Information on the SARS-CoV-2
A coronavirus called ”SARS-CoV-2“ has spread worldwide. It can cause a lung disease called ”COVID-19“. Flu-like symptoms with fever, headache, olfactory disturbance, cough and shortness of breath can occur, but sometimes the infection is accompanied by no symptoms at all. The full picture of the disease is a severe pneumonia that requires intensive care. The virus, and in particular the current ”delta-variant“, is very contagious. It is therefore very important that you do not enter our practice with flu-like symptoms. Meanwhile, several vaccines against the virus have received conditional marketing authorisation for one year because they could demonstrate good protection against the disease. Within that year, the manufacturers are obliged to conduct further studies. The German Governmental Vaccination Comission STIKO recommends vaccination for everyone over the age of 12, but it is crucial when dealing with some neurological and psychiatric diseases. These include autoimmune diseases (e. g. multiple sclerosis or myasthenia gravis), restricted mobility due to neurological conditions (e. g. muscle disorders or after a stroke), as well as severe depression, schizophrenia and dementia, since an infection with ”SARS-CoV-2“ can then have a more severe course.
Updated 30th August 2021 — Michael Vorwerg & Anna Maria Straub
General Infection Prevention Measures
In our practice we ask you to follow the general protective measures: Wash hands, Cover face with a FFP2 mask and Make space. Due to the limited space in the practice, we ask you to bring only one accompanying person. We have set up dispensers for hand disinfection in the entrance area of the practice, which you should use when entering the practice. If you have to cough or sneeze, please do so into a disposable handkerchief (and dispose of it immediately) or, if necessary, into the crook of your arm (not into your hand, not into the room and not towards other people). Please always wash your hands thoroughly afterwards. In our practice the wearing of a face and nose covering FFP2 mask is mandatory.
Appointments and Recipes
We want to keep the practice open during the coronavirus pandemic. The consultation hours will not change for the time being. However, it is necessary that we keep appointments short. If necessary, examinations can be postponed according to medical opinion. Follow-up prescriptions will be issued as soon as possible following a medical examination. If you only need a prescription, then an appointment is not absolutely necessary for those who have already visited us at least once in the current quarter. Please note that medication can be prescribed for a maximum of one quarter.
If Infection is Suspected
Should you fall ill with fever, cough and shortness of breath, we would ask you not to come to our practice. You should seek medical treatment if you have cold symptoms and have had previous contact with someone who has been diagnosed with the virus. This is especially important if you have a chronic lung disease or an impaired immune system (e. g. due to diabetes mellitus, HIV infection, immunotherapy, etc.). If you suspect that you are infected with the coronavirus, you should stay at home and call your family doctor, the emergency medical service (CALL 116117) or the coronavirus hotline of the Berlin health administration directly (CALL 030 90 28 28 28, daily 8 am - 8 pm).
Vaccination against SARS-CoV-2
We know that the coronavirus pandemic will only end if as many people as possible are vaccinated, because then the virus can no longer spread. Now that enough vaccine is available, as many people as possible over the age of 12 should get vaccinated. At the beginning of the vaccinations in early 2021, vaccines were only available in limited quantities. Therefore, people who are particularly at risk of suffering a severe course of the COVID-19 disease have been vaccinated first. These are mainly elderly people or those with internal diseases such as high blood pressure, diabetes mellitus or lung diseases. However, the ”risk groups“ also include people with neurological conditions such as dementia, mobility impairment due to muscle disorders or after a stroke, autoimmune diseases such as multiple sclerosis, severe depression or schizophrenia.
Meanwhile, several vaccines are available that protect with high efficacy, especially against severe courses of the disease. All of these vaccines were newly developed. They received conditional approval in the EU due to the urgency caused by the pandemic and are still in the scientific observation phase. Because the vaccine protection seems to decline over time, a booster vaccination will probably be necessary. So far, the German Standing Committee on Vaccination (STIKO) has not yet decided on this. It is expected that the booster vaccination will initially be offered to the risk groups at least 6 months after the first vaccination series and will be given with an mRNA vaccine. It is to be hoped that the willingness to vaccinate will not wane now, because higher infection rates are expected in the upcoming colder seasons.
All vaccines available in the EU aim to alert our immune system and immunise against the spike proteins of the SARS-CoV-2 coronavirus. Spike proteins are the dark red ”appendages“ that give coronaviruses their characteristic appearance. Although they are called ”spikes“, they do not look very spiky (more like pompons or bobbles in our eyes). With their help, the coronaviruses can penetrate our body cells.
