

Adults (>18 years old) within 14 days of CT-confirmed acute ischemic stroke onset were enrolled at Muhimbili National Hospital, Tanzania. The fluoxetine-treated group took 20mg fluoxetine daily for 90 days in a phase II trial and were compared to fluoxetine-untreated historical controls. The primary outcome was depression at 90 days, measured by the Patient Health Questionnaire-9 (PHQ-9). PHQ-9 scores were compared between fluoxetine-treated and -untreated groups. A score >=9 points was considered to reflect depression. A multivariable linear regression model assessed associations with post-stroke PHQ-9 scores.

RESULTS

Of the fluoxetine-treated (n=27) and -untreated (n=32) participants, the average age was 56.8 years old (39% women, 100% Black/African). The average presentation NIHSS score was 12.1 points and modified Rankin Scale (mRS) score was 3.5. The average mRS score at 90-day follow-up was 2.3. There was no significant difference between 90-day PHQ-9 scores in the fluoxetine-treated (mean=4.1 points, standard deviation=3.2; 11% depression) and untreated (mean=4.4, standard deviation=4.8; 19% depression) groups, p=.69. In the multivariable analysis, older age (β=0.08, p=.03) and higher NIHSS score (β=0.15, p=.04), but neither fluoxetine (β=0.57, p=.59) nor sex (β=-0.51, p=.63), were significantly associated with more depressive symptoms.

CONCLUSIONS

Our findings parallel results from trials from higher income settings that fluoxetine does not significantly improve post-ischemic stroke depression, although our sample size was small. More work is needed to depict the longitudinal nature and treatment of post-stroke depression in Sub-Saharan Africa.

Randomized Controlled Trials for Neuromyelitis Optica Spectrum Disorder: A Review of Trial Architecture

BACKGROUND

Neuromyelitis optica spectrum disorder (NMOSD) is a relapsing inflammatory disease that primarily affects the optic nerves and the spinal cord. Randomized controlled trials (RCTs) assessing treatments for NMOSD have only been performed in the past decade, and to date, there are 3 drugs approved by the US Food and Drug Administration (FDA) for antiaquaporin-4 immunoglobulin G seropositive NMOSD. This review assesses the characteristics and challenges of RCTs when evaluating treatments for NMOSD.

REVIEW SUMMARY

We conducted a review using the terms ("neuromyelitis optica" OR "NMO" OR "NMOSD") AND "clinical trial" in any language on March 28, 2021. Seven RCTs were included, and the trials' architecture was analyzed and synthesized. Overall, 794 subjects were randomized [monoclonal antibody intervention group, n= 493 (62.1%), placebo, n=196 (24.7%), and active control, n=105 (13.2%)]; 709 (89.3%) were females; and 658 (82.9%) were aquaporin-4 (AQP4) antibody seropositive. The primary outcome was time to relapse in 6/7 of the trials, and annualized relapse rate in the remaining one. Four RCTs used placebo in their design. Among the seven published RCTs, the trial design differed by the criteria used to define NMOSD relapse, selection of subjects, proportion of AQP4 immunoglobulin G seronegative patients, and baseline characteristics indicating NMO disease severity.

CONCLUSIONS

Ethical considerations for the use of placebo should change in light of the approval of 3 therapies for seropositive NMOSD. Remaining challenges for clinical trials in NMOSD include the assessment of long-term safety and efficacy, standardization of trial design and endpoints, and head-to-head study designs.

COVID-19 Vaccination Reactogenicity in Persons With Multiple Sclerosis

BACKGROUND AND OBJECTIVES

There are limited data on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine reactogenicity in persons with multiple sclerosis (PwMS) and how reactogenicity is affected by disease-modifying therapies (DMTs). The objective of this retrospective cross-sectional study was to generate real-world multiple sclerosis-specific vaccine safety information, particularly in the context of specific DMTs, and provide information to mitigate specific concerns in vaccine hesitant PwMS.

