Professional Documents
Culture Documents
For further details on this project or to submit updated information, please contact:
Tarun Dua
Department of Mental Health and Substance Abuse
World Health Organization
1211 Geneva 27
Switzerland
Tel + 41 22 791 3059, Fax: +41 22 791 4160, Email: duat@who.int, Web: www.who.int
Paul Rompani
Multiple Sclerosis International Federation
3rd Floor Skyline House
200 Union Street
London
SE1 0LX
Tel: +44 (0) 20 7620 1911, Fax: +44 (0) 20 7620 1922, Email: paul@msif.org, Web: www.msif.org
CONTE N T S
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Data collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Summary results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
The way forward . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
List of respondents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Annex: Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
FOREWORD
Benedetto Saraceno
Director
Department of Mental Health and Substance Abuse
World Health Organization
Alan Thompson
Chairman
International Medical and Scientic Board
Multiple Sclerosis International Federation
PREFA C E
The Atlas of MS provides, for the rst time, information and data on the global epidemiology of MS and the
availability and accessibility of resources for people with MS
at the country, regional, and global levels.
Knowing what resources are available in different countries
helps to provide useful insights and highlight differences,
gaps and inadequacies. Such internationally comparable
statistics on resources enable assessment and comparison of
the performance of national health systems and the health
of the particular populations they serve.
The Atlas of MS provides this information, considers the
resulting implications and suggests ways forward in the
global effort to improve the planning and delivery of health
care services. It is not only a reference, which relevant individuals, groups and organizations can consult, but it is also
an overview of the current issues facing people with and
affected by MS and those who work tirelessly to provide
support and services for them.
Paul Rompani
Deputy Chief Executive
Multiple Sclerosis International Federation
A C K N O W L EDGEMENTS
Dr Tarun Dua and Paul Rompani were responsible for completion of the data collection, data analyses, overall project
management and the writing of this report. Ms Rosa Seminario and Ms Rosemary Westermeyer helped with the data
management and provided administrative support.
The information from various countries, areas and territories
was provided by key persons working in the eld of MS
and/or neurology identied by MSIF, WHO regional ofces,
the ofces of WHO Representatives and the World Federation of Neurology. The respondents also handled the many
requests for clarication arising from the data. Contributions
of all these individuals has been valuable in the production
of this report. The list of respondents is included at the end
of the Atlas of MS.
Assistance in preparing the Atlas of MS for publication was
received from Tushita Bosonet and Chris Burgisser (graphic
design), Steve Ewart (maps) and Susan Kaplan (editing).
The contribution of each of the team members and partners,
together with input from many other unnamed people, has
been vital to the success of this project.
INTRODUCT I O N
Developing the Atlas of MS presented some unique challenges that reect the current status of MS services in
countries with low or middle incomes. Large differences
The primary purposes of this report are to stimulate additional systematic data gathering and to encourage the
development of much needed policy, services and training.
We very much hope that this initial publication will serve
these purposes.
M E T H O D O LOGY
Data collection
The Atlas of MS is based on the information and data collected by WHO and MSIF. At WHO, the work was led by
headquarters in close collaboration with the regional ofces.
The rst step in the development of the Atlas of MS was
to identify specic areas where information related to MS
resources and services was lacking. To obtain this information, a questionnaire was drafted in English in consultation
with a group of people from WHO and MSIF. A glossary of
terms used in the questionnaire was also prepared to ensure
that the questions were understood in the same way by different respondents. Subsequently, the draft questionnaire
and glossary were reviewed by selected experts. The resulting questionnaire was developed further, in consultation with
the Atlas of MS Oversight Group, and pilot tested and necessary changes were made. The denitions used in the glossary
are working denitions for the purpose of the Atlas of MS
project, and do not constitute ofcial WHO denitions.
The nal version of the questionnaire covered a wide range of
issues broken down into the following eight separate sections:
epidemiology
MS
of MS
support
diagnosis
of MS
management
treatment
quality
issues
of MS
of MS
in MS care.
The next step of the process was to identify the most relevant and appropriate person in each country to be invited to
act as country coordinator to be the focal point for gathering information and data within that country and organizing
the completion of the eight sections of the questionnaire.
For those countries with MSIF member societies or corresponding organizations, the country coordinator was either
the senior staff member or senior volunteer of the society or
the country representative on the MSIF International Medical
& Scientic Board. In addition, WHO regional ofces were
asked to identify a key person working in the eld of MS or
neurology in those countries where the MSIF has no liaison
person or this person was not available or not responsive.
For countries with no MSIF connection, the country coordinators were either WHO contacts developed through
the production of the WHO Atlas: Country Resources for
Neurological Disorders, 2004, individuals identied by MSIF
staff or members of the World Federation of Neurology.
The country coordinators were asked to consider which
individuals, groups and organizations in their country
would be best placed to complete the eight sections of the
questionnaire. The country coordinators were requested
to coordinate the completion of the questionnaire, making use of all possible sources of information available to
them. All respondents were asked to follow the glossary
denitions closely, to maintain uniformity and comparability of the information received. Throughout this process,
the Atlas of MS Project Work Group responded to questions and requests for clarication. Repeat requests for
completion of the questionnaire were sent to the country
coordinator in cases where there was a delay in returning
the completed questionnaire. In the case of incomplete or
internally inconsistent information, the respondents were
contacted to provide further information or clarication.
Where appropriate, documents were requested to support
completed questionnaires.
Eventually completed questionnaires were received from 64
countries. Another attempt was made to contact countries
that had not responded through MSIF member societies and
corresponding organizations, and contacts identied through
WHO Regional Ofces and World Federation of Neurology.
In order to improve representation across all WHO regions,
a shorter questionnaire was developed for completion by
contacts in those countries where little is known about MS
and/or there is low prevalence of MS. As a result of the
extra effort, data was gathered from 112 countries.
An electronic database was generated and received data
was entered. Both quantitative and qualitative data was
entered using suitable codes. Population gures were taken
from the World Health Report 2006 (WHO, 2006). Countries were grouped into the six WHO regions (Africa, the
Americas, Eastern Mediterranean, Europe, South- East Asia
and Western Pacic).
