Immune profiling of COVID-19 vaccine responses in people with multiple sclerosis on B cell-depleting therapy (preprint)

Background and ObjectivePeople with multiple sclerosis (pwMS) receiving B cell-depleting therapies have impaired antibody responses to vaccination. In a proportion of individuals, repeat vaccination against COVID-19 leads to seroconversion. We sought to describe the immune phenotype of pwMS on ocrelizumab, and identify clinical and immunological determinants of an effective vaccine response. MethodsThis was a single-centre, prospective cohort study. Peripheral blood samples were collected from pwMS receiving ocrelizumab (n = 38) pre and post administration of a third dose of mRNA COVID-19 vaccine. Immunogenicity was measured by T cell IFN{gamma} ELISpot, antibody titres, and live virus neutralisation. Humoral immunity was benchmarked against pwMS receiving natalizumab (n = 15), and against a correlate of real-world protection (50% reduction in incidence of infection) from SARS-CoV-2 ancestral and omicron BA.5 variants. The peripheral immune phenotype was comprehensively assessed by flow cytometry, and potential clinical and phenotypic determinants of response to vaccination identified. ResultsImmune cell populations relevant to disease and vaccine response were altered in pwMS receiving ocrelizumab versus natalizumab treatment, including depleted CD20-expressing B cell, T cell and NK cell populations, and elevated CD27+CD38+ T cell and NK8 cell frequencies. Following a third vaccine dose, 51% of pwMS on ocrelizumab were seropositive for SARS-CoV-2 receptor-binding-domain IgG, and 25% and 14% met the threshold for effective neutralisation of live SARS-CoV-2 ancestral and omicron BA.5 virus, respectively. B cell frequency at the time of vaccination, but not time since ocrelizumab infusion, was positively correlated with antibody response, while a strong negative correlation was observed between CD56bright NK cell frequency and antibody response in the ocrelizumab group. In this exploratory cohort, CD3-CD20+ B cells (% of lymphocytes; OR=3.92) and CD56bright NK cells (% of NK cells; OR=0.94) were predictive of an effective neutralising antibody response in second dose non-responders (AUC: 0.98). DiscussionOcrelizumab treatment was associated with an altered immune phenotype, including recently described T cell and NK populations with potential roles in disease pathogenesis. However, seroconversion was severely impaired by ocrelizumab, and less than half of those who seroconverted following a third vaccine dose demonstrated effective immunity against SARS-CoV-2 ancestral or omicron BA.5. B cell frequency was associated with an effective antibody response, while immunomodulatory CD56bright NK cells were identified as a potential negative determinant of response in those with inadequate B cell numbers. Immune phenotype rather than time since ocrelizumab infusion may help to stratify individuals for prophylaxis.

Determinants of SARS-CoV-2 IgG response and decay in Canadian healthcare workers: a prospective cohort study. (preprint)

Introduction Healthcare workers (HCWs) from an interprovincial Canadian cohort were asked to give serial blood samples to identify factors associated with anti-receptor binding domain (anti-RBD) IgG response to the SARS-CoV-2 virus. Methods Members of the HCW cohort donated blood samples four months after their first SARS-CoV-2 immunization and again at 7, 10 and 13 months. Date and type of immunizations and dates of SARS-CoV-2 infection were collected at each of four contacts, together with information on immunologically-compromising conditions and current therapies. Blood samples were analyzed centrally for anti-RBD IgG and anti-nucleocapsid IgG (Abbott Architect, Abbott Diagnostics). Records of immunization and SARS-CoV-2 testing from public health agencies were used to assess the impact of reporting errors on estimates from the random-effects multivariable model fitted to the data. Results 2752 of 4567 vaccinated cohort participants agreed to donate at least one blood sample. Modelling of anti-RBD IgG titer from 8903 samples showed an increase in IgG with each vaccine dose and with first infection. A decrease in IgG titer was found with the number of months since vaccination or infection, with the sharpest decline after the third dose. An immunization regime that included mRNA1273 (Moderna) resulted in higher anti-RBD IgG. Participants reporting multiple sclerosis, rheumatoid arthritis or taking selective immunosuppressants, tumor necrosis factor inhibitors, calcineurin inhibitors and antineoplastic agents had lower anti-RBD IgG. Supplementary analyses showed higher anti-RBD IgG in those reporting side-effects of vaccination, no relation of anti-RBD IgG to obesity and lower titers in women immunized early in pregnancy. Sensitivity analysis results suggested no important bias in the self-report data. Conclusion Creation of a prospective cohort was central to the credibility of results presented here. Serial serology assessments, with longitudinal analysis, provided effect estimates with enhanced accuracy and a clearer understanding of medical and other factors affecting response to vaccination.

