Skip to main content

Multiple Sclerosis: A Review with a Focus on the Middle East and North Africa Region

  • Living reference work entry
  • First Online:
Handbook of Medical and Health Sciences in Developing Countries

Abstract

Multiple sclerosis (MS), an autoimmune disease of the central nervous system (CNS), is the commonest nontraumatic disabling disease to affect young adults. The incidence of MS is increasing worldwide, along with the economic burden of the disease on healthcare systems and societies. The exact underlying cause of MS and its pathogenesis remain unclear, although complex gene-environment interactions almost certainly play a significant role. Epidemiology data indicates that vitamin D deficiency, smoking, and most significantly infection with the Epstein-Barr virus are likely to contribute to disease development. The introduction of the 2017 McDonald diagnostic criteria and improvement in diagnostic methods have allowed early diagnosis and treatment initiation. Moreover, therapies for MS have increased exponentially in number, efficacy, and risk. This is a comprehensive review that discusses MS pathogenesis, epidemiology, potential etiological factors, diagnosis, management, economic burden, challenges, and much more.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Institutional subscriptions

References

  • Ahmed, S. I., Aziz, K., Gul, A., Samar, S. S., & Bareeqa, S. B. (2019). Risk of multiple sclerosis in Epstein-Barr virus infection. Cureus, 11(9), e5699.

    PubMed  PubMed Central  Google Scholar 

  • Aljumah, M., Alroughani, R., Alsharoqi, I., Bohlega, S. A., Dahdaleh, M., Deleu, D., Esmat, K., Khalifa, A., Sahraian, M. A., Szólics, M., Altahan, A., Yamout, B. I., Rieckmann, P., & Daif, A. (2013). Future of management of multiple sclerosis in the Middle East: A consensus view from specialists in ten countries. Multiple Sclerosis International, 2013, 952321.

    Article  PubMed  PubMed Central  Google Scholar 

  • Alonso, A., & Hernán, M. A. (2008). Temporal trends in the incidence of multiple sclerosis: A systematic review. Neurology, 71(2), 129–135.

    Article  PubMed  PubMed Central  Google Scholar 

  • Ascherio, A., & Munger, K. L. (2007). Environmental risk factors for multiple sclerosis. Part II: Noninfectious factors. Annals of Neurology, 61(6), 504–513.

    Article  CAS  PubMed  Google Scholar 

  • Bjornevik, K., Cortese, M., Healy, B. C., Kuhle, J., Mina, M. J., Leng, Y., Elledge, S. J., Niebuhr, D. W., Scher, A. I., Munger, K. L., & Ascherio, A. (2022). Longitudinal analysis reveals high prevalence of Epstein-Barr virus associated with multiple sclerosis. Science, 375(6578), 296–301.

    Article  CAS  PubMed  Google Scholar 

  • Bohlega, S., Inshasi, J., Al Tahan, A. R., Madani, A. B., Qahtani, H., & Rieckmann, P. (2013). Multiple sclerosis in the Arabian Gulf countries: A consensus statement. Journal of Neurology, 260(12), 2959–2963.

    Article  PubMed  PubMed Central  Google Scholar 

  • Brownlee, W. J., & Ciccarelli, O. (2016). All relapsing multiple sclerosis patients should be managed at a specialist clinic – YES. Multiple Sclerosis, 22(7), 873–875.

    Article  CAS  PubMed  Google Scholar 

  • Burton, J. M., O’Connor, P. W., Hohol, M., & Beyene, J. (2012). Oral versus intravenous steroids for treatment of relapses in multiple sclerosis. The Cochrane Database of Systematic Reviews, 12, CD006921.

    PubMed  Google Scholar 

  • Correale, J., Balbuena Aguirre, M. E., & Farez, M. F. (2013). Sex-specific environmental influences affecting MS development. Clinical Immunology, 149(2), 176–181.