METHODOLO G Y
es
fic
Of
al
ion s
g
Re area
HO the rve
W nd
e
a ey s
h
t
ion
eg icas
R
an mer gion
ric
Af the A a Re gion n
si
f
Re gio n
HO
e
W ion o ast A ean
o
e
p
E
n R egi
g
Re uth- Euro anea fic R Offic
i
o
r
O
l
r
c
O
a
H OS
e
a
n
H
it
P
W H
W
ed ern
gi o
W
M
Re
st
n
e
r
ste O W
Ea
H
O
W
H
W
e
av
o h for
h
s w ata S
trie ed d of M
n
u
Co rovid tlas
p eA
th
s
Ye o
N
M E T H O D O LOGY
e
av
o h for
h
s w ata S
trie ed d of M
n
u
Co rovid tlas
p eA
th
Limitations
The most important limitation of the dataset is that in 67
of the 112 countries a single key person was the source of
all information. Although most respondents had access to
numerous ofcial and unofcial sources of information and
were able to consult neurologists within the country, the
data received should still be considered as reasonably, and
not completely, reliable and accurate. In some instances the
data are the best estimates by the respondents. In spite of
this limitation, the Atlas of MS is the most comprehensive
compilation of MS resources in the world ever attempted.
Because the sources of information in most countries were
the key persons working in the eld of MS, the dataset
mainly covers countries where there are MS societies, neurologists or other experts with an interest in MS or neurology. It is therefore likely that the Atlas of MS gives an over
positive view of neurological resources in the world, if we
consider the lack of experts or health professionals with an
interest in MS or neurology, which suggests that there are
likely to be very few or no resources in the remaining 82
(42%) of the WHO Member States.
10
est
rn
ste O W
a
E
H
W
HO
W
s
Ye o
N
METHODOLO G Y
11
RESULTS BY THEM E S
13
E P I D E M I O L OGY
T O TA L N U MBERS, PREVALENCE AND INCIDENCE
Limitations
Comparability
Complete
case ascertainment depends on access to medical care, local medical expertise, the number of neurologists, accessibility to and availability of new diagnostic
In
Salient ndings
Globally,
Regionally,
By
The
Globally,
Regionally,
the median estimated incidence of MS is greatest in Europe (3.8 per 100 000), followed by the Eastern
Mediterranean (2), the Americas (1.5), the Western Pacic
The
The
Implications
This
No
The
14
Typically,
our results conrmed the well established suggestion that there are strong geographical patterns to the
disease and that the frequency of MS varies by geographical region throughout the world, increasing with distance
from the equator in both hemispheres.
The
The
lack of data in approximately two thirds of the countries that responded reects the lack of published reports
in medical literature regarding the epidemiology of MS.
EPIDEMIOLO G Y
00
>1 00
-1 -60
1
.01
0
60 20.0 1-2 5
0- n
5.0
tio
ma
r
o
inf
No
er
S p on
M i
of lat
ce opu
n
p
le
va 00
Pre 00,0
1 =93
1.1
N
80
tio
la
pu
1.2
o
0p d
0
0
0, orl
10 e w
r
e
th
S p and
14.9
M
of ions
8.3
e
nc eg
0.3
ale O r
v
e
Pr WH 3
in 9
N=
as
ric
e
Am
Ea
rn
ste
5
30
ric
Af
2.8
di
an
89
e
ran
ter
e
rop
Eu
ia
As
st
ic
a
E
cif
Pa
d
uth
n
o
S
orl
er
W
est
W
n
tio
ula ies
p
o
tr
0 p coun
0
32
0
0, of
10 ups
r
e
o
S p e gr
10
M
m
of nco
0.5
e
nc t i
ale eren
v
f
e
w
Pr dif
Lo
n
i
93
1.3
=
dle
N
30
d
mi
le
er
idd
w
m
Lo
r
gh
Hi
pe
d
Up
orl
W
15
E P I D E M I O L OGY
AVERAGE AGE OF ONSET AND MALE/FEMALE RATIO
Salient Findings
Globally,
Globally,
Regionally,
Regionally,
By
By
Implications
The
It
2.1
16
e
ns
fo )
o
ge ars
e a n ye
g
(i
era
Av f MS
o
96
N=
the sample size is relatively small, the ndings also suggest that the age of onset is lower in many
developing countries and this might be suggestive of an
avenue for future research.
0
<2 5
-2
0
0
2
-3
25 -35
30 >35
on
ati
m
r
o
inf
No
EPIDEMIOLO G Y
AVERAGE AGE OF ONSET AND MALE/FEMALE RATIO
ale
-1
0.5 .5
-0
.3
0.3 5-0
2
.25
.
0
-0 0.2
2
.
<
0
n
tio
ma
r
o
inf
No
io
rat
m
/fe
ale S
M fM
o =98
2.4
N
29.3
29.4
26.9
29.2
29.5
33.3
fM
o
et
ns nd
o
of s a )
ge gion ears
a
y
e re
rag HO d (in
e
Av W orl
in e w
2.2
th =96
29.2
29.5
28.9
ric
Af
rn
29.2
an
e
an
err
it
ed
e
ast
29.3
as
ric
me
ld
S wor
M
f
he
oo dt
ati s an
r
0.5
n
le
ma regio
e
f
/
e
O
al
0.33
M WH
8
n
i
9
2.5
=
N
e
rop
Eu
ia
As
ast
ific
E
ac
th
P
d
u
So
orl
ern
W
est
W
nt
ere s)
f
f
i
r
w
n d ea
Lo
S i (in y
le
M
s
idd
of trie
t
m
le
n
se
er
dd
on f cou
mi
ow
f
L
r
gh
o
o
Hi
pe
d
ge ups
Up
a
orl
e gro
W
g
a
e
er
Av com
n
i
96
2.3
N=
0.5
0.6
0.5
0.5
0.4
0.5
0.31
0.5
ric
Af
ste
Ea
as
c
eri
Am
ran
er
dit
nM
28.9
ea
e
rop
Eu
ia
As
ast
ific
E
ac
th
P
d
u
So
orl
ern
W
est
W
0.5
S s
f M roup
o
io e g
rat
le ncom
a
i
m
/fe rent ies
e
l
e
r
a
M diff unt
w
in f co
2.6
Lo
o =98
N
0.5
Lo
le
idd
rm
we
pe
Up
le
dd
i
rm
gh
Hi
d
orl
W
17
M S O R G A NISATIONS
Salient Findings
Regionally,
Globally,
By
s
Ye o
N n
o
ati
rm
o
f
n
up
gro
S
n
fM ni
e o zatio
c
en ani try
ist
Ex r org oun
o ec 2
3.1
th 11
i
No
N=
91.3%
92.1%
76.7%
p
rou ps
S g grou
M
an me
th inco
i
w t
n
es
14.3%
tri ffere
n
i
u
o nd
c
of n i
ge atio
a
t
iz s
n
rce an rie
w
Pe r org unt
Lo
o f co 2
le
3.2
dd
o =11
mi
N
18
we
Lo
le
idd
m
er
Up
73.2%
gh
Hi
d
orl
W
3.3
ld
up wor
o
r
S g the
n M and
a
ns
th
wi egio
s
r
ie
ntr HO
ou n W
c
73.2%
of n i
ge atio
a
t
iz
n
rce an
Pe r org 2
o
11
N=
22.2%
95%
d
orl
W
MS ORGANISATIO N S
Implications
Many
countries in the world have no patient-driven support for people with MS, with low income countries being
signicantly less likely than high income countries to have
such groups. Inevitably this will have an impact on people
with MS in those countries, as MS groups or organizations
usually play an important role in distributing information
and providing support and services.