All vaccines cause our body to produce those spike proteins itself. These are then recognised and attacked by the immune system. This causes the so-called ”vaccination reaction“: pain at the injection site on the upper arm, feeling of illness or increased temperature. This vaccination reaction does not occur in all vaccinated people, but it is common. Meanwhile, the white blood cells (called lymphocytes) form antibodies against the spike proteins. Some of the lymphocytes then turn into ”memory cells“.
When coronaviruses are detected in the body after vaccination, dormant memory cells are rapidly reactivated. This produces a large number of lymphocytes, which in turn provide masses of antibodies. These ”weapons“ attack the viruses at their weakest point: the spike proteins.
Occasionally, however, side effects occur that were not anticipated. For example, after vaccination with the vector virus vaccines from AstraZeneca ”Vaxzevria“ and from Johnson & Johnson vaccine ”COVID-19 Vaccine Janssen“, thromboses (also in the head) and reduced blood platelets (thrombocytes) were observed. Rare side effects were also observed with the mRNA vaccines from BioNTech/Pfizer ”Comirnaty“ and Moderna ”Moderna COVID-19 Vaccine“, such as allergic reactions and, in children and adolescents, heart muscle inflammation. Even if these side effects are rare and usually harmless, it is important to know about them. Therefore, unexpected symptoms should be reported to the German Paul Ehrlich Institute. Please contact us if you experience any new symptoms such as headaches, neurological symptoms, chest pain or palpitations in connection with a vaccination.
BioNTech/Pfizer's vaccine Comirnaty received a conditional marketing authorisation in the EU in December 2020 as the first vaccine against coronaviruses. Moderna's COVID-19 Vaccine followed in January 2021. Both are licensed for people aged 12 years and older.
The vaccines are very similar. They consist of ”messenger RNA molecules“ (mRNA) that are packed into lipid nanoparticles. These are necessary to protect the unstable mRNA molecules and to channel them into the muscle cells on the upper arm. They differ slightly in their exact composition but this makes no difference in function. They fuse with the target cells and release their contents (the mRNA with the blueprint for the spike protein) into the muscle cell.
The mRNA is a ”messenger molecule“ that can be found in every cell of your body. It's function is to deliver genetic information from the cell nucleus to the production sites for proteins (the so-called ”ribosomes“). Because muscle cells have a high protein metabolism, there are always many different mRNA molecules in each cell. They are quickly degraded after use. This also happens with the mRNA of the vaccines. After only a few hours, they are no longer detectable in the body.
Both vaccines lead to the production of spike proteins of the coronavirus (SARS-CoV-2). The mRNA differs minimally between the two vaccines, but this does not make any difference in efficacy or tolerability that has been demonstrated so far. During the vaccination reaction, the spike proteins (and probably some muscle cells) are destroyed. After two to three days, no more spike protein is detectable in the muscle.
The tolerability of the mRNA vaccines is good, and in our experience the usual vaccination reactions are less pronounced than with the vector virus vaccines. After the vaccination was approved for children above 12 years of age, occasional cases of myocarditis have been reported. Therefore, even in younger adults, attention should be paid to complaints such as chest pain, palpitations, a drop in performance or water retention in the legs. Very rarely, allergic reactions occur directly after vaccination, which is why follow-up observation for 15 to 45 minutes is necessary.
The efficacy is high against all rampant virus mutations, but only if two vaccinations have been given.
It may sound strange to vaccinate with (vector) viruses against (corona) viruses. For both vaccines, adenoviruses ”infect“ the vaccinated muscle. This is necessary to smuggle the ”actual“ vaccine, a piece of DNA, into the cell nucleus of the muscle cells. The DNA contains the ”blueprint“ of the spike protein of the SARS-CoV-2 coronavirus. Unlike other viruses, the DNA is not integrated into our own DNA. It is nevertheless channeled into the cell nucleus and read there to form ”messenger RNA“ (mRNA). The mRNA serves as a messenger between the cell nucleus and the cell body to pass the blueprint of the spike protein. There, those spike proteins are finally produced to trigger the immune reaction. The spike proteins and probably most of the infected muscle cells are destroyed in the process, so that no vector viruses or spike proteins are detectable in the body after about three days.
The vaccine of the British-Swedish pharmaceutical company AstraZeneca ”Vaxzevria“ received conditional marketing authorisation in the EU in January 2021. Vaxzevria contains an adenovirus as a vector to channel the blueprint of the spike protein of the SARS-CoV-2 coronavirus into the muscle cells. Because such adenoviruses are very common, many people are already immune to them. In order to be able to use them as a vaccine, adenoviruses were used that ”actually“ infect chimpanzees which humans are usually not immune to. The virus has been modified so that it cannot reproduce. It was developed at the University of Oxford and is called ”ChAdOx1“.