Initial multiple sclerosis presentation as optic neuritis following COVID-19 vaccination: A case report (preprint)

Background The COVID-19 pandemic has been largely controlled upon the extensive vaccination campaigns done by many countries all over the world, with great efficacy and few adverse effects reported. However, since the beginning of the vaccination campaigns, few autoimmune and neurological manifestations were reported. Case presentation A previously healthy 23 years old female presented with acute unilateral optic neuritis in the right eye that started one week after receiving the second dose of COVID-19 vaccine. The patient had blurred vision which was partial then progressed over two days to involve the whole visual field along with mild pain upon ocular movement with no doubling of vision. The patient reports no prior neurological manifestations before the onset of this condition. Clinical and radiological features proved the diagnosis with Multiple Sclerosis (MS) later. The patient was treated with intra-venous Methylprednisolone and recovered well after few days of getting the treatment and was scheduled for follow-up to plan her further management. Conclusion This case may provide an association between COVID-19 vaccination and the development or triggering of MS. However, more data needs to be collected to look more in this regard.

Thematic analysis of multiple sclerosis research by enhanced strategic diagram.

Recent interest in multiple sclerosis research warrants literature analysis to evaluate the current state of the discipline and new research domains. This bibliometric review summarised the research trends and analysed research areas in multiple sclerosis over the last decade. The documents containing the term 'multiple sclerosis' in the article title were retrieved from the Scopus database. We used Harzing's Publish or Perish and VOSviewer for citation analysis and data visualisation, respectively. We found a total of 18,003 articles published in journals in the English language between 2012 and 2021. The emerging keywords identified utilising the enhanced strategic diagram were 'covid-19', 'teriflunomide', 'clinical trial', 'microglia', 'b cells', 'myelin', 'brain', 'white matter', 'functional connectivity', 'pain', 'employment', 'health-related quality of life', 'meta-analysis' and 'comorbidity'. This study demonstrates the tremendous growth of multiple sclerosis literature worldwide, which is expected to grow more than double during the next decade especially in the identified emerging topics.

Chronic purulent pericarditis: case report.

Purulent pericarditis is an infection of the pericardial space that produces pus that is found on gross examination of the pericardial sac or on the tissue microscopy. In this case report, we will discuss a 31-year-old male who presented with a chief complaint of low-grade fevers, dry cough and difficulty breathing for about two weeks which preceded after removing of dental also two weeks prior. He was admitted and treated as COVID-19 in the isolation ward, he later developed cardiac tamponade and during pericardiocentesis thick pus was discharged. Pus culture and Gene Xpert tests were all negative. After his condition improved, the patient was transferred to the general ward with the pericardial window still discharging pus. Pericardiectomy was chosen as definitive management. The key takeaway in this report is that Empirical treatment with RHZE (rifampin, isoniazid, pyrazinamide, and ethambutol) in resource-limited settings is recommended due to difficulty in identifying the exact cause at a required moment.

Persistently reduced humoral and cellular immune response following third SARS-CoV-2 mRNA vaccination in anti-CD20-treated multiple sclerosis patients (preprint)

ObjectiveTo examine humoral and cellular response in multiple sclerosis patients on anti-CD20 therapy after third BNT162b2 mRNA SARS-CoV-2 vaccination. MethodsA prospective longitudinal study design from first throughout third vaccination in Danish and American MS centers. All participants were treated with ocrelizumab. Antibody (Ab) levels were assessed before and after third vaccination using SARS-CoV-2 IgG II Quant assay (Abbott Laboratories). B- and T-lymphocytes enumeration was done with BD Multitest6-color TBNK reagent. Spike-specific T-cell responses were measured through PBMC stimulation with spike peptide pools (JPT Peptide Technologies). ResultsWe found that 14.0%, 37.7%, and 33.3% were seropositive after first, second and third vaccination. The median Ab-levels were 74.2 BAU/mL (range: 8.5-2427), 43.7 BAU/ml (range: 7.8-366.1) and 31.3 BAU/mL (range: 7.9-507.0) after first, second and third vaccination, respectively. No difference was found in levels after second and third vaccination (p=0.1475). Seropositivity dropped to 25.0% of participants before the third vaccination, a relative reduction of 33.3% (p=0.0020). No difference was found between frequencies of spike reactive CD4+ and CD8+ T-cells after second (0.65 {+/-} 0.08% and 0.95 {+/-} 0.20%, respectively) and third vaccination (0.99 {+/-} 0.22% and 1.3 {+/-} 0.34%), respectively. ConclusionIn this longitudinal cohort we found no significant increased humoral or cellular response with administration of a third SARS-CoV-2 mRNA vaccination. These findings suggest the need for clinical strategies to include allowance of B cell reconstitution before repeat vaccination and/or provision of pre-exposure prophylactic monoclonal antibodies. Key PointsO_ST_ABSWhat is already known on this topicC_ST_ABSStudies have described decreased humoral response and sustained T-cell reactivity after standard two-dose SARS-CoV-2 mRNA vaccination during anti-CD20 therapy in multiple sclerosis participants. What this study addsPersistently decreased humoral, but stable cellular reactivity following a third SARS-CoV-2 mRNA vaccination. How this study might affect research, practice or policyThe findings suggest the need for clinical strategies to include allowance of B cell reconstitution before repeat vaccination and/or provision of pre-exposure prophylactic monoclonal antibodies.