The
s
Ye o
N n
o
ati
rm
o
f
in
No
There
is no rm relationship between support and incidence, with, for example, the Eastern Mediterranean
p
having thegsecond-highest
incidence but lying fth in prorou
S
in
Mpatient-driven
visionofof
MS
support.
n
o
ce izati
n
e an try
ist
Ex r org oun
o ec 2
3.1
th 11
N=
91.3%
92.1%
76.7%
p
rou ps
S g grou
M
an me
th inco
i
w t
n
es
14.3%
tri ffere
n
i
u
o nd
c
of n i
ge atio
a
t
iz s
n
rce an rie
w
Pe r org unt
Lo
o f co 2
le
3.2
dd
o =11
mi
N
we
Lo
le
idd
m
er
Up
73.2%
gh
Hi
d
o rl
W
3.3
ld
up wor
o
r
S g the
n M and
a
ns
th
wi egio
s
r
ie
ntr HO
ou n W
c
73.2%
of n i
ge atio
a
t
iz
n
rce an
Pe r org 2
o
11
No
N=
22.2%
d
orl
95%
W
50%
a
ric
93.2%
Af
as
ric
75%
e
n
Am
ea
66.7%
n
e
rra
ite
rop
d
u
e
E
ia
M
As
st
ern
a
t
ific
E
s
ac
Ea
thP
u
So
ern
est
W
19
DIAGNOSIS
Salient Findings
The
Globally,
Regionally,
Regionally,
By
Regionally,
the Poser criteria are the criteria most commonly used in the Western Pacic (57.1%) followed by Africa
(35.7%), South-East Asia (33.3%), Europe (30%), the
Americas (29.4%) and the Eastern Mediterranean (8.3%).
The
Globally,
The
The
31%
MRI
iag
tM
es
n
mo
4.1
20
m
Co 94
N=
Sd
ed
us
rit
cc
ti
os
a
eri
Poser 31%
Schumacher 3%
McDonald 66%
DIAGNOSIS
14.3%
70.6%
29.4%
0%
35.7%
50%
83.3%
8.3%
8.3%
70%
30%
0%
ric
Af
66.7%
33.3%
0%
as
c
eri
42.9%
57.1%
0%
Am
a ld
eri
rit wor
c
c
e
sti th
no and
g
ia s
S d gion
M
re
st
ne HO
o
mm in W
Co sed
u
94
4.2
n
ea
an
ern
st
Ea
rr
ite
66%
ed
e
rop
Eu
uth
31%
ia
As
So
N=
ld
na
Do
ast
ic
cif
a
nP
ter
3%
es
W
er
orl
W
ch
a
um
ch
17.7%
29.4%
52.9%
56.5%
43.5%
0%
65%
35%
0%
79.4%
ed
us ies
a
i
r
ter nt
cri cou
c
i
f
t
os s o
gn roup
a
i
Sd eg
t M ncom
s
ne t i
mo eren
m
f
Co dif
in =94
4.3
N
ld
na
o
cD
um
ch
er
20.6%
0%
Lo
66%
we
Lo
le
dd
i
rm
pe
Up
31%
le
dd
i
rm
gh
Hi
3%
ac
d
orl
W
21
DIAGNOSIS
Implications
Although
Because
the time of initial diagnosis is particularly stressful, it deserves special attention from health care and
other providers.
Clinical
The
MS
The
.04
-0
9
0.0 -0.0 30
5
0. 00
0
.
00
.
0.1 31-1
>1
0.
on
ati
m
r
o
inf
No
s
ine
ch ion
a
t
m
RI pula
M
o
p
of
er ,000
b
0
m
Nu er 10 2
p =10
4.4
N
0.31
22
0
rld
0.17
,00 e wo
0
10 th
r
nd
pe
0.08
es ns a
n
i
o
h egi
c
0.004
a
0.03
0.35
DIAGNOSIS
Physicians must be sensitive to the major psychological, social, nancial, vocational and medical impact of
telling a person that she or he has MS. Patients must have
adequate time to ask questions of the physician. Newly
diagnosed patients should be referred to the national MS
society and to an MS nurse specialist or other health professional with MS treatment and counselling experience.
s
ine
ch ion
a
t
m
RI pula
M
o
f
p
ro 0
be 0,00
m
Nu er 10 2
p =10
4.4
2.2.2.
ti
ma
No
or
inf
0.31
0
rld
0.17
,00 e wo
0
10 th
r
d
n
pe
0.08
es ns a
n
i
o
i
h eg
c
0.004
r
ma
RI HO
M
W
of in
a
er ion
ric
b
Af
m lat
s
u
ca
N opu 2
eri
0
p
m
1
an
4.5
A
ne
N=
ern
st
Ea
rra
ite
ed
0.03
0.35
0.12
e
rop
Eu
ia
As
st
ic
a
E
cif
Pa
d
uth
n
o
r
S
orl
e
W
est
W
0.76
0
,00 s
00 roup
1
g
er
s p ome
e
c
0.15
in
ch t in
0.07
ma eren
I
R iff
0.01
f M in d
o
r on
e
mb ati ries
w
Nu opul unt
Lo
p f co 2
le
4.6
0
o =1
idd
0.12
le
rm
idd
we
m
r
gh
Hi
pe
d
Up
orl
W
Lo
23
Limitations
The
question on the most common topic of printed information was answered by only 61 countries the actual
gures are likely to be lower.
