The impact of COVID-19 epidemic on adult Myasthenia Gravis patients CURRENT STATUS: POSTED

Objects: To investigate the impact of COVID-19 epidemic on adult myasthenia gravis (MG) patients, in order to provide better medical advice for special patient population during the quarantine period. Methods: Adult MG patients were randomly recruited to participate. The survey consisted of self-designed questionnaires and the revised 15-item Myasthenia Gravis Quality of Life Questionnaire (MGQOL15r). Participation was strictly voluntary and remained anonymous. Results: A total of 214 adult MG patients (84 males and 130 females) gave valid replies. There were 49.53% patients reported they had the fear of COVID-19 outbreak at different levels. And female patients had a significant higher level of fear to COVID outbreak (p=0.009). It was found that the adult MG patients are more likely to be influenced by the COVID-19 epidemic compared to the general population. During the COVID-19 outbreak, 36.45% patients reported they got an improvement of MG disease severity. 57.01% patients reported they felt no change. 6.54% patients reported their condition got worse. The average of MGQOL15r score was 7.38±6.22. The higher level of the fear of COVID-19 outbreak, the higher score of MGQOL15r (p=0.029), the poorer quality of life. 96.73% patients hoped the specialist physicians could provide online consult. In addition, 64.95% patients would go to the tertiary hospital without hesitation if the Outpatients Department was opened even during the COVID-19 epidemic. has significant the psychological

14th 2020, while there are still no proven and specific antiviral therapeutics or vaccines.
It should be noted that this highly contagious disease not only has posed significant threats to international health and economy but also exerts considerable impacts on mental health 4 . In the face of extreme life-threatening tension and fear, people are trend to show some anxiety-related behaviors, including depression, anxiety disorders and increased use of alcohol and tobacco 5 . The previous work on the impact of severe acute respiratory syndrome (SARS) has indicated that this kind of grave public health emergencies bring great psychological stress to SARS survivors and related health care workers. Since the SARS outbreak in 2003, there has been a large number of surveys carried out to investigate the psychological problems including depression, anxiety and posttraumatic symptoms(PTSD) in SARS survivors and related health care workers 6,7 . However, it should be noted that these common mental health problems are not only restricted to infected patients and health care workers, as well as the general public and the population with special diseases. In this paper, we focused on a special population, the adult myasthenia gravis patients.
Myasthenia gravis (MG) is an autoimmune disease characterized by the presence of autoantibodies causing neuromuscular junction (NMJ) impairment 8 . The predominant manifestation is fatigable skeletal muscle weakness. Although the mechanisms leading to the production of pathogenic autoantibodies in MG remains unclear, it is strongly believed that environmental and psychological factors play crucial roles in the induction of MG. In order to maintain disease control, most MG patients are required to be treated with low-dose immunosuppressive drugs for a long time 9 .
However, long-term immunosuppressive therapy may lead to a slightly increased risk of infections 10 .
Since the outbreak of COVID-19, the Chinese government has taken a lot of powerful public health interventions to prevent the further disease transmission, such as early identification and isolation for suspected and confirmed patients, social distancing and community containment. Sensitivity analyses show these interventions could effectively lower the further transmission risk 11 . But the social isolation would bring great challenges to MG patients. It might be difficult for them to go back to the hospital to complete regular follow-up visits in time. And they would suffer from extreme fear and uncertainty like the general population. Therefore, timely attention to the MG patients during the

Procedure and Participates
From February 10, 2020 to February 24, 2020, we randomly contacted a number of MG patients who were over the age of 18 and were diagnosed with "Myasthenia Gravis" in the XiangYa Hospital Central South University. There were 231 patients agreed to participate in this questionnaire survey. All participants were informed and agreed before completing the electronic questionnaire, and then started to complete the questionnaire further, and the content did not contain identifying/confidential patient information.

Questionnaire Measures
The questionnaire consisted of four parts. The first part was self-designed questions to collect demographic information including gender, age, educational level, occupation and marital status. The second part was a series of questions about the cognition of COVID-19, aiming to investigate the psychological status and emotional response during COVID-19 outbreak. The third part was selfdesigned questions to look into the current therapies of MG and the related behaviors response.

Demographic characteristics of participants
There were 231 adult MG patients randomly recruited for this questionnaire survey study. Among them, 17 participants were excluded because of incomplete survey response or mismatch of age.
Thus, the data of 214 adult MG patients was finally enrolled in the analysis, consisting of 84 (84/214, 39.25%) males and 130 (130/214, 60.75%) females and the male: female ratio was 1:1.5. The demographic information was shown in Table 1.

Discussion
Since the COVID-19 outbreak, the Chinese government has taken several public healthy interventions like isolation, quarantine and social distancing to control further transmission. This study found that adult MG patients had different degrees of fear to this novel contagious disease under such conditions, which caused a negative impact on their life quality.
MG is rare chronic disorder, and is considered as a classic example of an anti-mediated autoimmune disease, with the characterizing symptom of localized or general muscle weakness 12 . In most cases, MG still requires chronic immunotherapy with immunosuppressive drugs to maintain disease control 13 . In this study, we focused on the impact of COVID-19 outbreak on this kind of special population, the adult MG patients. Because they are suffering from the chronic autoimmune disease and also trouble with the outbreak of COVID give a professional suggestion through the official account on WeChat or a website. Our findings raise the awareness that specialist physicians should provide professional advice for those people with chronic autoimmune diseases who require long-term immunosuppressive therapy as soon as possible once grave public health emergencies happened. On the one hand, it would help these patients better maintain their disease control. On the other hand, it would assist them with the management of emotional distress and improve the quality of life.
There are several limitations of this study. The participants were relatively small and recruited from one center. And the data were obtained by self-report. We only investigated the adult MG patients because the questionnaire required to be completed by the patients themselves in order to ensure the reality and reliability of the information. In addition, we were unable to directly to compare the individual participants longitudinally according to their previous medical records because the questionnaires were anonymous.
In summary, this study has shown that the COVID-19 outbreak has a significant impact on the quality of life and psychological status in adult MG patients. Compared to the general population, they are more likely to be influenced by the COVID-19 epidemic. Health care institutions will not only have to pay attention to control the MG disease severity, but also provide psychosocial supports in time. The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Abbreviations
Ethics approval and consent to participate All procedures performed in studies involving human participants were acquired patient's electronic informed consent and in accordance with the ethical standards of the Ethics Committee for Human