The COVID-19 pandemic has had devastating effects around the world, with the coronavirus causing SARS-CoV-2 infecting more than 170 million patients and causing more than 3.5 million deaths as of June 1, 2021. Fear and the resulting anxiety among the public and treating physicians frequently led to rapid changes in clinical practices and hospital classification decisions, many of which are not evidence-based and often harmful.
There have been wide variations globally and regionally in guidance related to mask use, testing protocols, vaccination and patient triage (both hospital admission and escalation to an intensive care unit), as well as the use of various pharmaceutical interventions in the treatment of patients with COVID-19. Many of these deviations from evidence-based healthcare result in substantial harm, diverting efforts and resources from data-driven, outcome-based best practices toward those that are of dubious effectiveness and even harmful.
As many countries continue to experience repeated waves of COVID-19, it is important to identify practical approaches that are evidence-based and can be implemented in the real world to optimize resource use and improve outcomes. Although they are important around the world, they are crucial in low- and middle-income countries, where resources are scarce.
The Choosing Wisely initiative was started to promote conversations between patients and doctors about how to avoid unnecessary medical interventions. Choosing Wisely’s mission is to help patients and doctors choose care that is evidence-based, unduplicated, harm-free and truly necessary.
It works by creating lists of “things doctors and patients should question,” something that is particularly appropriate for public health responses and management decisions in the current pandemic. In response to the widespread use of non-evidence-based practices, we started Choosing Wisely for COVID-19 to identify the “best decisions” for the general public, patients, and physicians.
| Recommendations for the general public |
1. Should I wear a well-fitting mask whenever I am in public?
A systematic review and meta-analysis of 10 adjusted (n = 2,647) and 29 unadjusted (n = 10,170) observational studies showed that the risk of infection was significantly reduced with masks (adjusted odds ratio (aOR), 0.15 and range 95% confidence interval (CI), 0.07–0.34, for adjusted studies; odds ratio (OR), 0.34 and 95% CI, 0.26–0.45, for unadjusted studies). N95 masks were associated with greater reductions in risk than surgical or other masks. Double masking is preferable to single masking, unless the masks are N95.
2. Avoid crowded places, especially indoors
A systematic review and meta-analysis of 9 adjusted (n = 7,782) and 29 unadjusted (n = 10,736) observational studies showed that the risk of infection was significantly reduced with a physical distance of > 1 meter (aOR, 0.18 and CI 95% CI, 0.09 to 0.38, for adjusted studies; OR, 0.30 and 95% CI, 0.20 to 0.44, for unadjusted studies). The greater the physical distancing, the lower the chance of infection . Maintaining adequate ventilation by opening doors and windows is an important measure to reduce the spread of infection.
3. Get tested if you have COVID-19 symptoms and isolate at home if symptoms are mild
Early testing and isolation at home is recommended if someone has symptoms of COVID-19, such as fever, sore throat, cough, loss of smell and/or taste. Testing enables a test, trace and isolate strategy, which is effective in controlling further spread. If someone has these symptoms and does not have access to reliable testing facilities, a syndromic diagnosis can be made . Most patients can be treated at home and recover well with regular monitoring of temperature and oxygen saturation. The only interventions necessary are maintaining hydration (plenty of oral fluids) and acetaminophen (paracetamol) for fever and body aches.
4. Seek medical help if you have difficulty breathing, or if your oxygen saturation drops below 92%
Patients who are breathless at rest or after exercise, or those with an oxygen saturation of <92% or those with a > 4% drop in oxygen saturation after an exercise test should seek medical help and should be appropriately evaluated. for medical treatment in hospital and non-hospital settings. Lying face down will help improve oxygen saturation.
5. Get vaccinated as soon as you’re eligible, and even if you’ve had COVID-19 in the past
Several randomized trials have demonstrated the effectiveness of several approved vaccines in preventing SARS-CoV-2 infection and severe illness and mortality due to COVID-19. Vaccination remains an extremely effective population-level strategy for the prevention and mitigation of COVID-19. This recommendation applies even if someone has had COVID-19 in the past.
| Recommendations for healthcare workers |
6. Do not prescribe unproven or ineffective therapies for COVID-19
There are currently no data supporting the use of favipiravir, ivermectin, azithromycin, doxycycline, oseltamivir, lopinavir - ritonavir, hydroxychloroquine, itolizumab, bevacizumab, plasma IFNuv-α herbal preparations for the treatment of COVID-19. Currently, the WHO does not recommend any of these. This list will need to be revised as new evidence emerges.