Salient Findings
The
most common means of providing information to people with MS (by MS organizations, health professionals and
pharmaceutical companies) in those countries that responded is through the distribution of printed material (70%)
(Figure 5.3), followed by a telephone helpline (53.7%), a
website (53.6%) and a newsletter (49.1%) (Figure 5.1).
material is available in 97.7% of the European
countries that responded followed by 89.5% of those in
the Americas, 55.6% in the Western Pacic, 50% SouthEast Asia, 40% in the Eastern Mediterranean and 16.7%
of African countries.
Printed
Printed
The
website is available in 84.1% of the European countries that responded, followed by 47.4% of those in the
Americas, 44.4% in the Western Pacic, 33.3% in the
Eastern Mediterranean, 25% in South-East Asia and
11.1% of African countries.
24
newsletter is available in 77.3% of the European countries that responded, followed by 55.6% in the Western
Pacic, 47.4% in the Americas, 25% in South-East Asia,
20% in the Eastern Mediterranean and 5.6% of Africa
countries that responded.
newsletter is available in 81.6% of high income countries, 68.2% of upper middle income countries, 24.1% of
lower income countries and 4.8% of low income countries.
Implications
Our
survey again highlights the signicant inequalities in the provision of basic and more specic forms of
information. For example, printed material is available
in nearly 95% of high income countries, but in less than
15% of low income countries. It is interesting to note the
relatively high provision of information via the Internet,
which may be a reection of the exibility of the medium,
the age group concerned and their embrace of technology. It is also probable that in countries where MS is less
commonly diagnosed, the absence of readily available
information is likely to further depress incidence gures.
People
ng
idi ns)
v
o
ea
pr
ies nt m
r
t
70%
e
un er
co diff
f
e o (by MS
tag tion ith
n
a ew
rce
53.7%
Pe form opl
e 0
n
53.6%
i
p
5.1
to =11
N
49.1%
The
This
nt
ere d
f
f
di
te
in prin S
s
M
e
tri ing th
un vid e wi
o
f c pro pl
86.4%
e o ups peo
g
a
o
o
t
t
r
65.5%
n
g on
i
rce e
Pe com mat
in for 0
5.2
in 11
94.7%
70%
N=
14.3%
Lo
ia
ter
dM
nte
Pri
le
Te
o
ph
e
eh
e
sit
eb
W
er
ett
sl
w
Ne
idd
rm
we
in
lpl
Lo
le
dd
i
rm
pe
Up
le
gh
Hi
d
orl
W
25
d
nte l
pri eria
f
at
yo
ilit ion m
b
a at
ail
Av form S
in r M 0
5.3
fo 11
N=
26
4.1.
People with MS must be offered good quality information as well as training for a wide range of health
promotion practices, depending on patient preferences
and their effectiveness in enhancing quality of life for the
individual.
No
s
Ye o
N n
tio
ma
r
o
inf
Limitations
Questions
Support
Salient Findings
Advocacy and campaigning
In
In
In
In
32% of the countries that responded, advice to governments about MS matters is not provided whereas in
55% of countries the government is advised by the MS
organization, in 34% by health professionals in the public
sector and in 3% by the pharmaceutical/biotech industry.
32% of the countries that responded, there is no lobbying or campaigning to improve the rights, entitlements
and quality of life of people with MS whereas in 65%
of countries that responded, the MS organization lobbies and campaigns on these issues; in 23% of countries,
these activities are also undertaken by health professionals in the public sector and in 16% also by industry.
8% of the countries that responded, educational meetings, seminars and conferences are not organized whereas in 83% of countries that responded they are provided
by the MS organization, in 54% by health professionals in
the public sector and in 46% by industry.
17% of the countries that responded, specic training
for health professionals in MS is not available, whereas
in 41% of countries that responded training is provided
by the MS organization, in 70% by health professionals in
the public sector and in 40% by industry.
Personal support
In
In
In
In
In
In
In
In
27
S U P P O RT AND SERVICES
In
Implications
Advocacy and campaigning
Personal support
In
MS
Health
and social care professionals should provide people with MS with the knowledge, skills and condence
to participate actively in all aspects of their own care and
encourage and support them to become expert patients.
There
is a specic lack of public and professional awareness of the dimension of MS in the domains of epidemiology and impact of disease on individuals, carers and
society, including impact on individual loss of independence, and cost of long-term care. In particular, the chronic
progressive nature of MS must be better conveyed to all.
28
Without
There
Mobility
ndings highlight the key role played by MS organizations in supporting, representing, advising and supporting
people with MS and acknowledging and addressing the
special needs of caregivers. Most MS-related services are
provided to the person with MS by family members and
other informal carers, who are themselves profoundly
affected by having a relative or friend with MS. These
family members and friends benet from services designed
to help them cope with the stress and other impacts of
the disease. Children can be affected by having a parent
with MS and may not fully understand the reasons for a
parents health problems, and think they have somehow
caused them or feel neglected as a member of the family.
3.1.
3.2.
3.3.
5.1.
5.2.
5.3.
5.4.
5.5.
5.6.
Services must be available to prevent physical, nancial and psychological abuse of people with MS by family
members and other informal caregivers.
6.1.
6.2.
For people with MS who cannot or do not drive, accessible transport services must be available and affordable.
29
D R U G T R E ATMENTS
AND ALTERNATIVE AND COMPLEMENTARY THERAPIES
Limitations
Questions
on the symptoms and recently licensed treatments of MS were only answered, in most cases, by
approximately 78 countries, the majority of which are
high income countries. Consequently the ndings are less
global than they are elsewhere in this Atlas of MS and
probably paint an overly positive picture.