    Article  CAS  PubMed  Google Scholar 

  • Cortese, I., Chaudhry, V., So, Y. T., Cantor, F., Cornblath, D. R., & Rae-Grant, A. (2011). Evidence-based guideline update: Plasmapheresis in neurologic disorders: Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology, 76(3), 294–300.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • D’hooghe, M., Van Gassen, G., Kos, D., Bouquiaux, O., Cambron, M., Decoo, D., Lysandropoulos, A., Van Wijmeersch, B., Willekens, B., Penner, I. K., & Nagels, G. (2018). Improving fatigue in multiple sclerosis by smartphone-supported energy management: The MS TeleCoach feasibility study. Multiple Sclerosis and Related Disorders, 22, 90–96.

    Article  PubMed  Google Scholar 

  • Dahham, J., Rizk, R., Kremer, I., Evers, S. M. A. A., & Hiligsmann, M. (2021). Economic burden of multiple sclerosis in low- and middle-income countries: A systematic review. PharmacoEconomics, 39(7), 789–807.

    Article  PubMed  PubMed Central  Google Scholar 

  • Dobson, R., Giovannoni, G., & Ramagopalan, S. (2013). The month of birth effect in multiple sclerosis: Systematic review, meta-analysis and effect of latitude. Journal of Neurology, Neurosurgery, and Psychiatry, 84(4), 427–432.

    Article  PubMed  Google Scholar 

  • Ford, H. (2020). Clinical presentation and diagnosis of multiple sclerosis. Clinical Medicine, 20(4), 380–383.

    Article  PubMed  PubMed Central  Google Scholar 

  • Ghasemi, N., Razavi, S., & Nikzad, E. (2017). Multiple sclerosis: Pathogenesis, symptoms, diagnoses and cell-based therapy. Cell Journal, 19(1), 1–10.

    PubMed  Google Scholar 

  • Glenn, J. D., & Mowry, E. M. (2016). Emerging concepts on the gut microbiome and multiple sclerosis. Journal of Interferon & Cytokine Research: The Official Journal of the International Society for Interferon and Cytokine Research, 36(6), 347–357.

    Article  CAS  Google Scholar 

  • Handel, A. E., Williamson, A. J., Disanto, G., Handunnetthi, L., Giovannoni, G., & Ramagopalan, S. V. (2010). An updated meta-analysis of risk of multiple sclerosis following infectious mononucleosis. PloS one, 5(9), e12496.

    Article  PubMed  PubMed Central  Google Scholar 

  • Hauser, S. L., & Cree, B. A. C. (2020). Treatment of multiple sclerosis: A review. The American Journal of Medicine, 133(12), 1380–1390.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Hedström, A. K., Hillert, J., Olsson, T., & Alfredsson, L. (2013). Smoking and multiple sclerosis susceptibility. European Journal of Epidemiology, 28(11), 867–874.

    Article  PubMed  PubMed Central  Google Scholar 

  • Hemmer, B., Archelos, J. J., & Hartung, H. P. (2002). New concepts in the immunopathogenesis of multiple sclerosis. Nature Reviews. Neuroscience, 3(4), 291–301.

    Article  CAS  PubMed  Google Scholar 

  • Hosseiny, M., Newsome, S. D., & Yousem, D. M. (2020). Radiologically isolated syndrome: A review for neuroradiologists. AJNR. American Journal of Neuroradiology, 41(9), 1542–1549.

    CAS  PubMed  PubMed Central  Google Scholar 

  • International Multiple Sclerosis Genetics Consortium, Wellcome Trust Case Control Consortium 2, Sawcer, S., Hellenthal, G., Pirinen, M., Spencer, C. C., Patsopoulos, N. A., Moutsianas, L., Dilthey, A., Su, Z., Freeman, C., Hunt, S. E., Edkins, S., Gray, E., Booth, D. R., Potter, S. C., Goris, A., Band, G., Oturai, A. B., Strange, A., & Compston, A. (2011). Genetic risk and a primary role for cell-mediated immune mechanisms in multiple sclerosis. Nature, 476(7359), 214–219.