METHODS

Between 3/2021 and 6/2021, participants in iConquerMS, an online people-powered research network, reported SARS-CoV-2 vaccines, experiences of local (itch, pain, redness, swelling, or warmth at injection site) and systemic (fever, chills, fatigue, headache, joint pain, malaise, muscle ache, nausea, allergic, and other) reactions within 24 hours (none, mild, moderate, and severe), DMT use, and other attributes. Multivariable models characterized associations between clinical factors and reactogenicity.

RESULTS

In 719 PwMS, 64% reported experiencing a reaction after their first vaccination shot, and 17% reported a severe reaction. The most common reactions were pain at injection site (54%), fatigue (34%), headache (28%), and malaise (21%). Younger age, being female, prior SARS-CoV-2 infection, and receiving the ChAdOx1 nCoV-19 (Oxford-AstraZeneca) vs BNT162b2 (Pfizer-BioNTech) vaccine were associated with experiencing a reaction after the first vaccine dose. Similar relationships were observed for a severe reaction, including higher odds of reactions among PwMS with more physical impairment and lower odds of reactions for PwMS on an alpha4-integrin blocker or sphingosine-1-phosphate receptor modulator. In 442 PwMS who received their second vaccination shot, 74% reported experiencing a reaction, whereas 22% reported a severe reaction. Reaction profiles after the second shot were similar to those reported after the first shot. Younger PwMS and those who received the mRNA-1273 (Moderna) vs BNT162b2 vaccine reported higher reactogenicity after the second shot, whereas those on a sphingosine-1-phosphate receptor modulator or fumarate were significantly less likely to report a reaction.

DISCUSSION

SARS-CoV-2 vaccine reactogenicity profiles and the associated factors in this convenience sample of PwMS appear similar to those reported in the general population. PwMS on specific DMTs were less likely to report vaccine reactions. Overall, the short-term vaccine reactions experienced in the study population were mostly self-limiting, including pain at the injection site, fatigue, headache, and fever.

Acute Disseminated Encephalomyelitis and Acute Hemorrhagic Leukoencephalitis Following COVID-19: Systematic Review and Meta-synthesis

BACKGROUND AND OBJECTIVES

Since the onset of the COVID-19 pandemic, a growing number of reports have described cases of acute disseminated encephalomyelitis (ADEM) and acute hemorrhagic leukoencephalitis (AHLE) following infection with COVID-19. Given their relatively rare occurrence, the primary objective of this systematic review was to synthesize their clinical features, response to treatments, and clinical outcomes to better understand the nature of this neurologic consequence of COVID-19 infection.

METHODS

Patients with a history of COVID-19 infection were included if their reports provided adequate detail to confirm a diagnosis of ADEM or AHLE by virtue of clinical features, radiographic abnormalities, and histopathologic findings. Cases purported to be secondary to vaccination against COVID-19 or occurring in the context of a preexisting relapsing CNS demyelinating disease were excluded. Case reports and series were identified via PubMed on May 17, 2021, and 4 additional cases from the authors' hospital files supplemented the systematic review of the literature. Summary statistics were used to describe variables using a complete case analysis approach.

RESULTS

Forty-six patients (28 men, median age 49.5 years, 1/3 >50 years old) were analyzed, derived from 26 case reports or series originating from 8 countries alongside 4 patient cases from the authors' hospital files. COVID-19 infection was laboratory confirmed in 91% of cases, and infection severity necessitated intensive care in 67%. ADEM occurred in 31 cases, whereas AHLE occurred in 15, with a median presenting nadir modified Rankin Scale score of 5 (bedridden). Anti-MOG seropositivity was rare (1/15 patients tested). Noninflammatory CSF was present in 30%. Hemorrhage on brain MRI was identified in 42%. Seventy percent received immunomodulatory treatments, most commonly steroids, IV immunoglobulins, or plasmapheresis. The final mRS score was ≥4 in 64% of patients with adequate follow-up information, including 32% who died.

DISCUSSION

In contrast to ADEM cases from the prepandemic era, reported post-COVID-19 ADEM and AHLE cases were often advanced in age at onset, experienced severe antecedent infection, displayed an unusually high rate of hemorrhage on neuroimaging, and routinely had poor neurologic outcomes, including a high mortality rate. Findings are limited by nonstandardized reporting of cases, truncated follow-up information, and presumed publication bias.

