The new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), also called COVID-19, named by The World Health Organization (WHO),1 has caused a pandemic that has rapidly affected the whole world and has caused a great threat to public health. The report showed more than 49.7 million cases of Covid-19 and more than 1.2 million deaths worldwide on November 10, 2020.2 The presence of COVID-19 is manifested by a variety of symptoms, ranging from no symptoms or mild symptoms to severe illness and death. Common symptoms include cough, fever, and breathlessness. Other reported symptoms are weakness, malaise, muscle pain, sore throat, loss of taste and/or smell.3

The first case of endemic pneumonia of unknown cause first broke out in Wuhan City, Hubei Province, China, in December 2019. As the outbreak coincided with the arrival of the Lunar New Year, interprovincial travel facilitated its spread. Within a month, it had spread massively to the 34 provinces of China.4 According to data from the National Health Commission of China, the total number of cases continued to rise sharply in early February, with an average of more than 3000 new confirmed cases per day. To control COVID-19, China has implemented unprecedented strict public health measures. On January 23, Wuhan City was lockdown via blocked connecting roads of the city to restrict travel. Subsequently, the Chinese government has adopted suitable prevention measures for all provinces, such as family confinement, the extension of national fairs, the closure of schools throughout the country, the banning of meetings, the closure of public facilities, and the closure city total to control the COVID-19 outbreak.5 These measures, mainly homed confinement, limited human mobility, and decreased new cases' appearance in a notable and sustained manner.6 It proved such restrictions harmed people's daily lives. Wuhan lifted quarantines on April 8, and so far, China has not yet relaxed its control measures. Except for isolated cases caused by infections from frozen products originating from other countries,7 all imported cases are from abroad. In the past six months, China's economic life and education have gradually recovered. However, despite China's control of the outbreak, the international spread of COVID-19 has accelerated since late February, with a growing number of countries reporting large numbers of infected.

The global COVID-19 pandemic has forced many countries to take containment measures to minimize the virus's spread, which has occurred in Spain. The Spanish government announced that it had entered a state of alarm on March 15, 2020, and then adopted a series of mandatory measures to restrict free movement. The first COVID-19 alert status ended on June 21, 2020.8 These measures are useful since they substantially reduced infections, which allowed starting a de-escalation phase towards the usual daily routine. However, in late September, there appeared to be a second outbreak across Europe. On October 9, 2020, the Spanish government announced that it had once again entered a state of alarm to establish the necessary measures to deal with the extraordinary risks caused by the uncontrolled spread caused by SARS-CoV-2. The second state of alarm for COVID-19 ended on October 24, 2020.8,9

A period of confinement or quarantine implies a radical change in the population's lifestyle, disrupting normal daily activities.10 Changes in Spanish adults (alcohol, tobacco, sleep time, and the consumption of fruits and vegetables) progressively decreased during COVID-19 confinement. The only habit that increased was alcohol consumption and the time of exposure to the TV screen and computers.11 However, the experience of a long period of confinement may have had a significant impact on those who have suffered the strictest restrictions on free movement and other potential consequences such as patients with Multiple Sclerosis (MS).

On March 11, 2020, Cuba reported the first confirmed cases of COVID-19 case, and on April 7, the stage of limited autochthonous transmission was declared.12 The Ministry of Public Health (MINSAP) developed a plan of activities to limit this disease's information and at the proper control of cases.13 On March 24, the country reported 40 new measures on different sectors to confront COVID-19. Due to the accumulated experiences in the fight against different epidemics, the Cuban National Health System (SNS) is well prepared to face this epidemiological challenge.14 With the appropriate measures that the government has taken and the population's efforts, Cuba achieved success against COVID-19 in three months. On June 18, the criteria for post-COVID-19 recovery in its three phases began to be gradually applied, except the Matanzas and Havana provinces.12,15 Subsequently, given the epidemiological complex in Havana, it decided to take new restrictive measures to reinforce physical isolation in the capital as of September 1. A month later, it indicated that the country would enter into force the new stages as the new normal, and this measure started on October 12.