    Article  Google Scholar 

  • Khoury, S. J., & Tintore, M. (2020). Multiple sclerosis in the Middle East and North Africa region. Multiple Sclerosis Journal – Experimental, Translational and Clinical, 6(1), 2055217319895540.

    Article  PubMed  PubMed Central  Google Scholar 

  • Koch-Henriksen, N., & Sørensen, P. S. (2010). The changing demographic pattern of multiple sclerosis epidemiology. The Lancet. Neurology, 9(5), 520–532.

    Article  PubMed  Google Scholar 

  • Kołtuniuk, A., & Chojdak-Łukasiewicz, J. (2022). Adherence to therapy in patients with multiple sclerosis-review. International Journal of Environmental Research and Public Health, 19(4), 2203.

    Article  PubMed  PubMed Central  Google Scholar 

  • Kotzamani, D., Panou, T., Mastorodemos, V., Tzagournissakis, M., Nikolakaki, H., Spanaki, C., & Plaitakis, A. (2012). Rising incidence of multiple sclerosis in females associated with urbanization. Neurology, 78(22), 1728–1735.

    Article  CAS  PubMed  Google Scholar 

  • Lublin, F. D., & Reingold, S. C. (1996). Defining the clinical course of multiple sclerosis: Results of an international survey. National Multiple Sclerosis Society (USA) Advisory Committee on Clinical Trials of New Agents in Multiple Sclerosis. Neurology, 46(4), 907–911.

    Article  CAS  PubMed  Google Scholar 

  • Lublin, F. D., Reingold, S. C., Cohen, J. A., Cutter, G. R., Sørensen, P. S., Thompson, A. J., Wolinsky, J. S., Balcer, L. J., Banwell, B., Barkhof, F., Bebo, B., Jr., Calabresi, P. A., Clanet, M., Comi, G., Fox, R. J., Freedman, M. S., Goodman, A. D., Inglese, M., Kappos, L., Kieseier, B. C., & Polman, C. H. (2014). Defining the clinical course of multiple sclerosis: The 2013 revisions. Neurology, 83(3), 278–286.

    Article  PubMed  PubMed Central  Google Scholar 

  • McDowell, T. Y., Amr, S., Culpepper, W. J., Langenberg, P., Royal, W., Bever, C., & Bradham, D. D. (2011). Sun exposure, vitamin D and age at disease onset in relapsing multiple sclerosis. Neuroepidemiology, 36(1), 39–45.

    Article  PubMed  Google Scholar 

  • Middle East and North Africa Committee for Treatment and Research in Multiple Sclerosis. MS Patient Registry [online] 2022. Available at: https://menactrims.org/ms-patient-registry/. Accessed 20 Nov 2022.

  • Miretti, M. M., Walsh, E. C., Ke, X., Delgado, M., Griffiths, M., Hunt, S., Morrison, J., Whittaker, P., Lander, E. S., Cardon, L. R., Bentley, D. R., Rioux, J. D., Beck, S., & Deloukas, P. (2005). A high-resolution linkage-disequilibrium map of the human major histocompatibility complex and first generation of tag single-nucleotide polymorphisms. American Journal of Human Genetics, 76(4), 634–646.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Moghtaderi, A., Rakhshanizadeh, F., & Shahraki-Ibrahimi, S. (2013). Incidence and prevalence of multiple sclerosis in southeastern Iran. Clinical Neurology and Neurosurgery, 115(3), 304–308.

    Article  PubMed  Google Scholar 

  • Montalban, X., Gold, R., Thompson, A. J., Otero-Romero, S., Amato, M. P., Chandraratna, D., Clanet, M., Comi, G., Derfuss, T., Fazekas, F., Hartung, H. P., Havrdova, E., Hemmer, B., Kappos, L., Liblau, R., Lubetzki, C., Marcus, E., Miller, D. H., Olsson, T., Pilling, S., & Zipp, F. (2018). ECTRIMS/EAN Guideline on the pharmacological treatment of people with multiple sclerosis. Multiple Sclerosis, 24(2), 96–120.