Sociodemographic and clinical factors associated with depression, anxiety, and general mental health in people with multiple sclerosis during the COVID-19 pandemic

Background People with multiple sclerosis (PwMS) may be at increased risk for psychological distress during COVID-19. We study the self-reported mental health of U.S. PwMS during COVID-19, prior to vaccine rollout. Methods A cross-sectional survey was distributed online to PwMS through iConquerMS (12/18/2020-02/10/2021). Depressive and anxiety symptom burdens and general mental health status were measured via the Patient-Health Questionnaire-9, Generalized Anxiety Disorder-7, and PROMIS Global Mental Health scales. Linear regression models assessed associations between mental health variables and age, sex, disability status, comorbidities, and social determinants of health. Results Of 610 U.S. PwMS (mean age 56 years, standard deviation 11, range 20-85; female, 81%; relapsing remitting disease, 62%; previous depression diagnosis, 40%), the prevalences of moderate-to-severe depressive and anxiety symptom burden were 27.4% and 14.7%, respectively; 55.1% endorsed fair/poor general mental health. PwMS who tested positive for COVID-19 (n = 47, 7.7%) reported higher depressive and anxiety symptom burdens (p < 0.05). Increased disability status score and social determinants of health were each associated with more depressive symptoms and worse general mental health. Younger age was associated with increased depressive and anxiety symptom burdens and worse general mental health. Female sex was associated with greater anxiety symptoms. Conclusion There are specific associations for worse mental health among PwMS during COVID-19 that reflect a combination of clinical, demographic, and social determinants of health. Multidisciplinary care teams and vigilance are important to address the ongoing mental health impacts of COVID-19 in PwMS.

Epilepsy stigma in the Republic of Guinea and its socioeconomic and clinical associations: A cross-sectional analysis

OBJECTIVE

We aim to quantify the degree of epilepsy stigma perceived by people living with epilepsy (PLWE) in the Republic of Guinea (2019 gross national income per capita, 930 USD) and analyze the demographic, social, and clinical factors associated with epilepsy stigma in this setting.

METHODS

A prospective convenience cohort of PLWE was recruited at the Ignace Deen Hospital in Conakry and evaluated by U.S. and Guinean neurology-trained physicians. A survey instrument exploring demographic, social, and clinical variables was designed and administered. The primary outcome measure was the Stigma Scale of Epilepsy (SSE), a 24-item scale with scores ranging from 0 (least stigma)-100 (most). Regression models were fit to assess associations between SSE score and pre-selected demographic, social, and clinical variables of interest.

RESULTS

249 PLWE (112 female; mean age 20.0 years; 22 % from rural locales; 14 % of participants >16 years old with no formal schooling; 11 % seizure-free for >=6 months) had an average SSE score of 46.1 (standard deviation = 14.5) points. Children had an average SSE score of 45.2, and adults had an average score of 47.0. There were no significant differences between self- and guardian-reported SSE scores (means = 45.8 and 46.5, respectively), p = .86. In univariate analyses, higher stigma scores were associated with more seizures (p = .005), more depressive symptoms (p = .01), and lower household wealth (p = .03). In a multivariable model including sex, educational level, household wealth, generalized tonic-clonic seizures, seizure frequency, and seizure-related burns, only higher seizure frequency (β = -2.34, p = .03) and lower household wealth (β = 4.05, p = .03) were significantly associated with higher SSE scores.

CONCLUSION

In this Guinean cohort of people living with poorly-controlled epilepsy, there was a moderate degree of perceived stigma on average. Stigma was associated with higher seizure frequency and lower household wealth-both potentially modifiable factors.

