Updated March 9, 2022.

The Philippine COVID-19 Living Recommendations document is brought to you by the Institute of Clinical Epidemiology, National Institutes of Health, UP Manila in cooperation with the Philippine Society of Microbiology and Infectious Diseases (PSMID). This was funded by the Department of Health (DOH) AHEAD Program through the DOST-Philippine Council for Health Research and Development (PCHRD) and the DOH-Disease Prevention and Control Bureau.

INTRODUCTION

Given the magnitude of the impact of COVID-19 in the country and the current priority given to it by health care providers, public health officials and the government, the need for clinical practice guidelines to optimize health care through effective management and control of the spread of this disease is imperative. Furthermore, an infodemic from the rapid pace of scientific developments on COVID-19 management is running side-by-side with the pandemic. We offer these living recommendations to health care providers to guide their diagnosis and treatment decisions on individual patient care. For policy makers and program managers, these living recommendations can serve to inform policy and provide timely guidance on effective interventions to be prioritized, implemented and made accessible to health care providers and the public.

While there are existing international guidelines and living systematic reviews on COVID-19, there is a need to localize the recommendations from the evidence in our setting by local experts, end-users and other relevant stakeholders. With the rapidly evolving science, the Living CPG development process is used wherein recommendations are switched to a living status based on the likelihood of new evidence and the importance of the recommendation in health care policy decision making. Living systematic reviews will be maintained to provide up-to-date, evidence-based living recommendations on the treatment, diagnosis, prevention and control of COVID-19.

SECTION LINKS:

Click on the sections below to see the recommendations.

Updated as of 29 November 2021

We suggest to do an initial screening for ANY influenza-like illness, typical and atypical COVID-19 symptoms* within the past 14 days in apparently healthy adults and children, especially for individuals with known exposure to a laboratory-confirmed case of COVID-19. (Very low certainty of evidence; Weak recommendation)

*Symptoms include but not limited to: fever/chills, cough, shortness of breath/dyspnea, sore throat, runny nose, myalgia, headache, fatigue/malaise, diarrhea, nausea/vomiting, abdominal pain, anosmia, ageusia, wheezing, chest pain, altered mental status, seizures, rash, pink eye

You can find the Evidence Summary here.

We recommend the use of the following specimens as alternative specimens to nasopharyngeal swab RT-PCR for the diagnosis of COVID-19 among symptomatic and asymptomatic patients suspected of COVID-19 in hospital and outpatient settings:

  • oropharyngeal swab (Moderate quality of evidence; Strong recommendation)
  • saliva drool/spit and oral saliva (Moderate quality of evidence; Strong recommendation)
  • nasal swab/wash (Moderate quality of evidence; Strong recommendation)
  • throat swab (Low quality of evidence; Strong recommendation)

We suggest the use of saliva swab and posterior oropharyngeal saliva specimens as an alternative specimen to nasopharyngeal swab RT-PCR for the diagnosis of COVID-19 among symptomatic and asymptomatic patients with suspected COVID-19 in hospital and community/outpatient settings. (Low quality of evidence; Conditional recommendation)

We recommend against the use of sputum as an alternative specimen to nasopharyngeal swab RT-PCR for the diagnosis of COVID-19. (Very low quality of evidence; Strong recommendation)

There is no evidence to recommend the use of bronchoalveolar lavage as an alternative specimen to nasopharyngeal swab RT-PCR for the diagnosis of COVID-19.

*SARS COV-2 RT-PCR of nasopharyngeal swabs remains the diagnostic test of choice to confirm the diagnosis of COVID-19 among suspected individuals.

You can find the Evidence Summary on RT-PCR of saliva samples here.

You can find the Evidence Summary on choice of specimens for RT-PCR here.

We suggest the use of pooled RT-PCR testing in targeted* low-risk and low-prevalence populations using a pool size of 5 in individuals suspected of COVID-19 infection. (Moderate quality of evidence; Conditional recommendation)

*Target population refer to the list of PSP and DOH

You can find the Evidence Summary here.

We suggest to repeat RT-PCR testing when the initial RT-PCR test is negative among symptomatic patients with high index of suspicion for COVID-19 infection. (Low quality of evidence; Conditional recommendation)

You can find the Evidence Summary here.

We recommend the use of both clinical risk assessment and RT-PCR* to screen for COVID-19 among asymptomatic individuals scheduled for non-emergency surgery (Very low quality of evidence; Strong recommendation).