    Article  PubMed  Google Scholar 

  • Multiple Sclerosis International Federation. Atlas of MS 3rd Edition [online] 2020. Available at: https://www.msif.org/wp-content/uploads/2020/12/Atlas-3rd-Edition-Epidemiology-report-EN-updated-30-9-20.pdf. Accessed 5 Aug 2022.

  • Munger, K. L., Zhang, S. M., O’Reilly, E., Hernán, M. A., Olek, M. J., Willett, W. C., & Ascherio, A. (2004). Vitamin D intake and incidence of multiple sclerosis. Neurology, 62(1), 60–65.

    Article  CAS  PubMed  Google Scholar 

  • National Clinical Guideline Centre (UK). (2014). Multiple sclerosis: Management of multiple sclerosis in primary and secondary care. National Institute for Health and Care Excellence (UK).

    Google Scholar 

  • National Multiple Sclerosis Society. MS prevalence [online] 2014. Available at: https://www.nationalmssociety.org/About-the-Society/MS-Prevalence. Accessed 9 Sept 2022.

  • Nourbakhsh, B., & Mowry, E. M. (2019). Multiple sclerosis risk factors and pathogenesis. Continuum, 25(3), 596–610.

    PubMed  Google Scholar 

  • Orton, S. M., Wald, L., Confavreux, C., Vukusic, S., Krohn, J. P., Ramagopalan, S. V., Herrera, B. M., Sadovnick, A. D., & Ebers, G. C. (2011). Association of UV radiation with multiple sclerosis prevalence and sex ratio in France. Neurology, 76(5), 425–431.

    Article  PubMed  PubMed Central  Google Scholar 

  • Otero-Romero, S., Sastre-Garriga, J., Comi, G., Hartung, H. P., Soelberg Sørensen, P., Thompson, A. J., Vermersch, P., Gold, R., & Montalban, X. (2016). Pharmacological management of spasticity in multiple sclerosis: Systematic review and consensus paper. Multiple Sclerosis, 22(11), 1386–1396.

    Article  CAS  PubMed  Google Scholar 

  • Palmer, A. J., Hitchens, P. L., Simpson, S., Jr., O’Leary, B., Colman, S., & Taylor, B. V. (2013). A novel method for calculating prevalence of multiple sclerosis in Australia. Multiple Sclerosis, 19(13), 1704–1711.

    Article  PubMed  Google Scholar 

  • Péloquin, S., Schmierer, K., Leist, T. P., Oh, J., Murray, S., & Lazure, P. (2021). Challenges in multiple sclerosis care: Results from an international mixed-methods study. Multiple Sclerosis and Related Disorders, 50, 102854.

    Article  PubMed  Google Scholar 

  • Polman, C. H., Reingold, S. C., Banwell, B., Clanet, M., Cohen, J. A., Filippi, M., Fujihara, K., Havrdova, E., Hutchinson, M., Kappos, L., Lublin, F. D., Montalban, X., O’Connor, P., Sandberg-Wollheim, M., Thompson, A. J., Waubant, E., Weinshenker, B., & Wolinsky, J. S. (2011). Diagnostic criteria for multiple sclerosis: 2010 revisions to the McDonald criteria. Annals of Neurology, 69(2), 292–302.

    Article  PubMed  PubMed Central  Google Scholar 

  • Public Health Agency of Canada. Preventing Chronic Disease Strategic Plan 2013–2016 [online] 2016. Available at: http://www.phac-aspc.gc.ca/cd-mc/diabetes-diabete/strategy_plan-plan_strategique-eng.php. Accessed 9 Sept 2022.

  • Pugliatti, M., Sotgiu, S., & Rosati, G. (2002). The worldwide prevalence of multiple sclerosis. Clinical Neurology and Neurosurgery, 104(3), 182–191.

    Article  PubMed  Google Scholar 

  • Rosati, G. (2001). The prevalence of multiple sclerosis in the world: An update. Neurological Sciences: Official Journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology, 22(2), 117–139.

