Developing guidelines for COVID-19 management: A moving target. An invited commentary on “Evidence based management guideline for the COVID-19 pandemic - Review article”

The COVID-19 pandemic is moving at a rapid rate, both in global transmission and in our knowledge about the disease. Health authorities across the world are scrambling to delineate best practices for everything from appropriate personal protective equipment, to anti-viral therapy, and ARDS management strategies. It that context, Nicola et al. present an excellent consolidation of what we currently know about the disease and what evidence we have to support particular management approaches [1]. They offer an evidence-based summary of the known epidemiology of the disease and the preventative measures being used to slow transmission, including social distancing, school closures, and quarantining. They also review the current treatment recommendations for those with severe disease, including a brief discussion of experimental treatments.

While this is a valuable review, several aspects of COVID-19 management are already in flux. Despite the authors' recommendation against routine mask use, many governments, including the United States, are now recommending widespread public use of cloth masks to help decrease transmission, with some emerging evidence that masks may have efficacy with limited risks [2]. Also, in contrast to the authors’ argument, the use of chloroquine-based medications, promoted through open-label, non-randomized data from France, has become a controversial treatment with disagreement about the potential benefits and rising concerns about the cardiac toxicity, among other serious side effects [3]. Other treatments such as convalescent plasma transfusion and remdesivir are also gaining substantial interest and may prove to be effective therapies, but more randomized data is needed [4]. These recent, and relatively dramatic changes in consensus about appropriate treatments for COVID-19, imply that we should proceed very cautiously as we establish a standard set of prevention and treatment guidelines.

As many countries emerge from the peak of transmission, it is becoming increasingly clear that public health officials will need to determine the role for antibody testing and vaccinations. Recent evidence suggests asymptomatic prevalence may be as high as 15% in specific populations, potentially affecting strategies for screening and tracing in some regions [5]. Antibody testing is still not widely available, making it difficult to honestly assess the breadth of the pandemic and the potential for herd immunity. Vaccinations will also be a vital aspect of any future population-level interventions, although the timeline of their availability remains unclear. These continued uncertainties, about both the epidemiology of COVID-19 and the readiness of vital public health tools such as testing and vaccinations, requires flexibility in the interpretation of evidence-based standards and caution is imperative. Unfortunately, evidence is lagging behind the speed of the pandemic, so we must vigilant in regularly reassessing our current strategies.

Provenance and peer review

Invited Commentary, internally reviewed.