The vaccine of the Belgian pharmaceutical company Janssen (which belongs to the US pharmaceutical group Johnson & Johnson) received a conditional marketing authorisation in the EU in March 2021 under the trade name of COVID-19 Vaccine Janssen. It is often referred to as the Johnson & Johnson vaccine. As a vector virus, this vaccine uses a type 26 adenovirus called ”Ad26.COV2.S“. It was possible to use this human virus, i. e. one that ”specialises“ in humans, as a vector. It was modified so that it cannot reproduce. The advantage of the vaccine is that it achieves good efficacy even with a single vaccination dose.
The tolerability of the two vector virus vaccines is good. As with many vaccinations, there is often pain at the injection site, flu-like symptoms such as headaches, feelings of illness, fatigue or fever. These can last from hours to a few days.
After occasional cases of blood clots in the head (”cerebral sinus venous thrombosis“) occurred, vaccination with the AstraZeneca vaccine ”Vaxzevria“ was temporarily suspended in March 2021, and deliveries of the COVID-19 Vaccine Janssen from Johnson & Johnson were temporarily stopped in April. However, because the risk was considered very low, COVID-19 disease occurs at higher risk and there was too little vaccine overall, vaccination was resumed for people over 65 years of age. People under 65 who received AstraZeneca vaccine as a first dose should receive an mRNA vaccine as a second or booster dose. This combination is considered particularly effective.
The efficacy is sufficient against all rampant viral mutations and at least protects against a severe course of COVID-19 disease. However, a mild course cannot always be avoided.
Immunotherapy, risk of infection and vaccination
In our practice we treat people with so-called autoimmune diseases such as multiple sclerosis or myasthenia gravis. Those have in common that they are caused by a malfunction of the body's immune system. Roughly speaking, the body ”accidentally“ forms antibodies against its own cells and attacks them. The most common of these disorders in our practice is multiple sclerosis. About every thousandth person in Europe is affected by this disease.
The treatment of autoimmune diseases aims to suppress the immune system and is called immunotherapy. There are now many different immunotherapies with very different modes of action.
Some immunotherapies can weaken the body's defence against bacteria and viruses. Thus, vaccinations against tetanus, diphtheria, whooping cough, measles, rubella, mumps, chickenpox virus (varicella zoster), influenza and now also against COVID-19 are recommended before starting treatment. Especially under therapy with drugs such as cladribine, alemtuzumab, ocrelizumab, ofatumumab or rituximab, the risk of a severe course of COVID-19 is increased without vaccination.
According to current knowledge, vaccination itself does not increase the risk of reactivation of autoimmune diseases. For example, there are no indications so far that vaccination against COVID-19 triggers relapses of multiple sclerosis. However, that risk exists for the ”normal“ course of infectious diseases, which is why protection through vaccination is very important.
Vaccination is recommended for MS patients above the age of 12. In addition, a third vaccination is advised if the autoimmune disease has led to physical limitation, immunotherapy with drugs such as ocrelizumab, rituximab, fingolimod or ozanimod is being administered, or no antibodies against coronaviruses are detectable in the blood after vaccination.
Many immunotherapies interfere with the vaccination response, so that sufficient protection against COVID-19 cannot be established. In order to achieve vaccine protection after all, alternatives such as interrupting the immunotherapy for the vaccination or a third vaccination have been discussed. Because there is not yet enough knowledge about the optimal way, it has not yet been possible to develop a definitive concept. However, there is a consensus in our practice that ongoing immunotherapies should not be interrupted. Therefore, we will consider a third vaccination at a low threshold.
For a brief overview, the following are the findings to date on the immunotherapies we most frequently use (based on the recommendations of Prof. Dr. med. Ralf Gold and Prof. Dr. med. Judith Haas).
Azathioprine therapy increases the risk of SARS-CoV-2 infection, which may depend on the dose and the number of lymphocytes in the blood. Also, the vaccination against COVID-19 may not be sufficiently effective, which is why we are considering a third vaccination.
Cladribine therapy increases the risk of SARS-CoV-2 infection by reducing lymphocytes. The drug can also impair the vaccination response. Nevertheless, it has been shown that there is a good increase in antibodies after vaccination against COVID-19. Vaccination should be done at the earliest 4 months after the last therapy cycle, ideally when the lymphocyte counts have normalised.