7. Do not use medications such as remdesivir and tocilizumab, except in specific circumstances where they may be helpful .
Tocilizumab is useful only in patients who are severely ill, receive steroids, have signs of inflammation, and have rapidly increasing oxygen needs. Use in other clinical situations is not beneficial and is probably harmful. Remdesivir has marginal efficacy in shortening recovery time in adults when given early to patients requiring oxygen in some trials, but not others. It does not reduce mortality and is not indicated in other clinical situations.
8. Use steroids judiciously only in patients with hypoxia and monitor blood sugar levels to keep them in the normal range
Randomized trials have shown benefits with short-term use (5 to 10 days) of steroids such as dexamethasone (6 mg). per day) in COVID-19 patients requiring oxygen. The sicker the patient, the greater the benefit. Other steroid equivalents such as methylprednisolone (16 mg twice daily) or prednisolone (20 mg twice daily) may be used. Steroids do not benefit and may harm patients who do not need oxygen . There is no data to support longer use of steroids (>10 days) or a higher dose of steroids. It is important to maintain glycemic control in patients taking steroids to reduce the risk of secondary fungal infections such as mucormycosis . It is not necessary to type steroids after use for 5 to 10 days.
9. Do not routinely perform investigations that do not guide treatment, such as CT scans and inflammatory biomarkers
There is no data to support the routine use of chest CT scans, CT scores, or inflammatory biomarkers such as ferritin, IL-6, LDH, and procalcitonin to grade the severity of COVID-19 or guide treatment protocols.
10. Don’t ignore non-COVID-19 critical illness management during the pandemic
Several studies have shown that care for diseases such as cancer, tuberculosis, and heart and kidney disease, and conditions such as mental health, childbirth, perinatal care, and childhood immunization, has suffered during the pandemic. This has serious implications on your results. Essential healthcare services must continue to be provided during any pandemic. For example, it is estimated that the suspension of cancer services will cause more deaths than those due to COVID-19 during the pandemic.
Choosing Wisely ’s recommendations for the prevention, care and control of COVID-19 include the best evidence currently available and address practices that are common, inefficient, low-value or harmful in the response to COVID-19 in several countries. All recommendations are based on strong evidence and can improve outcomes for global pandemic control. These are especially relevant in low- and middle-income countries, where resources are scarce, public health spending is low, and optimal utilization is crucial.
We emphasize that these recommendations are not intended to replace treatment protocols; instead, they aim to promote shared decision-making by patients and physicians, and provide guidance to treating physicians and the general public.
Our consensus list of recommendations for the control of COVID-19 has several implications.
First, it provides guidance to the general public on simple measures that could decrease their risk of contracting COVID-19; We emphasize the importance of appropriate use of masks, avoiding crowded places, and encouraging adequate ventilation indoors, based on increasing understanding of SARS-CoV-2 transmission.
Second, this consensus list provides practical guidance to patients on what to do when they develop symptoms or test positive for COVID-19, including recognizing symptoms and signs that require medical attention. Guidance to patients is important, as health systems must also adopt a hospital triage system in which patients with mild to moderate illness are not admitted to the hospital, so precious hospital beds are reserved for patients with more serious illnesses.
Third, the consensus list provides clear recommendations to the general public on vaccination , as vaccines provide the most important path to pandemic control.
Fourth, the consensus list encourages clinicians to make evidence-based, outcome-based treatment decisions that will optimize resources and avoid waste. By disseminating these recommendations, we are also discouraging defensive medical practice by doctors who fear litigation or criticism if they do not treat patients with unproven therapies.
Finally, we emphasize the importance of maintaining essential non-COVID-19 health areas such as cancer, tuberculosis, kidney and heart diseases, mental health and reproductive health even during major pandemics, as the consequences of not doing so are dire. During subsequent waves of the pandemic, policy decisions must ensure that, while care for COVID-19 is maintained, the provision of other essential healthcare services continues uninterrupted.