Update on the management of multiple sclerosis during the COVID-19 pandemic and post pandemic: An international consensus statement

In this consensus statement, we provide updated recommendations on multiple sclerosis (MS) management during the COVID-19 crisis and the post-pandemic period applicable to neurology services around the world. Statements/recommendations were generated based on available literature and the experience of 13 MS expert panelists using a modified Delphi approach online. The statements/recommendations give advice regarding implementation of telemedicine; use of disease-modifying therapies and management of MS relapses; management of people with MS at highest risk from COVID-19; management of radiological monitoring; use of remote pharmacovigilance; impact on MS research; implications for lowest income settings, and other key issues.

Electronic pill bottles to monitor and promote medication adherence for people with multiple sclerosis: A randomized, virtual clinical trial

OBJECTIVE

We perform a randomized trial to test the impact of electronic pill bottles with audiovisual reminders on oral disease modifying therapy (DMT) adherence in people with MS (PwMS).

METHODS

Adults with multiple sclerosis (MS) taking an oral DMT were randomized 1:1 for 90 days to remote smartphone app- and pill bottle-based (a) adherence monitoring, or (b) adherence monitoring with audiovisual medication reminders. Optimal adherence was defined as the proportion of doses taken ±3 h of the scheduled time. Numbers of missed pills and pills taken early, on time, late, and extra were recorded. A multivariable regression model tested possible associations between optimal adherence and age, MS duration, cognitive functioning, and number of daily prescription pills.

RESULTS

85 participants (66 female; mean age 44.9 years) took dimethyl/diroximel fumarate (n = 49), fingolimod (n = 26), or teriflunomide (n = 10). Optimal adherence was on average higher in the monitoring with reminders arm (71.4%) than the monitoring only arm (61.6%; p = 0.033). In a multivariable model, optimal adherence was less likely in younger participants (p < 0.001) and those taking more daily prescription pills (p < 0.001). In the monitoring only arm, 4.0% of doses were taken early, 61.6% on time, 5.6% late, 4.4% in excess, and 24.4% were missed. In the reminders arm, these proportions were 3.4%, 71.4%, 3.7%, 8.7%, and 12.8%, respectively.

CONCLUSION

We map real-world oral DMT adherence patterns using mHealth technology. PwMS who received medication reminders had higher optimal adherence. Nonadherence was more nuanced than simply missing pills. Developing strategies to improve adherence remains important in longitudinal MS care.

Radiologically isolated syndrome: A single-center, retrospective cohort study

BACKGROUND

Radiologically Isolated Syndrome (RIS) likely represents the earliest detectable form of multiple sclerosis (MS). There are recognized risk factors for conversion of RIS to clinically definite central nervous system (CNS) demyelinating disease. We aim to characterize a new clinical cohort with RIS and to analyze previously established risk factors for conversion to clinically definite disease.

METHODS

A medical records search was performed for patients who were diagnosed with RIS by their treating neurologist at our institution in Boston, USA, from January 2005 to April 2020. Demographic data, clinical outcomes, and treatment courses were analyzed. The time to first clinical event representing a demyelinating disease attack or last follow up without clinically definite disease was calculated for each person. Hazard ratios (HRs) for known risk factors for the conversion of RIS to clinically definite disease were calculated using Cox proportional hazards models.

RESULTS

Of 89 patients, the median age at RIS diagnosis was 41.0 years (76% female, 8% with a family history of MS and 16% of any autoimmune disorder, 66% never smokers, 40% BMI >30 kg/m², 45% with spinal cord MRI lesions). Clinically definite disease was observed in 16 patients (18%) during follow-up (median time to first event 3.4 years; median follow-up duration of full cohort 3.8 years). Median EDSS for those who developed clinically definite disease was 1.25 (range: 0-4) at most recent follow up. Of 84 patients with longitudinal brain imaging, 42 (50%) had new demyelinating lesions. Gadolinium-enhancing lesions were seen in 36 patients (43%) at either baseline (n=24) or follow-up (n=12). Most patients had at least one T1-hypointense lesion (n=70, 83%). Five patients underwent ultra-high field MRI (7 Tesla); all were positive for central vein sign, two demonstrated leptomeningeal enhancement, and one was found to have cortical lesions. Out of 30 patients with susceptibility-weighted imaging acquired during routine clinical care, 8 had at least one paramagnetic rim positive lesion. Previously reported risk factors for conversion to MS were not significant: age ≤37 years HR 1.3 (95% confidence interval (CI), 0.47-3.5), male sex 1.5 (95% CI, 0.41-5.2), and spinal cord lesions 1.3 (0.47-3.4). Nearly one-third of RIS patients (n=26) took a disease modifying therapy (DMT) for MS (median total treatment duration on any DMT=2.7 years). The sub-cohort treated with a DMT had a statistically significantly greater number of recognized risk factors for conversion to clinically definite disease compared with the untreated group (p=0.028). Most patients took a DMT for MRI changes demonstrating new demyelinating disease activity (n=16). Dimethyl fumarate (n=9) and glatiramer acetate (n=7) were the most frequently prescribed DMTs. A second-line DMT was started in 10 patients.