mRNA-COVID19 vaccination can be considered safe and tolerable for frail patients (preprint)

Background Frail patients are considered at relevant risk of complications due to COVID-19 infection and, for this reason, are prioritized candidates for vaccination. As these patients were originally not included in the registration trials, fear related to vaccine side-effects and disease worsening was one of the reasons for vaccine hesitancy. Herein we report the safety profile of the prospective, multicenter, national VAX4FRAIL study (NCT04848493) to evaluate vaccines in a large trans-disease cohort of patients with solid or hematological malignancies, neurological and rheumatological diseases. Methods Between March 3rd and September 2nd, 2021, 566 patients were evaluable for safety endpoint: 105 received the mRNA-1273 vaccine and 461 the BNT162b2 vaccine. Frail patients were defined per protocol as patients under treatment with hematological malignancies (131), solid tumors (191), immune-rheumatological diseases (86), and neurological diseases (158), including multiple sclerosis and generalized myasthenia. The impact of the vaccination on the health status of patients was assessed through a questionnaire focused on the first week after each vaccine dose. Results The most frequently reported moderate-severe adverse events were pain at the injection site (60.3% after the first dose, 55.4% after the second), fatigue (30.1% - 41.7%), bone pain (27.4% - 27.2%) and headache (11.8% - 18.9%). Risk factors associated with the occurrence of severe symptoms after vaccine administration were identified through a multivariate logistic regression analysis: age was associated with severe fever presentation (younger patients vs. middle-aged vs. older ones), females presented a higher probability of severe pain at the injection site, fatigue, headache, and bone pain; the mRNA-1237 vaccine was associated with a higher probability of severe pain at the injection site and fever. After the first dose, patients presenting a severe symptom were at a relevant risk of recurrence of the same severe symptom after the second one. Overall, 11 patients (1.9%) after the first dose and 7 (1.2%) after the second one required to postpone or suspend the disease-specific treatment. Finally, 2 fatal events occurred among our 566 patients. These two events were considered unrelated to the vaccine. Conclusions Our study reports that mRNA-COVID-19 vaccination is safe also in frail patients as expected side effects were manageable and had a minimum impact on patient care path.

Cellular and humoral immunity to SARS-CoV-2 infection in multiple sclerosis patients on ocrelizumab and other disease-modifying therapies: a multi-ethnic observational study (preprint)

Objective: To determine the impact of MS disease-modifying therapies (DMTs) on the development of cellular and humoral immunity to SARS-CoV-2 infection. Methods: MS patients aged 18-60 were evaluated for anti-nucleocapsid and anti-Spike RBD antibody with electro-chemiluminescence immunoassay; antibody responses to Spike protein, RBD, N-terminal domain with multiepitope bead-based immunoassays (MBI); live virus immunofluorescence-based microneutralization assay; T-cell responses to SARS-CoV-2 Spike using TruCulture ELISA; and IL-2 and IFN{gamma} ; ELISpot assays. Assay results were compared by DMT class. Spearman correlation and multivariate analyses were performed to examine associations between immunologic responses and infection severity. Results: Between 1/6/2021 and 7/21/2021, 389 MS patients were recruited (mean age 40.3 years; 74% female; 62% non-White). Most common DMTs were ocrelizumab (OCR) - 40%; natalizumab - 17%, Sphingosine 1-phosphate receptor (S1P) modulators -12%; and 15% untreated. 177 patients (46%) had laboratory evidence of SARS-CoV-2 infection; 130 had symptomatic infection, 47 - asymptomatic. Antibody responses were markedly attenuated in OCR compared to other groups (p[≤]0.0001). T-cell responses (IFN{gamma}) were decreased in S1P (p=0.03), increased in natalizumab (p<0.001), and similar in other DMTs, including OCR. Cellular and humoral responses were moderately correlated in both OCR (r=0.45, p=0.0002) and non-OCR (r=0.64, p<0.0001). Immune responses did not differ by race/ethnicity. COVID-19 clinical course was mostly non-severe and similar across DMTs; 7% (9/130) were hospitalized. Interpretation: DMTs had differential effects on humoral and cellular immune responses to SARS-CoV-2 infection. Immune responses did not correlate with COVID-19 clinical severity in this relatively young and non-disabled group of MS patients.