Cortisone therapy increases the risk of SARS-CoV-2 infection, probably dose dependent. You will have to pay particularly strict attention to hygiene measures during high-dose cortisone therapy and to temporarily reduce contacts if necessary. Cortisone can also interfere with the vaccination response. Under low-dose continuous medication, we consider a third vaccination against COVID-19. In the case of high-dose cortisone treatment, vaccination should take place at the earliest two, preferably four weeks later.
If a reduction in lymphocytes occurs during therapy with dimethyl fumarate, the risk of infection with SARS-CoV-2 probably is increased. If the lymphocyte count is normal, no increased risk is assumed. So far, there is also no evidence of reduced vaccine protection against COVID-19 during therapy with dimethyl fumarate. Therefore, vaccination can be carried out as in healthy persons, and sufficient protection can be expected.
Fingolimod therapy leads to a reduction in the number of lymphocytes in the blood. Therefore, the risk of infection with SARS-CoV-2 is increased. Fingolimod also interferes with the vaccination response. Studies have shown a strongly reduced, sometimes even completely absent production of antibodies after vaccination against COVID-19 under treatment with fingolimod. Because interrupting the therapy carries the risk of reactivation of the disease, the consensus in our practice is to continue the therapy. A third vaccination is necessary.
So far, there is no evidence of an increased risk of infection with SARS-CoV-2 or a reduced vaccination protection against COVID-19 under therapy with glatiramer acetate. Therefore, vaccination can be given as in healthy individuals and adequate protection can be expected. If possible, vaccination should not be given on a therapy day.
So far, there is no evidence of an increased risk of infection with SARS-CoV-2 or a reduced vaccination protection against COVID-19 under therapy with interferons. Therefore, vaccination can be given as in healthy individuals, and adequate protection can be expected. If possible, vaccination should not be given on a therapy day.
So far, there is no evidence of an increased risk of infection with SARS-CoV-2 or a reduced vaccination protection against COVID-19 under therapy with natalizumab. Therefore, vaccination can be given as in healthy individuals, and adequate protection can be expected. If possible, vaccination should not be given on a therapy day.
Therapy with ozanimod leads to a reduction in the number of lymphocytes in the blood. Therefore, the risk of infection with SARS-CoV-2 is increased. Ozanimod also interferes with the vaccination response. Studies have shown a strongly reduced, sometimes even completely absent production of antibodies after vaccination against COVID-19 under treatment with fingolimod. This is very likely transferable to ozanimod. Because an interruption of the therapy carries a risk of reactivation of the disease, there is a consensus in our practice to continue the therapy. A third vaccination is necessary.
The drugs ocrelizumab, ofatumumab and rituximab reduce the number of so-called ”b-cell lymphocytes“ in the blood. These are responsible for antibody production. There is an increased risk of infection with SARS-CoV-2. The therapy also interferes with the vaccination response. Studies could prove the reduced antibody production in the blood. Under therapy with ocrelizumab and rituximab, vaccination against COVID-19 is recommended about four to six months after the last infusion. In addition, we are considering a third vaccination. There is currently no recommendation for the newly approved drug ofatumumab, but we are also considering a third vaccination, too.
Therapy with ponesimod leads to a reduction in the number of lymphocytes in the blood. Therefore, the risk of infection with SARS-CoV-2 is increased. Ponesimod also interferes with the vaccination response. Studies have shown a strongly reduced, sometimes even completely absent production of antibodies after vaccination against COVID-19 under treatment with fingolimod. This is very likely transferable to ponesimod. Because an interruption of the therapy carries a risk of reactivation of the disease, there is a consensus in our practice to continue the therapy. A third vaccination is necessary.
Therapy with siponimod leads to a reduction in the number of lymphocytes in the blood. Therefore, the risk of infection with SARS-CoV-2 is increased. Siponimod also interferes with the vaccination response. Studies have shown a strongly reduced, sometimes even completely absent production of antibodies after vaccination against COVID-19 under treatment with fingolimod. This is very likely transferable to siponimod. Because an interruption of the therapy carries a risk of reactivation of the disease, there is a consensus in our practice to continue the therapy. A third vaccination is necessary.
So far, there is no known increased risk of infection with SARS-CoV-2 during therapy with teriflunomide. However, teriflunomide can interfere with the vaccination response by reducing lymphocytes in the blood. So far, it is not sufficiently known whether sufficient protection against COVID-19 is achieved. We are considering a third vaccination.
COVID-19 app of the Charité Hospital for risk assessment
Corona screening centers in Berlin
Information on the corona virus provided by Senate Chancellery
Information on the corona virus provided by Robert Koch Institute (RKI)
Information on the corona virus provided by Wikipedia