    Article  CAS  PubMed  Google Scholar 

  • Sadovnick, A. D., Armstrong, H., Rice, G. P., Bulman, D., Hashimoto, L., Paty, D. W., Hashimoto, S. A., Warren, S., Hader, W., & Murray, T. J. (1993). A population-based study of multiple sclerosis in twins: Update. Annals of Neurology, 33(3), 281–285.

    Article  CAS  PubMed  Google Scholar 

  • Scalfari, A., Neuhaus, A., Daumer, M., Deluca, G. C., Muraro, P. A., & Ebers, G. C. (2013). Early relapses, onset of progression, and late outcome in multiple sclerosis. JAMA Neurology, 70(2), 214–222.

    Article  PubMed  Google Scholar 

  • Simpson, S., Jr., Taylor, B., Blizzard, L., Ponsonby, A. L., Pittas, F., Tremlett, H., Dwyer, T., Gies, P., & van der Mei, I. (2010). Higher 25-hydroxyvitamin D is associated with lower relapse risk in multiple sclerosis. Annals of Neurology, 68(2), 193–203.

    CAS  PubMed  Google Scholar 

  • Smolders, J., Menheere, P., Kessels, A., Damoiseaux, J., & Hupperts, R. (2008). Association of vitamin D metabolite levels with relapse rate and disability in multiple sclerosis. Multiple Sclerosis, 14(9), 1220–1224.

    Article  CAS  PubMed  Google Scholar 

  • Soelberg Sorensen, P., Giovannoni, G., Montalban, X., Thalheim, C., Zaratin, P., & Comi, G. (2019). The multiple sclerosis care unit. Multiple Sclerosis, 25(5), 627–636.

    Article  PubMed  Google Scholar 

  • Thompson, A. J., Banwell, B. L., Barkhof, F., Carroll, W. M., Coetzee, T., Comi, G., Correale, J., Fazekas, F., Filippi, M., Freedman, M. S., Fujihara, K., Galetta, S. L., Hartung, H. P., Kappos, L., Lublin, F. D., Marrie, R. A., Miller, A. E., Miller, D. H., Montalban, X., Mowry, E. M., & Cohen, J. A. (2018). Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria. The Lancet. Neurology, 17(2), 162–173.

    Article  PubMed  Google Scholar 

  • Trapp, B. D., Peterson, J., Ransohoff, R. M., Rudick, R., Mörk, S., & Bö, L. (1998). Axonal transection in the lesions of multiple sclerosis. The New England Journal of Medicine, 338(5), 278–285.

    Article  CAS  PubMed  Google Scholar 

  • Turner, A. P., Sloan, A. P., Kivlahan, D. R., & Haselkorn, J. K. (2014). Telephone counseling and home telehealth monitoring to improve medication adherence: Results of a pilot trial among individuals with multiple sclerosis. Rehabilitation Psychology, 59(2), 136–146.

    Article  PubMed  Google Scholar 

  • Wallin, M. T., Campea, S., & Haselkorn, J. K. (2015). Multidisciplinary management of a patient with multiple sclerosis: Part 1. Neurologists’ and Physiatrists’ perspectives. Federal Practitioner: For the Health Care Professionals of the VA, DoD, and PHS, 32(Suppl 3), 14S–17S.

    PubMed  Google Scholar 

  • Weiner, H. L., Dau, P. C., Khatri, B. O., Petajan, J. H., Birnbaum, G., McQuillen, M. P., Fosburg, M. T., Feldstein, M., & Orav, E. J. (1989). Double-blind study of true vs. sham plasma exchange in patients treated with immunosuppression for acute attacks of multiple sclerosis. Neurology, 39(9), 1143–1149.

    Article  CAS  PubMed  Google Scholar 

  • Weinshenker, B. G., O’Brien, P. C., Petterson, T. M., Noseworthy, J. H., Lucchinetti, C. F., Dodick, D. W., Pineda, A. A., Stevens, L. N., & Rodriguez, M. (1999). A randomized trial of plasma exchange in acute central nervous system inflammatory demyelinating disease. Annals of Neurology, 46(6), 878–886.