New Onset Focal Seizure Following COVID-19 Vaccination: Case Report (preprint)

Introduction: As more novel COVID-19 vaccines are being rolled out in a frantic pace globally, any complication that might be related to COVID-19 vaccines should be highlighted, especially since COVID-19 vaccines are relatively new, and side effects may yet to be fully elucidated. We report a case of a healthy 18-year-old male who presented with new onset focal seizures 5 days after receiving 1 st dose of Oxford/AstraZeneca COVID-19 vaccine. Case Presentation The patient was treated with intravenous phenytoin and oral levetiracetam 250mg twice daily with no further events. There was no documented fever. CT venogram and EEG were unremarkable. MRI brain revealed generalised atrophy including mild bilateral hippocampal atrophy with no evidence of sclerosis. There was no predilection for seizures identified from the patient’s history. The patient was discharged the following day on levetiracetam and advised to proceed with the 2 nd dose of Oxford/AstraZeneca COVID-19 vaccination in 3 months’ time. Conclusion: Seizures following COVID-19 vaccination have only been reported in a handful of cases. COVID-19 vaccination could lower seizure threshold, or unmask an underlying predisposition for epilepsy. As most COVID-19 vaccines worldwide are given in 2 doses, clinicians should consider maintaining patients on anti-seizure drugs if vaccination was thought to be a provoking factor.

Impact of mass vaccination on SARS-CoV-2 infections among the total multiple sclerosis population receiving immunomodulatory disease-modifying therapies in England (preprint)

This study aimed to understand changes in the risk of SARS-CoV-2 infection among all people with multiple sclerosis (MS) receiving immunomodulatory disease-modifying therapies (DMTs) in England, compared to the general population, following mass vaccination. Longitudinal data collected by the National Health Service (NHS) England on all MS DMT prescriptions and the UK Health Security Agency on all registered SARS-CoV-2 test results were analysed. The incidence rate ratio of SARS-CoV-2 infection among people with MS taking DMTs compared to the general population was calculated before (November 2020-January 2021) and after (July-August 2021) mass vaccination. Risk of SARS-CoV-2 infection among people on ocrelizumab or fingolimod compared to the general population increased following liberalisation of COVID-19 restrictions (during March-July 2021) despite mass vaccination. No changes were found with other DMTs. These findings converge with the impaired immune response to vaccines observed with ocrelizumab and fingolimod.

Efficacy and safety of a third SARS-CoV-2 vaccination in multiple sclerosis vaccine non-responders (preprint)

Importance: Vaccination against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to protect against coronavirus disease of 2019 (COVID-19) is recommended for patients with multiple sclerosis (pwMS). However, approximately 80% of all pwMS treated with anti-CD20 therapy (rituximab, ocrelizumab) or fingolimod have low or absent humoral immunity after vaccination with two doses of SARS-CoV-2 mRNA vaccines. The efficacy and safety of a third vaccine dose in this group is largely unknown. Objective: To characterize the humoral immunogenicity and the safety of a third dose of mRNA-COVID-19 vaccine in anti-CD20- or fingolimod-treated pwMS with low or absent humoral immunity (i.e., anti-SARS-CoV-2 IgG <70 arbitrary units (AU) and <5 AU, respectively) after two vaccinations. Design, setting and participants: 130 anti-CD20- or fingolimod-treated pwMS with low or absent humoral immunity despite full vaccination against SARS-CoV-2, received a third dose of SARS-CoV-2 mRNA vaccine. Humoral immunity (i.e., antibody response against SARS-CoV-2) and the frequency and characteristics of side-effects were analyzed in all participants. Exposures: A third vaccine dose against SARS-CoV-2 with BNT162b2- or mRNA-1273-COVID-19 vaccine. Main outcomes and measures: Patient- and treatment-specific variables were acquired using a digital questionnaire, the Norwegian Immunization Registry and hospital journals. Humoral immunity was assessed by measuring SARS-CoV-2 SPIKE receptor-binding domain (RBD) IgG response. Low/absent humoral immunity was assumed in cases of AU<70 after anti-SPIKE protein-based serology 3-5 weeks after revaccination. Results: A third dose of SARS-CoV-2 mRNA vaccine increased anti-SARS-CoV-2 SPIKE RBD IgG levels significantly. The proportion of patients with assumed protective humoral immunity (anti-SARS-CoV-2 SPIKE RBD IgG > 70 AU) were 25% among patients using anti-CD20 therapy and 7% among those treated with fingolimod. No adverse events were registered during the study period. Conclusion and relevance: A third dose of mRNA-COVID-19 vaccine was associated with significantly increased levels of anti-SARS-CoV-2 SPIKE RBD IgG, and hence assumed protective humoral immunity - in anti-CD20- or fingolimod-treated pwMS with low or absent humoral immunity despite full vaccination. The effect of a third vaccine dose was limited and more prominent among those treated with anti-CD20 therapy.

