Multiple sclerosis during an emergency or crisis: A narrative review focused on the effect of war and COVID-19 pandemic

Abstract

Background: Armed conflict fractures the systems that multiple sclerosis (MS) care depends on, yet MS-specific guidance for war is scarce. The aim of this study is to synthesize evidence on MS care during armed conflict and other crises, and to develop practical, crisis-ready recommendations to maintain treatment continuity, reduce inequities, and guide clinicians and policymakers. Methods: We reviewed peer-reviewed literature (2000-2025) on MS during conflicts; when MS-war data were scarce, we utilized transferable evidence from COVID-19 MS studies. Results and conclusion: War disrupts disease-modifying therapies (DMT) supply, safety monitoring, rehabilitation, and continuity of care, widening inequities. A key controversy was whether to continue higher-risk DMTs with limited labs/MRI, and which monitoring to prioritize. Our recommendations established a five-action basis: create a single MS crisis hub (information, tele-access, patient passports), safeguard DMTs with lean pharmacovigilance and predefined substitutions, adopt tele-first care with a relapse pathway favoring high-dose oral steroids when appropriate, deliver equity-first outreach via mobile clinics and transport/fee support, and run a minimal data loop (stock, relapses, severe adverse events, hospitalizations, brief fatigue screening) for weekly course correction. Additionally, the basis of recommendations was transformed into a three-stage guideline figure.