MS is a chronic autoimmune disease of the central nervous system in which inflammation, demyelination, and axonal loss occur even in the early stages of the disease.16 Some research proved the connection between other types of coronavirus and demyelinating diseases. However, few studies reported the association between SARS-CoV-2 and the deterioration of MS.17 The proportion of MS patients studied with a risk of death from COVID-19 is less than 1%, in particular, the vast majority do not receive any treatment with DMT.18 COVID-19 has spread rapidly worldwide, significantly affecting people's lives, the social economy, and health systems. During the initial phase of the COVID-19 outbreak in China, more than half of those surveyed rated the psychological impact as moderate to severe. About a third reported mild to severe anxiety.19

The prevalence and incidence of MS vary widely between different countries and different geographic areas. Kurtzke proposed in 1980 to divide the different areas of the world into three geographical regions concerning the prevalence of MS: High>30/100,000, Medium 5–25/100,000, and Low risk <5/100,000.20 The prevalence of China,20 Cuba,21 and Spain22 are 3–5, 10–15, and 80–180 per 100,000 inhabitants, respectively. Therefore, we conducted these investigations to analyze the socio-occupational effects of the COVID-19 pandemic in patients with MS in three different countries: China, Spain, and Cuba. At the same time, to study the pandemic's impact on patients with MS in various stages.

In April, we have compared the socio-economic impact of COVID-19 on RRMS patients between China and Spain in a previous study.20 This research, a continuation of prior research, is based on studies of different races, countries, and continents and compares the impact of the new crown pandemic on RRMS patients (Chinese and Western) in three countries first time.

COVID-19 is raging across the planet, some countries such as Europe and Latin America have been secondary outbreaks to some extent. Under this situation, the aspect of labor, economic and training activity is badly affected.

In this study, the ratio of men to women was approximately 1:2. The mean age was 38.9 ± 12.1, China, Spain, and Cuba were 33.2 ± 9.2, 46.2 ± 10.2, and 46.2 ± 10.2, respectively. It declared the age range of MS patients are between 20 and 50 years of age; the ratio of men and women is about 1:2 ~ 3,23,24 which is matching to the epidemiological characteristics of MS.

One of the particularly significant findings of our study was that MS patients did not show a high rate of infection, relapse, and worsening rates of three countries were in the low percentage. Some research proved that continuing disease modification therapy in MS patients during an outbreak does not increase the risk of developing COVID-19.25,26 We consider that COVID-19 less affect MS patients. However, the interesting finding was that the relatives and friends of Spanish MS patients have been more susceptible to COVID-19; the proportion is 32.7% in Spain, 14.2% in Cuba, and 0.52% in China, The possible reason could be widespread of COVID-19 in Spain.27 Since Wuhan released from quarantine on April 8, the strict control of anti-epidemic measures by the Chinese government, there have been almost no other cases of MS with COVID-19 infection apart from sporadic cases in the past six months.

Although Spain currently is one of the countries most affected by COVID-19, it has less impact on the sick's work, training, and economy compared with China and Cuba in accordance; this is consistent with the results of our survey in April between China and Spain.20 Tourism has represented a very important source of income in Cuba, so that the pandemic has caused a great impact on its economy due to the closure of the borders. In the treatment respect, lack of imported medicine in Cuba and China restricted patient to receive effective treatment. Spain is less affected on patient treatment due to socioeconomic subsidies and a reliable health system and less medicine restriction. Specifically, Spanish patients were easily accessible to MS drugs. The weakness of Chinese healthcare still restricts patients to get medicine even this phenomenon has improved compared to six months ago. Besides, the age should be considered; since the patients of China are generally younger and the majority of the university students do not have work. Therefore, the COVID-19 could have some impact.

During the pandemic, visible effects were also observed in public transport and shopping modes, for many people, public transport is the main means, and sometimes it is the only one. A study has reported that 48% of Americans considered themselves to be taking public transport would increase the risk of infecting COVID-19, 2/3 participants believe that you have to be very careful when traveling by plane.28 The pandemic has affected the means of transportation in different ways.29 Because public transport is a closed space that favors the transmission of infectious diseases from person to person, it can become a vector of COVID-19. Compared with other two countries, China implement measures on improvement of public transportation safety such as strengthen ventilation of airports, train stations, bus stations, increase disinfection of stations and vehicles, augmenting ventilation, restriction of passenger flow.30 Until now, China had not had any massive transmission of Covid-19 caused by public transport services and therefore the effectiveness of these measures are effectively prevent massive spread of Covid-19 via public transport services in China.31 As described in this research, during the pandemic, people's travel mode was significantly influenced especially in transport.