We recommend the use of both clinical risk assessment and Antigen-Rapid Diagnostic Test (Ag-RDT)** to screen for COVID-19 among asymptomatic individuals scheduled for non-emergency surgery when RT-PCR testing is not available or when prolonged turnaround time is considered (Very low quality of evidence; Strong recommendation).

*Use high-risk PPE regardless of RT-PCR or Ag-RDT test results in areas with prevalence of 1% or higher. **Ag-RDT should have a Sn of 80% and Sp of 97%

You can find the Evidence Summary here.

Updated as of 22 November 2021

We suggest using antibody tests that accurately measure IgG or total antibodies to determine COVID-19 seroprevalence among adults when needed for public health purposes. (Very low certainty of evidence; Weak recommendation)

We suggest against using antibody tests detecting IgM to determine COVID-19 seroprevalence among adults when needed for public health purposes. (Very low certainty of evidence; Weak recommendation)

We suggest against using lateral flow immunoassay (LFIA) tests to determine COVID-19 seroprevalence among adults when needed for public health purposes. (Very low certainty of evidence; Weak recommendation)

We recommend against routine measurement of SARS-CoV-2 antibody titers after vaccination. (No evidence; Strong recommendation)

You can find the Evidence Summary here.

We recommend against the use of SARS-CoV-2 Ab testing to diagnose presumptive COVID-19 reinfection among symptomatic patients previously diagnosed with COVID-19* (Very low quality of evidence; Strong recommendation).

*NAAT (RT-PCR) and Genomic sequencing are the recommended diagnostic tests to confirm COVID-19 reinfection.

You can find the Evidence Summary here.

Updated as of 17 December 2021

(Note: Does not yet include recent evidence regarding the Omicron variant and shall be updated in the next phase of recommendations)

For asymptomatic, not severely immunocompromised fully vaccinated adults, we suggest the use of the following symptom-based criteria for return to work clearance: (Very low certainty of evidence; Weak recommendation)

  1. At least 8 days have passed since the first positive COVID-19 RT-PCR test; AND
  2. No symptoms have developed during this period.

For asymptomatic, not severely immunocompromised not fully vaccinated adults, we suggest the use of the following symptom-based criteria for return to work clearance: (Very low certainty of evidence; Weak recommendation)

  1. At least 10 days have passed since the first positive COVID-19 RT-PCR test; AND
  2. No symptoms have developed during this period.

For symptomatic, not severely immunocompromised adults with mild-to-moderate COVID-19 diagnosis and any vaccination status, we suggest the use of the following symptom-based criteria for return to work clearance: (Very low certainty of evidence; Weak recommendation)

  1. At least 10 days have passed since the onset of symptoms; AND
  2. No fever during the previous 24 hours; AND
  3. There has been substantial improvement in respiratory symptoms of the acute illness.

For symptomatic, not severely immunocompromised adults with severe-to-critical COVID-19 diagnosis and any vaccination status, we suggest the use of the following symptom-based criteria for return to work clearance: (Very low certainty of evidence; Weak recommendation)

  1. At least 21 days have passed since the onset of symptoms; AND
  2. No fever during the previous 24 hours; AND
  3. There has been substantial improvement in respiratory symptoms of the acute illness.

For symptomatic, severely immunocompromised adults* with any vaccination status, we suggest the use of the following for return to work clearance: (Very low certainty of evidence; Weak recommendation)

  1. At least 22 days have passed since the onset of symptoms; AND
  2. No fever during the previous 24 hours; AND
  3. There has been substantial improvement in respiratory symptoms of the acute illness; AND
  4. PCR test results are negative on at least 1 respiratory specimen.

*Severely immunocompromised individuals include the following:

  • Individuals receiving active chemotherapy for cancer
  • Being within one year out from receiving a hematopoietic stem cell or solid organ transplant
  • Untreated HIV infection with CD4 <200
  • Primary immunodeficiency
  • Taking immunosuppressive medications (e.g., drugs to suppress rejection of transplanted organs or to treat rheumatologic conditions such as mycophenolate and rituximab)
  • Taking more than 20mg a day of prednisone for more than 14 days

You can find the Evidence Summary here.