CD19 B cell repopulation after ocrelizumab, alemtuzumab and cladribine: Implications for SARS-CoV-2 vaccinations in multiple sclerosis (preprint)

BackgroundCD20 depletion is a highly-effective treatment for relapsing multiple sclerosis that maintains B cells at low levels through six monthly dosing of 600mg ocrelizumab. This dosing schedule is associated with inhibition of seroconversion following SARS-CoV-2 vaccination, in contrast to the high levels of seroconversion following treatment with alemtuzumab and cladribine tablets. A number of emerging reports suggest that repopulation of 1-3% B cells facilitates seroconversion after CD20-depletion. The frequency of this occurring following repeated ocrelizumab treatment, after other DMT, and after treatment cessation is largely unknown. MethodsRelapse data, lymphocyte and CD19 B cell numbers were extracted from phase II ocrelizumab extension study (NCT00676715) data supplied by the manufacturer via the Vivli Inc, trial data-request portal. Repopulation data of oral cladribine from the phase III CLARITY study (NCT00213135) was supplied by the European Medicines Agency; and the alemtuzumab phase III CARE-MS I (NCT00530348) and CARE-MS II (NCT00548405) trial data were supplied by the manufacturer via the clinicalstudydatarequest.com portal. ResultsOnly 3-5% of people with MS exhibit 1% B cells at 6 months after the last infusion following 3-4 cycles of ocrelizumab, compared to 50-55% at 9 months, and 85-90% at 12 months. During this time relapses occurred at consistent disease breakthrough rates compared to people during standard therapy. In contrast most people (90-100%) exhibited more than 1% B cells during treatment with either cladribine or alemtuzumab. ConclusionsFew people repopulate peripheral B cells with standard ocrelizumab dosing, however an extending the dosing interval by 3-6 months may allow many more people to potentially seroconvert in the relative absence of excess relapse-activity. Most people demonstrate B cell repletion within 3 months of the last treatment of alemtuzumab and cladribine. This may help protect against severe COVID-19.

Thematic analysis of multiple sclerosis research by enhanced strategic diagram (preprint)

This bibliometric review summarised the research trends and analysed research areas in multiple sclerosis (MS) over the last decade. The documents containing the term "multiple sclerosis" in the article title were retrieved from the Scopus database. We found a total of 18003 articles published in journals in the English language between 2012 and 2021. The emerging keywords identified utilising the enhanced strategic diagram were "covid-19", "teriflunomide", "clinical trial", "microglia", "b cells", "myelin", "brain", "white matter", "functional connectivity", "pain", "employment", "health-related quality of life", "meta-analysis" and "comorbidity". In conclusion, this study demonstrates the tremendous growth of MS literature worldwide, which is expected to grow more than double during the next decade especially in the identified emerging topics.

COVID-19 Severity in Multiple Sclerosis: Putting Data Into Context (preprint)