Salient Findings
The
The
The
Drugs
The
The
Patient
30
The
Other
DRUG TREAME N T S
74.5%
68.9%
68.6%
64.2%
se
ea
s
i
d
th le
wi ilab
s
a
e
tri av
un nts
o
f c me S
e o treat h M
g
a
t
it
b
-1
en ying le w
c
r
f
)
eta
b
Pe odi eop
us
on
eo
p
r
m
n
e
r
7.3
ne
rf
fo =106
uta
tro
nte
bc
50%
40%
40%
s
tom
p
ym le
f s eop
o
p
e
tag d by
n
rce nte
Pe rese MS
p ith
7.1
w =88
31%
45.3%
)
n
lar
xa
(su
ito
scu
1a
u
te
M
a
t
am
eta
be
ac
ntr
n
i
r
(
o
e
a
er
-1
ram
erf
eta
ati
Int
l
b
G
ron
rfe
e
t
In
I
22%
17.5%
y
t
i
ic
15%
ast
ms
sp
e
l
r
o
b
ue
on
pro
10%
tig
cti
ry
a
n
F
o
es
u
s
nc
10%
en
ysf
a
S
d
e
c
urb
ss/
lan
ist
ne
l
a
d
k
e
B
l
w
ea
ua
bo
rw
in
Vis
nd
Pa
oto
a
M
s
er
d
d
lem
b
n
o
Bla
pr
tio
nc
ral
u
u
f
ys
vio
ld
ha
ua
be
x
/
e
Se
itiv
gn
o
C
77%
85%
82.7%
56.6%
52.5%
89.9%
96%
s
rug S
d
fM
th
wi s o
s
m
e to
tri
un ymp
o
s
y
fc t
icit
e o trea
ast
g
p
ms
s
a
o
nt le t
or
ble
e
e
o
n
r
c
b
r
p
gu
tio
Pe vaila
ry
ati
nc
F
o
es
u
s
8
f
a =8
n
nc
ys
7.2
a
Se
b
N
/d
r
ss
ne
ak
e
rw
oto
M
u
Vis
ist
d
al
72.9%
81.8%
de
lad
ce
lan
Ba
el
ow
db
an
gn
Co
ra
iou
av
eh
b
e/
itiv
in
Pa
al
xu
Se
s
lem
b
pro
on
cti
un
ysf
31
D R U G T R E ATMENTS
AND ALTERNATIVE AND COMPLEMENTARY THERAPIES
Implications
Presenting symptoms
symptomatic treatments
Our
The
understanding of symptomatic pain has been improving. Until the mid-1980s MS was widely considered to be
a painless condition. It is now widely recognized that MS
can cause pain and that at least one third of all people
with MS will feel some level of pain at some time. (See
MSIF, Pain and MS, MS in focus, issue 10, July 2007)
MS
Less
well understood by both neurologists and the public at large, is fatigue associated with MS. In general,
researchers are increasing their efforts to understand
fatigue, as the majority of people with MS will experience
this invisible but severe and disabling symptom at some
point during the course of their disease. Fatigue impacts
on a person's health-related quality of life and ability to
work. Health care professionals need to include assessments of fatigue in their routine care of patients with
MS and should be able to offer strategies to help them
deal with any fatigue they might experience. (See MSIF,
Fatigue, MS in focus, issue 1, February 2003)
The
32
Relapse treatments
The
Complementary treatments
MS
There
Finding
DRUG TREAME N T S
All people with MS must have access to evidencebased, quality health care.
2.4.1.
2.1.2.
Health care for people with MS includes medically-effective treatments, including symptom and disease
modifying drugs, rehabilitation services, appropriate and
affordable enabling technology that is tailored to the
needs of people with MS, and continuing care services.
People with MS have access to medical care, treatments
and therapies appropriate to their needs.
75%
se
ea ome
s
i
40%
d nc
ng t i
34%
ivi eren
e
rec iff
le in d
p
t
o
10%
pe en
of atm ries
e
e
t
r
g
t
n
nta ng cou
f
rce yi
Pe odif ps o
u
m
w
7.4
Lo
gro =106
le
N
idd
Lo
rm
we
Up
le
idd
m
er
50%
gh
Hi
d
orl
W
%
00 ot nt
1
n
e
n
61.1%
tha S do reatm
s
es h M g t
l
57.7%
t
n
y
i
i
wh le w dify
29.6%
s
o
p
n
e
so peo se m
oic
27.8%
a
h
e
c
y
r
le ea
lic
nt
o
e
i
ain ligib dis
p
t
e
M f e ive
Pa
tic
ing
o ce
t
rac
nd
7.5
p
u
4
e
l
F
gis
r
5
N=
ica
lin
Ge
ne
c
ral
ss
ce
Ac
to
o
rol
eu
n
a
33
H U M A N R E SOURCES
Limitations
A
Salient Findings
Globally,
Globally,
the median estimated number of MS neurologists is 0.04 per 100 000 (with an interquartile range of
00.19) (Figure 8.1).
Regionally,
the median estimated number of MS neurologists per 100 000 is greatest in Europe (0.19) followed
by the Americas (0.03) the Western Pacic (0.01) and the
Eastern Mediterranean (0.004). The median estimated
number of MS neurologists per 100 000 in South-East
Asia and Africa is zero.
By
By
By
Globally,
In
Regionally,
Globally,
there are MS nurses in 75% of the countries that responded in Europe, followed by South-East
Asia (50%), the Americas (44.4%), the Western Pacic
(44.4%) and the Eastern Mediterranean (14.3%). None of
the 18 countries that responded in Africa has MS nurses.
Regionally,
Globally,
hospital-based interdisciplinary teams are available in 73.3% of the countries that responded whereas
community based interdisciplinary teams are available in
32.8% of the countries that responded.
Regionally,
Implications
MS neurologists
MS nurses
Without
An
34
MS nurse plays a vital role as an educator, care provider, and advocate for patients and families affected by
MS and MS nurses are emerging as a leading force in
providing care to people with MS. While there is currently
little evidence of effectiveness for the MS nurse specialist
role, there is evidence for its appropriateness, although
more rigorous primary research is required to test this.
HUMAN RESOUR C E S
MS
of ts
r
e
is
mb log 000
Nu euro 00, ion
n er 1 lat
8.1
p opu 4
p =10
.05
< 0 0.1
50.3
0.0 .11- .99
0
0
>1
1n
0.3
tio
ma
r
o
inf
No
es n
urs latio
n
u
S
M op
of 0 p
r
e
00
mb 0,
Nu er 10 4
p =10
8.2
N
.03
< 0 0.1
3.29
0.0 1-0 0.5
1
1- 0.5
0.
