Multiple sclerosis affects an estimated 2·8 million people worldwide. Although the past few years have seen substantial improvements in procedures for diagnosis, prognosis, and monitoring, and an expansion in the therapeutic landscape, there are stark disparities in the care of people with the disease. The third edition of the Multiple Sclerosis International Federation (MSIF) Atlas of MS reports that about two-thirds of patients with multiple sclerosis worldwide are living in countries that do not have national guidelines for the diagnosis and treatment of the disease. On World Brain Day (July 22), and through further engagement, MSIF are joining forces with the World Federation of Neurology to advocate for a heightened focus on improving quality of life for people with multiple sclerosis and their care partners.The Atlas of MS was launched in 2008 by MSIF, in collaboration with WHO, to address the absence of data on multiple sclerosis in many countries. Part 1 of the third edition of the Atlas reports the prevalence and incidence of multiple sclerosis in 115 countries. Part 2 of the Atlas, drawing on data from 107 countries, highlights the many barriers and inequalities that patients can face not only to get a diagnosis, but also to access disease modifying therapies (DMTs) and rehabilitation.An early diagnosis of multiple sclerosis is essential to either enable prompt treatment with DMTs that can minimise relapses and reduce future disability or, where such therapies are not available, allow for lifestyle changes to help manage the disease and improve quality of life. According to the MSIF Atlas, implementation of the 2017 McDonald diagnostic criteria in clinical practice correlates with country wealth, with around 98% of high-income countries compared with less than half (40%) of low-income countries using these criteria. The most common barrier to their use was lack of awareness or training for neurologists. Worryingly, about 83% of countries have barriers that further preclude early diagnosis of multiple sclerosis, such as a scarcity of qualified health-care professionals and the prohibitive cost of the diagnostic equipment and tests.

The MSIF Atlas also uncovers fundamental barriers to equitable access to treatment. Experts in about 14% of countries surveyed report having no licensed DMTs available. This proportion increases to 70% of low-income countries, including 60% of African countries. Globally, the most common barrier to accessing therapies is their high cost. Other challenges are the low number of health-care professionals, poor knowledge of DMTs among clinicians, and logistical problems with the continuous supply of DMTs. The MSIF Atlas also reports on the high unmet need for rehabilitation and symptom management, particularly in low-income countries, which are essential for a good quality of life. Therapies for fatigue and cognitive impairment are not available in about two-fifths of countries.

New evidence-based recommendations on the use of MRI in diagnosis, prognosis, and disease monitoring in multiple sclerosis unify guidelines from European and North American expert groups. The recommendations address major issues concerning the use of MRI in clinical practice that have arisen in the past few years, and highlight the essential role of MRI for diagnosis as well as assessment of treatment efficacy and prediction of treatment response. However, the recommendations are unlikely to be widely applicable in low-income countries where regular use of imaging procedures is challenging.

The MSIF Atlas makes some recommendations to address the disparities in care, including calls for every country to have a national plan or dedicated management guidelines; improvements to the availability and affordability of a range of DMTs through advocacy efforts and evidence-based guidance on the use of off-label DMTs; joint efforts between organisations and networks that focus on neurological conditions to tackle shared challenges, such as the number and training of neurologists and access to cost-effective approaches to management; and stronger collaboration between health-care authorities, research institutions, patient organisations, and health-care professionals in the collection of data to establish and monitor care standards.

The development of new and potentially more sensitive and specific imaging techniques than are currently widely available represents an important opportunity as new treatments emerge. However, addressing imbalances in care is essential to ensure that all people affected by multiple sclerosis are able to benefit from progress in the field.

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DOI: https://doi.org/10.1016/S1474-4422(21)00170-8

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