Background: It is unclear how multiple sclerosis (MS) affects the severity of Covid-19.Methods: Hospitalization, Intensive Care Unit (ICU) admission and death after Covid-19 diagnosis of 1362 MS patients were compared to the age and sex-matched Italian population in a retrospective observational case-cohort study with population-based control. The observed vs the expected events were compared in the whole MS cohort and in different subgroups (higher-risk: EDSS>3 or at least one comorbidity, lower-risk: EDSS<=3 and no comorbidities) by the chi-square test and the risk excess was quantified by Risk Ratios (RR).Findings: The risk of severe events was about twice the risk in the age and sex-matched Italian population: RR=2·12 for hospitalization (p<0·001), RR=2·19 for ICU admission (p<0·001) and RR=2·43 for death (p<0·001). The excess of risk was confined to the higher-risk group (n=553). In lower-risk patients (n=809) the rate of events was close to that of the Italian age and sex-matched population (RR=1·12 for hospitalization, RR=1·52 for ICU admission, and RR=1·19 for death). In the lower-risk group, an increased hospitalization risk was detected in patients on anti-CD20 (RR=3·03, p=0·005), while a decrease was detected in patients on interferon (0 observed vs 4 expected events, p=0·04).Interpretation: Overall the MS cohort had a risk of severe events that is twice the risk in the age and sex-matched Italian population. This excess of risk is mainly explained by EDSS and comorbidities, while a residual increase of hospitalization risk was observed in patients on anti-CD20 therapies and a decrease in people on interferon.Funding Information: None.Declaration of Interests: MP. Sormani reports grants from Roche, during the conduct of the study; personal fees from Biogen, Merck, Roche, Sanofi, Novartis, Medday, Geneuro, Celgene, Mylan outside the submitted work.N. De Rossi received speaker honoraria from Biogen Idec, Genzyme, Novartis, Sanofi-Aventis; received funding for participation in advisory board to Novartis, Biogen and Genzyme-Sanofi and for travel to scientific meetings from Biogen Idec, Teva, Sanofi-Genzyme, Roche, Almirall and Novartis.M Filippi is Editor-in-Chief of the Journal of Neurology, Associate Editor of Human Brain Mapping, Associate Editor of Radiology, and Associate Editor of Neurological Sciences; received compensation for consulting services and/or speaking activities from Alexion, Almirall, Bayer, Biogen, Celgene, Eli Lilly, Genzyme, Merck-Serono, Novartis, Roche, Sanofi, Takeda, and Teva Pharmaceutical Industries; and receives research support from Biogen Idec, Merck-Serono, Novartis, Roche, Teva Pharmaceutical Industries, Italian Ministry of Health, Fondazione Italiana Sclerosi Multipla, and ARiSLA (Fondazione Italiana di Ricerca per la SLA). He received speaker’s honoraria from the following companies: Biogen, Merck, Novartis, Roche, Sanofi-Genzyme, and TEVA.M. Radaelli received speaker honoraria from Biogen Idec, Sanofi-Genzyme, Novartis and Merck Serono and funding for travel to scientific meetings from Biogen Idec, Sanofi-Genzyme, Novartis, Merck Serono, Teva and Roche.P. Immovilli reports personal fees from Roche, personal fees from Biogen, personal fees from Merck, outside the submitted work.M. Capobianco reports personal fees and non-financial support from Biogen, personal fees and non-financial support from Merck Serono, personal fees and non-financial support from Roche, personal fees and non-financial support from Novartis, personal fees and non-financial support from Sanofi, personal fees from Almirall, outside the submitted work.P. Confalonieri has received honoraria for speaking or consultation fees from Novartis and Biogen, has received funding for travel to attend scientific events or speaker honoraria from Merck Serono, Biogen Idec, Teva and Roche. He has also received institutional research support from Merk-Serono, Novartis and Roche. He is also principal investigator in clinical trials for Biogen, Merck Serono, Roche.M.Inglese received research grants from NIH, DOD, NMSS, FISM, and Teva Neuroscience; received fees for participating in advisory boards from Roche, Biogen, Merck and Genzyme.M. Trojano reports grants and personal fees from Biogen, grants and personal fees from Novartis, grants and personal fees from Roche, grants and personal fees from Merck, personal fees from Sanofi, personal fees from TEVA, from null, outside the submitted work.G. Comi reports personal fees from Novartis, Teva Pharmaceutical Industries Ltd, Teva Italia Srl, Sanofi Genzyme, Genzyme Corporation, Genzyme Europe, Merck KGgA, Merck Serono SpA, Celgene Group, Biogen Idec, Biogen Italia Srl, F. Hoffman-La Roche, Roche SpA, Almirall SpA, Forward Pharma, Medday, Excemed, outside the submitted work.F. Patti reports grants from Biogen, grants from Merck, grants from FISM, grants from Onlus association, grants from University of Catania, personal fees from Almirall, personal fees from Bayer, personal fees from Biogen, personal fees from Merck, personal fees from Roche, personal fees from Sanofi, personal fees from TEVA, outside the submitted work.M. Salvetti reports grants and personal fees from Biogen, grants and personal fees from Merck, grants and personal fees from Novartis, grants and personal fees from Roche, grants and personal fees from Sanofi, grants and personal fees from Teva, grants from Italian Multiple Sclerosis Foundation, grants from Sapienza University of Rome, outside the submitted work.I .Schiavetti, L. Carmisciano, C. Cordioli, G Brichetto, E Cocco, P Cavalla, I Pesci, A Zito, GA Marfia, P Perini, V Brescia Morra, G. Tedeschi, C. Scandellari, M. Battaglia have nothing to disclose.Ethics Approval Statement: The study was approved by the Regional Ethics Committee of Liguria (University of Genoa) (n 130/2020 – DB id 10433) and at a national level by Agenzia Italiana del Farmaco (AIFA).