> ion
0.3
at
rm
nfo
i
No
35
H U M A N R E SOURCES
Implications
Other health professionals
The
Hospital-based
reported in just under one third of countries. The interdisciplinary approach brings together professionals with a
range of relevant skills who have the ability to contribute
to a group effort on behalf of the patient, resulting in a
synergistic treatment programme producing more effective care than each discipline could achieve individually.
The
The
2.3.2.
36
HUMAN RESOUR C E S
0.19
0
0.004
0
0.03
0
es
urs orld
n
S ew
M
nd nd th
a
a
ts
gis ions
o
l
eg
ro
eu O r
S n WH
f M in
r o 00
e
0
mb 0,
Nu er 10 4
es
p =1 0
urs
n
8.3
S
N
0
a
ric
Af
0.07
as
ric
e
Am
0
n
ea
0.0004
0.01
an
n
ter
rr
ite
ed
e
rop
Ea
Eu
uth
0.04
st
Ea
ia
As
a
nP
ter
es
W
es
tri
s oun
e
urs f c
0.07
S n ps o
0
d M grou
n
e
sa
0.02
ist com
g
n
o
i
l
0
t
o
r
eu ren
0
S n diffe
M
n
f
i
ro 0
be 0,00
m
w
Lo
Nu er 10 4
0
p
1
=
8.4
N
e
r
we
Sn
urs
es
0.01
ic
cif
So
orl
W
0.21
0.12
dd
mi
Lo
pe
Up
0.04
le
dd
i
rm
0.01
gh
Hi
d
orl
W
37
Limitations
Questions
Salient Findings
The
Regionally,
Financial
Regionally,
rehabilitation and health benets are available to people with MS in 85% of the countries in Europe
that responded, followed by 78.6% of those in the
Eastern Mediterranean, 77.8% of those in the Western
Pacic, 66.7% of those in the Americas, 50% of those in
South East Asia and 12.5% of the African countries that
responded.
Rehabilitation
Regionally,
38
By
income band, nancial support in the form of tax benets was reported to be available in 75% of high income
countries, 70% of upper middle income countries, 29.6%
of lower middle income countries and none (0%) of the
low income countries.
Regionally,
Tax
Regionally,
Workplace
Implications
Recent
Many
Many
Disability
The
68.6%
67.7%
t
en s
m
e
ion
tl
nti reg
e
ity HO
bil n W
a
s
di
Si
on th M
m
i
om le w rld
tc
os peop e wo
M r
on
fo nd th 2
ati
9.2
a =10
ns
ts
e
p
efi
N
ry
eta
co
d
ate
rel
be
pla
ork
52%
51%
48%
ce
fits
on
ne
h
ew
t
e
m
l
h
b
/
t
a
me
e
x
ial
ho
Ta
s in
nc
dh
e
t
i
a
n
h
f
t
Fin
ne
na
in
Be
tio
fits
ita
e
l
i
n
b
Be
ha
Re
39
7.4.
1.6.
7.5. When people with MS do retire from paid employLegislation must be enacted that protects the rights
68.6% and encouragement, they must be provided counselling
of people with MS and other people with disabilities
against discrimination in all aspects of social and commument to develop alternative, voluntary67.7%
activities that can
nity life. Enforcement of these laws is to be consistent and
ll the void often left by the loss of work. The transition
effective. Among other things, these laws require governout of paid employment is to be planned well in advance
52%
t
en MS
s receive all of the services to
ments, employers, building owners, transportation organto ensure people ewith
m
n
51%
o
l
tit regi to prepare for alternate occuwhich they are
izations, and others to make reasonable adjustments to
en entitled,
O
y
48%
H
ilitactivities,
improve accessibility for people with disabilities. These
pationsabor
and to avoid the stress that may
W
n
dis S i
laws are to ensure that people with MS have access to all
accompany
on th M abrupt, unplanned transitions from work to
m
types of nancial instruments, including current accounts
wi
om retirement.
t c ople orld
s
and savings accounts, credit cards, insurance, loans, andMo pe e w
th
Eligibility criteria and application
procedures for pubion
for nd 8.1.
2
all forms of nancial assistance.
9.2
sat
0and
s
a lic
n
t
1
i
private
disability
entitlements
and
means-tested
e
ef
N=
mp
en
e
o
c
b
c
7.1. Services must be available to allow people with MS
cash assistance must
burdensome
d and not
y be fair
pla unduly
tar
ate
ork
fits
ne
rel
e
w
nor restrictive.
to continue employment as long as they are productive
o
n
h
e
lt
/m
the
me
ea
xb
ial
ho
and desire to work.
Ta
s in
nc
dh
e
t
i
a
n
8.2. Cash
h
f
payment
levels
t private disability
Fin
ne for public and
na
in
Be
tio
fits
7.2. Employers must provide job modications and other
benetsiland
must be high
ita means-tested cash assistance
e
n
b
Be
ha for people with MS to have
adaptations or accommodations to enable people with
enough
an adequate standRe
ard of living.
MS to continue working. Employers must be educated
about the nature and symptoms of MS, and how job
8.3. Disability entitlements must be exible, allowing for
modications can often enable people with MS to remain
partial disability, to enable people with MS to take time
productive employees for many years.
off when needed or to continue working part-time, if
7.3. Employers should provide time off for family memdesired.
bers and other informal care-givers to accommodate the
unexpected needs of people with MS. Employers should
be educated about the roles of family members in treating
and managing acute exacerbations and symptoms of MS.