CONCLUSION

We characterize a new cohort of RIS patients, demonstrating time to clinically evident demyelinating disease from RIS diagnosis of approximately 3.4 years. Our data suggest that early use of a DMT in RIS may mitigate the impact of recognized risk factors on the occurrence of clinically evident disease and reduce the likelihood of conversion to clinically definite CNS demyelinating disease in high-risk individuals.

COVID-19 vaccine hesitancy in multiple sclerosis: A cross-sectional survey

BACKGROUND

Vaccine willingness among people living with multiple sclerosis (PwMS) requires assessment following the approval of the first COVID-19 vaccines, since there remains uncertainty on multiple aspects of COVID-19 vaccination in immunosuppressed patients.

OBJECTIVE

To understand COVID-19 and influenza vaccine willingness and its associations among PwMS, following the approval of the first two mRNA COVID-19 vaccines.

METHODS

A survey was distributed to PwMS via an online platform from December 2020 to February 2021. Logistic regression models were constructed to determine the relationship between (1) COVID-19 and (2) influenza vaccination willingness with demographic and clinical characteristics.

RESULTS

Of 701 responding PwMS, 76.6% were COVID-19 vaccine willing. COVID-19 vaccine willingness was significantly associated with influenza vaccine willingness (p < 0.001). In multivariable models, older age increased the odds of COVID-19 and influenza vaccine willingness (odds ratios (ORs) > 1) and other race decreased the odds of COVID-19 and influenza vaccine willingness (ORs < 1); higher functional disability decreased the odds of COVID-19 vaccine willingness (OR = 0.88, 95% confidence interval = 0.80-0.96). Prevalent vaccine-related concerns include safety (n = 244) and efficacy (n = 122).

CONCLUSION

Our findings identify demographic and clinical factors as well as concerns influencing vaccine hesitancy in PwMS. These results may inform effective public health interventions to improve vaccine acceptability in this at-risk group.

CNS demyelination with TNFα inhibitor exposure: A retrospective cohort study

OBJECTIVE

To study long-term outcomes in patients with CNS demyelinating events exposed to TNFa-inhibitors (TNFai), including subsequent clinical relapse, MRI lesions, and use of disease modifying therapy (DMT) for MS.

METHODS

Adult patients evaluated for a CNS demyelinating disease during TNFai use were identified at Mass General Brigham [01/1998-08/2020] and analyzed in clinically-relevant subgroups. Inclusion criteria required a first neurological event while taking a TNFai, MRI lesions consistent with demyelination, and the absence of a more probable alternative diagnosis.

RESULTS

21 cases (mean age 44 years, 20 female, 14 ≥ 2 MS risk factors) had an index neurological event (INE) at a median of 12 months (range 1-176) from onset of TNFai use (adalimumab in 10, etanercept 6, infliximab 5). MRI lesions were most often present in periventricular (16/20, 80%) and spinal zones (10/20, 50%); 37% (7/19) met ≥ 2 Barkhof criteria at onset. CSF testing was abnormal in 64% (7/11). 67% (10/15) with available follow-up MRIs developed new lesions by a median of 29.5 months of MRI surveillance (median MRI surveillance 60 months); 55% (11/20) met ≥ 2 Barkhof criteria. 47% (8/17) suffered a clinical relapse by a median of 40.5 months of clinic follow-up (median clinic follow-up since INE: 26 months). In patients discontinuing TNFai (18/21, 86%) at INE onset, 56% (10/18) had further evidence of CNS demyelination. Six patients (6/21, 29%) started an MS disease modifying therapy (DMT) at INE of whom 50% (3/6) had subsequent disease activity. Continuing or restarting TNFai was followed by relapse in 75% (3/4). 65% (13/20) met 2017 McDonald criteria for MS at INE with another 10% (15/20, 75%) by study conclusion.