Some studies show that before the pandemic in Spain, consumers bought food mainly in supermarkets (96.6%), small stores (39.21%) and on the Internet (7.56%). There are not significant changes during the period of COVID-19 (p = 0.095).32 Meanwhile, china showed that online shopping become to the mean trend. To be specific, storing or purchasing food online play a key role in people's daily life. There are no differences in the dietary diversity score of the families.33 But the data of online purchases in Cuba have increased significantly. Shopping online has been a common phenomenon in China and Spain; it has established a complete sector platform. However, the Cuban government has promoted the development of the digital business during the pandemic; for that reason, an evident increase in online shopping has been observed in Cuban patients concerning Chinese and Spanish patients.34

COVID-19 not only affects the physical state, but also affects its social, economic, and psychological aspects. Our study prioritizes those who might need more help, psychologists, professionals, and social workers, who offer mental health services can at least begin to solve mental health problems, even during their confinement. In these three countries, the frequency of digital use has increased, which may also be due to the popularity of telecommuting, online learning,35 and strengthened communication with families and friends.20 Studies have found that the daily amount of time spent looking at the screen is much higher than recommended for adults, which can contribute to mental illnesses, such as depression, etc.36

During the COVID-19 pandemic, more than half of the population experienced changes in their eating habits, decreased physical activity, and increased appetite.37 which is similar to our research in three counties. The reason is that the gym's closure, prohibition physical exercise in the park or sports field might restrict people to do exercise, which lead people more focus on cooking food. It can cause a sedentary lifestyle that favors the appearance of some chronic diseases such as obesity, high blood pressure, diabetes mellitus, cardiovascular disease, etc.38–41 Diet habit change is also related to quarantine, Robinson et al. reported that 56% of its casuistry was written with the increase in the frequency of the diet42 and is considered another risk factor related to the diseases above.40–42

The results of studies on confidence in beating COVID-19 are more subtle. In general, the severity of COVID-19 in a region and the results of government prevention measures have a positive effect on the confidence of the inhabitants of the region, and the relationship depends on the health and level of physical activity of the region/individual. In the countries most affected by COVID-19 (for example: Cuba and Spain), reduced exercise frequency, excessive food intake, and prolonged confinement trips may have little confidence in victory over COVID-19.

Primary health care (PHC) has played an indispensable role in the fight against COVID-19.43,44 The family and community approach of PHC, with a territorial and intersectoral perspective, may be contributing to better prevention and control of the pandemic. Spain and Cuba have established a universal PHC system, accumulating much experience to face the pandemic.11,45 However, COVID-19 has raised the alarm about PHC in China, especially in the place where it originates, with doctors' generous support in different regions and the central level, China achieved a success in Wuhan, and eventually at the national level.

This study has certain limitations. First, the study is based on an Internet questionnaire, the COVID-19 pandemic varies from country to country, might not reflect really situation. Secondly, the collected data were subdivided into three groups (China, Spain, and Cuba), and each group include less, it will lead to publication bias.

During the pandemic, family support was more effective in China than in Cuba and Spain. Neither COVID-19 infections nor the number of outbreaks/relapses increased significantly in the confinement period in any of the three countries. Patients in all three countries used digital or social media platforms more frequently, probably to try to maintain personal relationships. The psychological and cognitive disorders of the patients will have to be studied at least within a year. Regarding their economic situation, Spanish MS patients received a significantly less negative impact than Cuba and China. The physical state has been maintained acceptably in the tres countries but especially better in China. The Chinese and Cubans trust more in the control of the pandemic than the Spanish, who are more pessimistic.

Guo-Xun Zhang, Run-Ze Zhao and Wen-Ting Zhang conceived and designed the study. Guo-Xun Zhang, Run-Ze Zhao and Wen-Ting Zhang responsible for data collection and analysis and drafted the manuscript. Wen-Jin Yu, Xiao-Jie Zhang, Shuai-Shuai Gao, IR. Olivera Leal, Maria Cáceres Toledo, Zurina Lestayo O'Farrill, Antonio Carrilllo-Vico, Jing-Ye Zhu and Pascual Amoedo R assist in data collection and provide advice. Izquierdo Guillermo and Gang Zhao responsible for conceptualization, reviewed and revised the paper. All authors read and approved the manuscript.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.