S
M
th
i
w
le
op orld
e
p
or e w
s f d th
t
i
f
52%
ne an
be ions
e
c
g
a
pl O re
ork
W WH 2
in =10
9.3
31.3%
N
d
orl
50%
W
57.1%
a
ric
67.5%
Af
as
ric
25%
e
n
Am
ea
33.3%
n
e
rra
ite
rop
d
u
e
E
ia
M
As
st
ern
a
t
ific
E
s
ac
Ea
thP
u
So
ern
est
W
No
40
No
y
tar S
ne h M
o
it
/m
ial ple w
c
n o
ina e
f f for p
o
y
n
ilit io
ab nsat
l
i
a
e
Av omp 2
c
10
9.1
N=
60%
s
Ye o
N n
o
ati
m
r
o
inf
69.4%
44.4%
21.1%
52%
S
M
th tries
i
w un
le
op of co
e
w
p s
Lo
for oup
le
s
r
t
idd
efi e g
m
le
n
m
e
er
dd
e b inco
mi
ow
c
L
r
gh
Hi
pe
pla ent
d
Up
ork iffer
orl
W d
W
2
in =10
9.4
N
41
10
M A J O R I S S UES
Salient Findings
The
The
The
40%
8.4%
37.9%
17.9%
35.8%
10.1
31.6%
30.5%
0%
rt
po
27.4%
M
th
wi
e
l ls
op
pe iona
r
ss
fo
es rofe
u
s
p
r is lth
ajo ea
M nd h
a
95
N=
S
M
ith nals
w
o
le essi
op
f
Pe pro
h
t
l
a
He
14.7%
26.3%
n
o
ati S
fs
20%
c
o
M
du
ck
/e bout
25.3%
La
n
y
o
ilit
ati lic a
21.1%
ab rapy
m
l
b
i
r
u
a
o
av the
inf of p
22.1%
n
f
g
o
o
nt
/n ifyin
ck
e
2.1%
y
t
i
d
La
m
o
y
bil
22.1%
ssi se m
plo
e
m
c
s
e
e
ac isea
u
o
26.3%
s
t
n
s
d
i
d
No of
ted
ate
l
a
n
l
e
re
tio y
sr
ita
ty
ue
21.1%
bil erap
uri
Iss
a
c
reh sioth
l se
f
a
e
i
r
o
y
c
ca
ity ph
/so
1.1%
of
bil ing
ce
s
a
l
t
n
i
d
s
s
a
a
u
r
o
e
l
15.8%
v
c
u
c
lac t
ns
n a in
igh
c p spor
hi
no lities
i
H
t
l
l
/
8.4%
b
a
ity faci
pu tran
He
es
bil
i
c
n
i
14.7%
i
s
g
s
v
s
rs din
ce
ser ntre
ac
rrie nclu
h
t
e
a
l
n
i
b
a Sc
of
No
al
he
rm nts
tur
of ing M
c
o
f
y
u
d
tr
ilit
in r gra
ts
ras
ab inclu
g
ail
efi ts o
Inf
1.1%
din
v
n
be men
clu care
na
f
n
o
i
o
e
l
e
N
e
t
t
y
i
i
r
t nt
a
p
bil
ing
f c res
ila s, e
lud ent
y o and
c
va port
t
i
n
a
i ipm
n
p
nu e
me equ
nti hom
No e su
o
o
h
c
d
t
om
of
s a lise
inc
ck
ier ecia
r
r
La
ba f sp
o
al
tur ility
c
u
b
i
r
t
s
ras ces
Inf n ac
no
p
l su
ia
oc
42
MAJOR ISS U E S
10
Implications
Globally
38.9%
14.7%
13.7%
21.1%
12.6%
4.2%
7.4%
4.2%
7.4%
48.4%
is
os
6.3%
gn ogy)
a
i
l
d no
9.5%
o
t ch
ity
ted s/te
5.3%
bil sts
i
a
s
l
s
i
re es
cce olog
31.6%
es proc
a
u
r
Iss e,
on neu
ps
n
u
/
m
(ti
ity of
gro
bil
ort
ila
p
a
n
p
v
tio
/su
na
5.3%
isla
ies
No
t
g
e
e
i
dl
12.6%
on
oc
i
s
n
t
a
S
S
ca
5.3%
du ut M
licy
fM
e
o
o
/
n abo
ck
ty
op
o
i
0%
i
t
l
a
t
i
L
a
ls
ab y
ted
rm iona
ail erap
4.2%
o
v
f
ela
s
r
n a ic th
f in rofes
es
o
o
20%
u
s
p
/n at
Iss
ck
ue
lity tom
La alth
iss
i
b
S
he
ssi ymp
nM
of
ce
rt
hi
ac of s
c
po
2.1%
r
n
up
ea
s
No
s
l
e
r
a
12.6%
c
f
o
rs
liti
ck
he
po
t
f
La
O
o
ck
lity
La
ibi ms
s
s
a
ce
ac y te
ity
on linar
n
bil
/
ssi rses
ity iscip
e
l
i
cc nu
b
ila erd
na S
va f int
no of M
a
/
o
y
n
ilit
No
ab
ail
v
na
No
43
S U M M A RY RESULTS
Epidemiology
MS
The
MS
Symptoms
The
There
is a lack of reliable, valid and robust data from epidemiological or economic impact studies and reports published in medical literature (especially in Africa and parts
of Asia where the prevalence is reported to be low).
MS Organizations
Many
countries in the world have no patient-driven support for people with MS.
Diagnosis
availability and accessibility of magnetic resonance
imaging (MRI) technology varies widely.
Health
There
There
Owing
In
In
The
Accessible
Time
Poor
Inequalities
Information
There
There
Income
People
The
44
SUMMARY RESU LT S
Human resources
Major issues
In
There
Inadequate
MS
lack
of social support
lack
lack
issues
health
related to employment
insurance and social security-related issues.