A case-control study of autoimmune AEFIs following COVID-19 vaccination reported to VAERS (preprint)

Autoimmune adverse effects following immunisation (AEFIs) are widely regarded as a chief concern driving vaccine hesitancy. This case-control study seeks to shed light on the true risk of autoimmune AEFIs associated with the COVID-19 vaccine through a case-control analysis of VAERS reports. Reports of autoimmune aetiology were matched with reports of non-autoimmune controls. Statistical analysis reveals that the safety profile of COVID-19 vaccines with regard to autoimmune AEFIs is highly favourable. In particular, neuroautoimmune AEFIs have statistically significant reporting odds ratios below unity (Guillain-Barre syndrome: 0.35, multiple sclerosis: 0.70, transverse myelitis: 0.79), indicating a reduced association of reports of these conditions with the COVID-19 vaccine versus other vaccines. Only three autoimmune aetiologies exceed a ROR of 2.0 and thus present a potential signal. Of these, myasthenia gravis (ROR = 3.90, p < 0.001, 95% CI: 2.63-5.80) may be the result of epidemiological confounding factors not sufficiently controlled by matching, as the population most likely to develop myasthenia gravis was strongly prioritised in the COVID-19 vaccine’s initial rollout. Immune thrombocytopaenia (ROR = 26.83, p < 0.001, 95% CI: 16.93-42.54) is a clear safety signal, confirming a large number of case reports and studies that indicate a risk of immune thrombocytopaenic events following the COVID-19 vaccine. The lone strong safety signal of immune thrombocytopaenia notwithstanding, this study attests to the safety of the COVID-19 vaccine where autoimmune conditions are concerned. Through quantifying the risk of autoimmune disorders associated with COVID-19 vaccination, this study contributes to a growing body of evidence supporting the safety of such vaccines.

Intra-individual reproducibility as essential determinant of clinical utility of smartphone-based neurological disability tests (preprint)

Technological advances, lack of medical professionals, high cost of face-to face encounters and disasters such as COVID19 pandemic, fuel the telemedicine revolution. Numerous smartphone apps have been developed to measure neurological functions. However, their psychometric properties are seldom determined. Lacking such data, it is unclear which designs underlie’ eventual clinical utility of the smartphone tests. We have developed the smartphone Neu rological Fun ction T ests S uite (NeuFun-TS) and are systematically evaluating their psychometric properties against the gold-standard of complete neurological examination digitalized into NeurEx TM App. This paper examines the fifth, and thus far the most complex NeuFun-TS test, the “Spiral tracing”. We generated 40 features in the training cohort (22 healthy donors [HD] and 105 multiple sclerosis [MS] patients) and compared their intraclass correlation coefficient, fold-change between HD and MS and correlations with relevant clinical and imaging outcomes. We assembled the best features into machine-learning models and examined their performance in the independent validation cohort (56 MS patients). We show that by aggregating multiple neurological functions, complex tests such as spiral tracing are susceptible to intra-individual variations, decreasing their reproducibility and thus, clinical utility. Simple tests, reproducibly measuring single function(s) that can be aggregated to increase sensitivity are preferable in app design.

Large-scale genomic study reveals robust activation of the immune system following advanced Inner Engineering meditation retreat (preprint)

The positive impact of meditation on human wellbeing is well documented, yet its molecular mechanisms are incompletely understood. We applied a comprehensive systems biology approach starting with whole blood gene expression profiling combined with multi-level bioinformatic analyses to characterize the co-expression, transcriptional, and protein-protein interaction networks to identify meditation-specific core network after an advanced 8-day Inner Engineering retreat program. We found the response to oxidative stress, detoxification, and cell cycle regulation pathways were downregulated after meditation. Strikingly, 220 genes directly associated with immune response, including 68 genes related to interferon (IFN) signaling were upregulated, with no significant expression changes in the inflammatory genes. This robust meditation-specific immune response network is significantly dysregulated in multiple sclerosis and severe COVID-19 patients. The work provides a foundation for understanding the effect of meditation and potential implications to voluntarily and non-pharmacologically improve the immune response before immunotherapy for many conditions, including multiple sclerosis and COVID-19 vaccination.

Development of Humoral and Cellular Immunological Memory Against SARS-CoV-2 Despite B-Cell Depleting Treatment in Multiple Sclerosis (preprint)