    Article  CAS  PubMed  Google Scholar 

  • Westerlind, H., Ramanujam, R., Uvehag, D., Kuja-Halkola, R., Boman, M., Bottai, M., Lichtenstein, P., & Hillert, J. (2014). Modest familial risks for multiple sclerosis: A registry-based study of the population of Sweden. Brain: A Journal of Neurology, 137(Pt 3), 770–778.

    Article  PubMed  Google Scholar 

  • Wollin, J., Dale, H., Spenser, N., & Walsh, A. (2000). What people with newly diagnosed MS (and their families and friends) need to know. International Journal of MS Care, 2(3), 29–39.

    Article  Google Scholar 

  • Xiang, X. M., & Bernard, J. (2021). Telehealth in multiple sclerosis clinical care and research. Current Neurology and Neuroscience Reports, 21(4), 14.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Yamout, B. I., & Alroughani, R. (2018). Multiple sclerosis. Seminars in Neurology, 38(2), 212–225.

    Article  PubMed  Google Scholar 

  • Yamout, B. I., Dahdaleh, M., Al Jumah, M. A., Al-Shammri, S., Al Sharoqi, I., Al-Tahan, A. R., Bohlega, S., Deleu, D., Inshasi, J., Khalifa, A., & Szólics, M. (2010). Adherence to disease-modifying drugs in patients with multiple sclerosis: A consensus statement from the Middle East MS Advisory Group. The International Journal of Neuroscience, 120(4), 273–279.

    Article  PubMed  Google Scholar 

  • Yamout, B., Sahraian, M., Bohlega, S., Al-Jumah, M., Goueider, R., Dahdaleh, M., Inshasi, J., Hashem, S., Alsharoqi, I., Khoury, S., Alkhawajah, M., Koussa, S., Al Khaburi, J., Almahdawi, A., Alsaadi, T., Slassi, E., Daodi, S., Zakaria, M., & Alroughani, R. (2020). Consensus recommendations for the diagnosis and treatment of multiple sclerosis: 2019 revisions to the MENACTRIMS guidelines. Multiple Sclerosis and Related Disorders, 37, 101459.

    Article  CAS  PubMed  Google Scholar 

  • Yazdannik, A., Abolhassani, S., Taleghani, F., & Zamani, A. (2015). The challenges of healthcare delivery to people with multiple sclerosis in Iran. Journal of Education and Health Promotion, 4, 83.

    PubMed  PubMed Central  Google Scholar 

  • Zeineddine, M., Boumediene, F., Al-Hajje, A., et al. (2022 October 26–28). Barriers to access multiple sclerosis disease-modifying therapies in Middle East and North Africa: A regional survey-based study. Paper presented at: The 38th Congress of the European Committee for Treatment and Research in Multiple Sclerosis, Amsterdam.

    Google Scholar 

  • Zhang, P., Wang, R., Li, Z., Wang, Y., Gao, C., Lv, X., Song, Y., & Li, B. (2016). The risk of smoking on multiple sclerosis: A meta-analysis based on 20,626 cases from case-control and cohort studies. PeerJ, 4, e1797.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 2023 Springer Nature Switzerland AG

About this entry

Check for updates. Verify currency and authenticity via CrossMark

Cite this entry

Zeineddine, M., Al-Hajje, A., Ismail, G. (2023). Multiple Sclerosis: A Review with a Focus on the Middle East and North Africa Region. In: Al-Worafi, Y.M. (eds) Handbook of Medical and Health Sciences in Developing Countries . Springer, Cham. https://doi.org/10.1007/978-3-030-74786-2_47-1

Download citation

  • DOI: https://doi.org/10.1007/978-3-030-74786-2_47-1

  • Received:

  • Accepted:

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-74786-2

  • Online ISBN: 978-3-030-74786-2

  • eBook Packages: Springer Reference MedicineReference Module Medicine

Publish with us

Policies and ethics