CONCLUSIONS

With extended follow-up, a majority of patients had a relapsing CNS demyelinating disorder-as evidenced by new MRI lesions or clinical relapses-despite TNFai discontinuation.

Low-field portable brain MRI in CNS demyelinating disease

A low-field (80 mT), portable MRI scanner has been developed that may address barriers to MRI for people with multiple sclerosis (MS). As a proof of concept study, we imaged two participants with central nervous system demyelinating disease by both a standard 1.5 Tesla MRI and the portable MRI scanner. These images demonstrate the ability to identify a solitary demyelinating lesion in early stage disease and cortical atrophy and chronic white matter changes in late stage disease. In spite of device limitations, including border distortion and lower image quality, the portable device has important implications for addressing barriers to care in people with MS.

Neurologic Manifestations of the World Health Organization's List of Pandemic and Epidemic Diseases

The World Health Organization (WHO) monitors the spread of diseases globally and maintains a list of diseases with epidemic or pandemic potential. Currently listed diseases include Chikungunya, cholera, Crimean-Congo hemorrhagic fever, Ebola virus disease, Hendra virus infection, influenza, Lassa fever, Marburg virus disease, Neisseria meningitis, MERS-CoV, monkeypox, Nipah virus infection, novel coronavirus (COVID-19), plague, Rift Valley fever, SARS, smallpox, tularemia, yellow fever, and Zika virus disease. The associated pathogens are increasingly important on the global stage. The majority of these diseases have neurological manifestations. Those with less frequent neurological manifestations may also have important consequences. This is highlighted now in particular through the ongoing COVID-19 pandemic and reinforces that pathogens with the potential to spread rapidly and widely, in spite of concerted global efforts, may affect the nervous system. We searched the scientific literature, dating from 1934 to August 2020, to compile data on the cause, epidemiology, clinical presentation, neuroimaging features, and treatment of each of the diseases of epidemic or pandemic potential as viewed through a neurologist's lens. We included articles with an abstract or full text in English in this topical and scoping review. Diseases with epidemic and pandemic potential can be spread directly from human to human, animal to human, via mosquitoes or other insects, or via environmental contamination. Manifestations include central neurologic conditions (meningitis, encephalitis, intraparenchymal hemorrhage, seizures), peripheral and cranial nerve syndromes (sensory neuropathy, sensorineural hearing loss, ophthalmoplegia), post-infectious syndromes (acute inflammatory polyneuropathy), and congenital syndromes (fetal microcephaly), among others. Some diseases have not been well-characterized from a neurological standpoint, but all have at least scattered case reports of neurological features. Some of the diseases have curative treatments available while in other cases, supportive care remains the only management option. Regardless of the pathogen, prompt, and aggressive measures to control the spread of these agents are the most important factors in lowering the overall morbidity and mortality they can cause.

Central nervous system disease with JC virus infection in adults with congenital HIV

OBJECTIVE

The aim of this study was to describe the natural history of individuals with congenital HIV who develop JC virus (JCV) infection of the central nervous system (CNS).

METHODS

We retrospectively evaluated individuals with congenital HIV who met criteria for progressive multifocal leukoencephalopathy (PML) or JCV granule cell neuronopathy (JCV GCN) at three major healthcare centres in the northeast USA. Data on adherence to combined antiretroviral therapy (cART), neurologic symptoms, serum markers of immunity and HIV infection, cerebrospinal fluid (CSF) analyses, radiographic features, modified Rankin Scale (mRS) scores and survival were collected from the electronic medical record up to a censoring date of 1 August 2020.