B-cell depleting therapies are widely used as immunomodulating agents for autoimmune diseases such as multiple sclerosis. The possible impact of B-cell depletion on development of humoral and cellular immunity to viruses and specifically SARS-CoV-2 has raised concerns with the COVID-19 pandemic. We here determined humoral and cellular responses in participants of an observational trial comprising several multiple sclerosis disease modulatory drugs (COMBAT-MS; NCT03193866). Patients on B-cell depleting treatment, who previously had COVID-19-like symptoms, developed anti-SARS-CoV-2 antibodies and/or T-cell memory irrespective of their B-cell depletion status. Furthermore, antibody titers were similar to those observed with other treatments or controls, and anti-SARS-CoV-2 T-cells displayed functional similarity to controls producing IFN-γ and TNF. These results inform on the role of B- and T-cells in SARS-CoV-2 immunity and provide evidence that B-cell depleting therapy does not substantially abrogate SARS-CoV-2 immunological memory, in turn suggesting a low risk for reinfection and potentially responsiveness to vaccination.Funding: The COMBAT-MS study is funded through a Patient-Centered Outcomes Research Institute (PCORI) Award (MS-1511-33196), modified to include the sub-study reported herein. Additional funding was obtained from the Swedish Medical Research council (grant no. 2017-03054), Swedish Brain Foundation, NEURO Sweden, Tetra Laval, Region Stockholm, Knut and Alice Wallenberg foundation, Erling-Persson family foundation and Petrus och Augusta Hedlunds Stiftelse.Conflict of Interest: Tomas Olsson has received unrestricted grants for extended multiplesclerosis studies in relation to COVID-19 from Biogen and Merck. Not related to this manuscript, T. O. has received unrestricted grants, advisory board/ lectures from Biogen, Merck, Novartis, and Sanofi and F. P. has received research grants from Genzyme, Merck KGaA and UCB, and fees for serving as Chair of DMC in clinical trials with Parexel. All other authors declare no competing interests.Ethical Approval: Study procedures were conducted under the following ethical permits approved by the Swedish ethical review authority; COMBAT-MS: 2017/32-31/4; STOPMSII: 2009/2107-31/2; 2020 00052, with written informed consent from participants.

Evaluation of the Combined Effect of Mobility and Seasonality on the COVID-19 Pandemic: A Lombardy-Based Study (preprint)

Background: Restrictions to human mobility had a significant role in limiting SARS-CoV-2 spread. It has been suggested that environmental seasonality might affect viral transmissibility. Our study retrospectively investigates the combined effect that seasonal environmental factors and human mobility play on transmissibility of SARS-CoV-2 in Lombardy, in 2020.Methods: Environmental data were collected from accredited open-source web services. Aggregated mobility data for different points of interests were collected from Google Community Reports. Rt was used as a proxy for SARS-CoV-2 transmissibility. Assuming a non-linear correlation between selected variables, we used a Generalized Additive Model (GAM) to investigate with univariate and multivariate analyses the association between seasonal environmental factors (UV-index, temperature, humidity, and atmospheric pressure), location-specific mobility indices, and Rt .Findings: UV-index was the most effective environmental variable in predicting Rt . An optimal two-week lag-effect between changes in explanatory variables and Rt was selected. The association between Rt variations and individually taken mobility indices differed: Grocery & Pharmacy, Transit Station and Workplaces displayed the best performances in predicting Rt when individually added to the multivariate model together with UV-index, accounting for 85·0%, 85·5% and 82·6% of Rt variance, respectively.Interpretation: According to our results, both seasonality and social interaction policies played a significant role in curbing the pandemic. Non-linear models including UV-index and location-specific mobility indices can predict a considerable amount of SARS-CoV-2 transmissibility in Lombardy during 2020.Funding Statement: The authors did not receive any specific funding for this manuscript.Declaration of Interests: MF is editor-in-chief of the Journal of Neurology; received compensation for consulting services and speaking activities from Biogen Idec, Merck-Serono, Novartis, Teva Pharmaceutical Industries; and receives research support from Biogen Idec, Merck-Serono, Novartis, Teva Pharmaceutical Industries, Roche, the Italian Ministry of Health, Fondazione Italiana Sclerosi Multipla, and ARiSLA (Fondazione Italiana di Ricerca per la SLA). YMF, LB, GS, TR and MV declare no competing interests.

Acute Endotheliitis (Type 3 Hypersensitivity Vasculitis) in Ten COVID-19 Autopsy Brains (preprint)

Central nervous system (CNS) involvement in COVID-19 may occur through direct SARS-CoV-2 invasion through peripheral or cranial nerves or through vascular endothelial cell infection. The renin-angiotensin system may play a major part in CNS morbidity. Effects of hypoxia have also been implicated in CNS lesions in COVID-19. This communication reports on ten consecutive autopsies of individuals with death due to COVID-19 with decedent survival ranging from 30 minutes to 84 days after admission. All ten brains examined had neutrophilic microvascular endotheliitis present in variable amounts and variably distributed. Importantly, this acute stage of type 3 hypersensitivity vasculitis can be followed by fibrinoid necrosis and inner vascular wall sclerosis, but these later stages were not found. These results suggest that a vasculitis with autoimmune features occurred in all ten patients. It is possible that viral antigen in or on microvascular walls or other antigen-antibody complexes occurred in all ten patients proximate to death as a form of autoimmune vasculitis.