issues
People
lack
The
lack
of research in MS issues
lack
to
make health services, including MS centres and rehabilitation facilities, accessible and available
develop
improve
45
T H E WAY F ORWARD
CONCLUSIONS AND SUMMARY OF ISSUES AND ACTIONS
Invest
Invest
Stimulate
Develop
Invest
46
LIST OF RESPONDE N T S
Country,
territory or area
Country,
territory or area
Name
Canada
Deanna Groetzinger
Jon Temme
William J. Mcilroy
Chile
Xu Xianhao
Name
Afghanistan
Sayed Azimi
Albania
Vjollca Koko
Algeria
Colombia
Argentina
Fernando J. Caceres
Ins Acevedo
Costa Rica
Alexander Parajeles
Yamileth Ramirez
Armenia
Felix Chilingaryan
Cte dIvoire
Thrse Sonan-Douayoua
Australia
Trevor Farrell
Rex Simmons
Elizabeth McDonald
W.M. Carroll
Croatia
Jasminka Matic
Danica Ekic
Slava Podobnik-arkanji
Mirta Jane
Austria
Lder Deecke
Fritz Leutmezer
Helene Kallina
Cuba
Bahrain
Adel Al Jishi
Cyprus
Pantzaris Marios
Bangladesh
Anisul Haque
Czech Republic
Svatopluk Cablik
Barbados
Sonia Wilson-Mwansa
David OCorbin
Democratic Republic
of the Congo
Daniel Tshala-Katumbay
Alexei Karchevski
Gennady Makarevich
Anatoli Duk
Elena Tomashevskaya
Denmark
Einar Berdal
Birgit Tchsen
Dominican Republic
Dana Guttmann
Belgium
Christiane Tihon
M.B. DHooghe
Ecuador
Patricio Abad
Egypt
Mai Sharawy
Benin
Fata Bahtijarevic
Azra Alajbegovic
Mariann Klemets
Maria Ktt
Katrin Gross-Paju
Brazil
Suely Berner
Nadine Renzi Rossi
Dagoberto Callegaro
Ethiopia
Guta Zenebe
Finland
Anssi Kemppi
Juhani Ruutiainen
Pia-Nina Vekka
France
Jean-Marie Eral
Etienne Roullet
Jean-Louis Dousset
Gabon
Belarus
Bulgaria
Alexandra Efsseneva
Christo Balabanov
M.Klissurski
Burkina Faso
Athanase Millogo
Cameroon
47
L I S T O F R E SPONDENTS
Country,
territory or area
Georgia
Rusudan Pantsulaia
Marina Kiziria
Khatuna Mikaberidze
Germany
Dorothea Pitschnau-Michel
Gabriele Seestaedt
Hans-Peter Hartung
Bernhard Hemmer
Greece
Anastasios Orologas
Guatemala
Guinea
Yves Morel
Mohamed Mmah Diaby
Haiti
Marlange Jerome-Dutton
Honduras
Marco T. Medina
Hungary
Andras Guseo
Iceland
Sigurbjrg rmannsdttir
Sverrir Bergmann
India
Iraq
Country,
territory or area
Name
Lithuania
Rasa Kizlaitiene
Aldona Droseikiene
Luxembourg
Freichel Paulette
Ren Metz
Haan Yves
Gansen Anja
Camporese Rina
Haas Fernand
Madagascar
Andriantseheno Marcellin
Malawi
Terttu Heikinheimo-Connell
Malaysia
Malta
Leslie Agius
Norbert Vella
Mexico
Merced Velzquez
Concepcin Lujan Uranga
Moldova
Lisnic Vitalie
Mongolia
Shuren Dashzeveg
Morocco
Mohamed Yahyaoui
Namibia
Bianca Ozcan
Netherlands
Marga Nijenhuis
Daeter-Hilgers-Hintzen
Rogier Hintzen
Nora Holtrust
Ireland
Graham Love
Stanley Hawkins
Aidan Larkin
Israel
Kahana Esther
New Zealand
Amy Greenwood
Ernie Willoughby
Italy
Nicaragua
Japan
Kazuo Fujihara
Nigeria
Adesola Ogunniyi
Jordan
Norway
Kjell-Morten Myhr
Turid Hesselberg
Kazakhstan
Zhannat Idrissova
Pakistan
Abdul Malik
Kenya
Juzar Hooker
Razia Mohamedali
Paraguay
Kuwait
Suhail Alshammari
Peru
Latvia
Guntra Cirule
Maija Metra
Liga Mazure
Skaidrite Beitlere
Darwin Vizcarra
Ana Chereque
Poland
Izabela Odrobinska
Halina Bartosik-Psujek
Krzysztof Selmaj
Zbigniew Stelmasiak
Lebanon
48
Name
Bassem Yamout
LIST OF RESPONDE N T S
Country,
territory or area
Name
Portugal
Jorge Da Silva
Rui Pedrosa
Qatar
Hassan Al Hail
Republic of Korea
Kwang Ho Lee
Romania
Berha Mihaela
Vasile Titus Mihai
Russian Federation
Alexey Boiko
Saudi Arabia
Amal Abdulrahman
Senegal
Serbia
Tatjana Dakic
Tatjana Pekmezovic
Nevenka Rasic
Jelena Drulovic
Vanja Taleski
Lenka Babic
Country,
territory or area
United Arab Emirates
United Kingdom of Great
Britain and Northern Ireland
Name
Jihad Said Inshasi
Sharon Haffenden
Alasdair Coles
Lynda Finn
Kathryn White
Jane Petty
Nicholas G. LaRocca
Beverly Noyes
John Richert
Nancy Holland
Susan Sanabria
Uruguay
Venezuela
(Bolivarian Republic of)
Arnoldo Soto
Viet Nam
Le Duc Hinh
Yemen
Hesham Awn
Singapore
Benjamin Ong
Zambia
Masharip Atadzhanov
Slovakia
Lubica Prochazkova
Zimbabwe
Jens Mielke
Slovenia
Beatrika Koncan-Vracko
South Africa
Spain
Sri Lanka
Sweden
Arja Hill
Switzerland
Vera Rentsch
Andrea Gern
Jrg Kesselring
Herbert Keller
Ahmad Khalifa
Thailand
Naraporn Prayoonwiwat
Lodi Gogovska
Tunisia
Chokri Mhiri
Turkey
Aysegl nlsoy
Aksel Siva
Nevin Sutlas
Ukraine
Nehrych Tetiana
49
ANNEX
GLOSSARY: DEFINITIONS AND DESCRIPTIONS OF TERMS USED
50
Information: communication of knowledge by various channels regarding, for example, symptoms, prognosis, treatment, support services, lifestyle, family issues, legislation and
research.
AN N E X
GLOSSARY: DEFINITIONS AND DESCRIPTIONS OF TERMS USED
Motor weakness/dysfunction or spasticity: include involuntary contractions, jerking and twitching of muscles, muscle
weakness, partial or mild paralysis, stiffness, restricted free
movement of affected limbs, involuntary leg movements,
foot drag, slurred speech and related speech problems.
Prevalence: estimated total number of cases of MS at a particular point in time in a specied population usually given as
number per 100 000 population.
Relapse: (also called a clinical/neurological attack, exacerbation or are-up) is the subacute appearance of a neurological
abnormality that must be present for at least 24 hours in the
absence of fever or infection and characterized by the sudden
worsening of an MS symptom or symptoms or the appear-
51
The results of the survey made for the ATLAS OF MS reveal a lack
of services and resources allocated to the care of people with MS.
The situation is of particular concern in most low and middle income
countries. The data clearly indicate that:
no one country provides adequate resources;
in many countries the resources that are available