RESULTS

Among 10 adults with congenitally acquired HIV, nine were diagnosed with definitive PML and one was diagnosed with probable JCV GCN. Individuals presented at the time of their PML or JCV GCN diagnosis with a mean mRS of 2.0 (standard deviation 1.0). A premorbid mRS was documented for six patients and was zero in all cases. The most common risk factor was confirmed cART nonadherence in nine individuals. Five individuals with PML and one with JCV GCN died, with a latency from symptom onset to death of approximately 3 months for three individuals, and approximately 2 years for the remaining two.

CONCLUSION

Youth-adulthood transition is a high-risk point for dropping off from medical care. The study of this timepoint in people living with HIV could help inform effective care in these individuals.

Encephalitis and meningitis in Western Africa: a scoping review of pathogens

OBJECTIVE

To give an overview of the recently reported literature on the aetiologies of meningitis and encephalitis in western sub-Saharan Africa.

METHODS

We conducted a scoping review following PRISMA guidance on published meningitis and encephalitis cases in the 16 countries of the United Nations-defined western sub-Saharan African region as identified in cohort studies, case series, and case reports, published 01/01/2000-08/01/2020, and available in four databases in August 2020 with an abstract in English, French or Italian.

RESULTS

There were 38 distinct pathogens identified from 91 cohort studies' data and 48 case reports or case series' data. In cohort-level data, the majority of cases were caused by Neisseria meningitidis (71.5%), Streptococcus pneumoniae (17.6%) and Haemophilus influenzae (7.3%). In case report- and case series-level data, 40.5% of patients were <18 years old, 28.6% were female, and 28.6% were known to be immunocompromised. The case fatality rate was 39.3%. The most commonly reported pathogens among immunocompetent patients were Salmonella species (13 cases) and Ebola virus (9 cases), and the most commonly reported pathogen among immunocompromised patients was Cryptococcus neoformans (18 cases). Most cohort cases (52.3%) derived from Niger followed by Burkina Faso (28.6%). Most cases from single reports or series were reported from Nigeria (21.4%), Mali (20.2%) and Burkina Faso (19.0%).

CONCLUSIONS

Given the small number of pathogens reported, our findings underscore the need to better screen, diagnose and monitor populations in western sub-Saharan Africa for additional CNS pathogens, including those posing significant outbreak risks.

Eastern equine encephalitis and use of IV immunoglobulin therapy and high-dose steroids

OBJECTIVE

To determine the clinical presentation and patient outcomes after treatment with IV immunoglobulin (IVIG), high-dose steroids, or standard of care alone in Eastern equine encephalitis (EEE), a mosquito-borne viral infection with significant neurologic morbidity and mortality.

METHODS

A retrospective observational study of patients admitted to 2 tertiary academic medical centers in Boston, Massachusetts, with EEE from 2005 to 2019.

RESULTS

Of 17 patients (median [IQR] age, 63 [36-70] years; 10 (59%) male, and 16 (94%) White race), 17 patients had fever (100%), 15 had encephalopathy (88%), and 12 had headache (71%). Eleven of 14 patients with CSF cell count differential had a neutrophil predominance (mean = 60.6% of white blood cells) with an elevated protein level (median [IQR], 100 mg/dL [75-145]). Affected neuroanatomic regions included the basal ganglia (n = 9/17), thalamus (n = 7/17), and mesial temporal lobe (n = 7/17). A total of 11 patients (65%) received IVIG; 8 (47%) received steroids. Of the patients who received IVIG, increased time from hospital admission to IVIG administration correlated with worse long-term disability as assessed by the modified Rankin Scale (mRS) (r = 0.72, p = 0.02); steroid use was not associated with the mRS score. The mortality was 12%.

CONCLUSIONS

Clinicians should suspect EEE in immunocompetent patients with early subcortical neuroimaging abnormalities and CSF neutrophilic predominance. This study suggests a lower mortality than previously reported, but a high morbidity rate in EEE. IVIG as an adjunctive to standard of care may be considered early during hospitalization.