India covid guidelines- a living synthesis and guideline process
2Department of Infectious diseases,Christian Medical College, Vellore, India
3Center for biostatistics and evidence based medicine, India
4Rt.Professor of Psychiatry, Christian Medical College,Vellore, India
5Emeritus Professor, Liverpool School of Tropical Medicine, United Kingdom
COVID-19 has had an unprecedented impact worldwide on health, healthcare, societies, and economies. Evidence for interventions emerged rapidly but was difficult to examine systematically in a short span of time. Few guidelines used formal evidence synthesis and GRADE approaches, particularly when tailoring to low- and middle-income countries (LMICs). To address this gap, Christian Medical College, Vellore, India, partnered with the Clinical Infectious Diseases Society of India (CIDS), Cochrane Infectious Diseases Group, Prof BV Moses Center for evidence-informed healthcare, and experts from 16 institutions in India and globally to form The Covid Management Guidelines India Group.
Objectives: To produce guidelines for the management of patients with acute COVID-19 in secondary and tertiary care settings in India.
Methods: The process incorporated GRADE and Cochrane Rapid Review approaches to identify and prioritise questions in areas of equipoise, screen and extract data from available studies, synthesise and determine certainty in the evidence, and enable expert working groups to produce recommendations or best practice statements tailored for India and other LMICs using the GRADE Evidence to Decision framework, which was all disseminated on a widely accessible platform: https://indiacovidguidelines.org.
Results: In the course of the project, clinicians across the country were trained in the development of guidelines using formal evidence synthesis and the GRADE approach. The guideline group comprising core, steering, methodology, evidence synthesis, dissemination, and intervention expert working groups with clearly defined roles and responsibilities synthesised guidelines pertaining to the use of interventions used in the treatment of COVID-19, including antivirals, anti-inflammatory, anticoagulation, antibodies, respiratory support, and other supportive management. Although acceptability and applicability of the guidelines is being investigated formally through a survey, one example of impact is that one state (Kerala, India) adopted our recommendation on anticoagulation in the state’s COVID-19 guidelines. An external advisory panel ensured scientific challenge and applicability to settings outside of those in which the experts practice.
Conclusions: This unique partnership applied a transparent GRADE approach to ensuring scientific rigor and an evidence-based approach taking into account local contextual factors in making clear timely guidelines relevant to India.