Updated as of 17 December 2021

To guide the decision to admit adult patients with COVID-19 to the hospital:

We suggest the use of age, BUN, number of comorbidities, CRP, SpO2/FiO2 ratio, platelet count, Heart rate (ABC2-SPH) risk score, Confusion Urea Respiration Blood Pressure (CURB-65) severity score, Risk Stratification in the Emergency Department in Acutely Ill Older Patients (RISE-UP) score, and Rapid Emergency Medicine Score (REMS). (Low certainty of evidence; Weak recommendation) 

There is insufficient evidence to recommend the use of 4C Mortality Score, COVID Outcome Prediction in the Emergency Department (COPE) model, and Quick Sepsis-related Organ Failure Assessment (qSOFA) score. (Very low certainty of evidence)

To guide in the expectant monitoring of hospitalized adult patients:

We suggest the use of the 4C Deterioration model. (Low certainty of evidence; [Weak] recommendation)

There is insufficient evidence to recommend the use of Modified Early Warning Score (MEWS) and National Early Warning Score 2 (NEWS2), Clinical Frailty Scale (CFS), and the COVID-GRAM model. (Very low certainty of evidence)

You can find the Evidence Summary here.

Updated as of 29 November 2021

There is insufficient evidence to recommend the use of breath test in detecting COVID-19 infection. (Low certainty of evidence)

You can find the Evidence Summary here.

Updated as of 13 December 2021

There is insufficient evidence to recommend the use of specific cut-off values of CRP, LDH and Ferritin to guide the initiation of immunotherapy in patients with COVID-19 (Very low certainty of evidence)

You can find the Evidence Summary  here.

We suggest the use of D-dimer to guide anticoagulation of adult patients with COVID-19, because of its significant association with mortality, thromboembolism, and worsening of disease (Low quality of evidence; Conditional recommendation).

You can find the Evidence Summary  here.

Updated as of November 11, 2021

We suggest the use of self-administered rapid antigen test for the diagnosis of COVID-19 in symptomatic individuals, provided that ALL OF THE FOLLOWING conditions are met: (Low certainty of evidence; Weak recommendation)

  1. Ease of collecting samples is ensured;
  2. Ease of interpretation is ensured;
  3. Test kits have passed flex studies; AND
  4. Individuals present with symptoms for less than 7 days.

We suggest against the use of self-administered rapid antigen test for routine screening of COVID-19. (Low certainty of evidence; Weak recommendation)

You can find the Evidence Summary here.

Updated as of 22 November 2021

There is insufficient evidence to recommend an RT-PCR cycle threshold cut-off value* to determine infectivity among COVID-19 confirmed patients. (Very low certainty of evidence)

*Interpretation of RT-PCR cycle threshold values may vary and is dependent on the PCR assay used, gene target, sample type, and timing of sample collection.

You can find the Evidence Summary here.

Updated as of 22 November 2021

We suggest pulse oximetry with close clinical monitoring by qualified medical personnel in suspected and confirmed COVID-19 patients especially those who are at high risk for deterioration. (Very low certainty of evidence; Weak recommendation)

You can find the Evidence Summary here.

Updated as of 29 November 2021

We suggest against the use of PF4 antibody ELISA Heparin Induced Thrombocytopenia (HIT) test kits and non-ELISA rapid HIT test kits for COVID-19 Vaccine Induced Thrombosis and Thrombocytopenia (VITT). (Low certainty of evidence; Weak recommendation)

You can find the Evidence Summary here.

Updated as of 29 November 2021

We suggest against using serum tryptase for patients who had anaphylaxis after receiving COVID-19 vaccine. (Very low certainty of evidence; Weak recommendation)

You can find the Evidence Summary here.

Updated as of 13 December 2021

For initiating antibiotic therapy

We suggest against the use of procalcitonin alone as a basis for initiating antibiotic therapy among COVID-19 confirmed patients. (Very low certainty of evidence; Weak recommendation)

For discontinuing antibiotic therapy

If available, we recommend using a procalcitonin level of less than or equal to 0.25 ng/mL for discontinuing antibiotic therapy among COVID-19 confirmed patients. (Very low certainty of evidence; Strong recommendation)

You can find the Evidence Summary here.

Updated as of 13 December 2021

Chest X-Ray

We suggest against the use of chest x-ray to diagnose COVID-19 infection among asymptomatic individuals.(Very low certainty of evidence; Weak recommendation)

We suggest chest x-ray to facilitate rapid triage, infection control, and clinical management among any of the following: (Very low certainty of evidence; Weak recommendation)

  • patients with mild features of COVID-19 at risk for progression
  • patients with moderate to severe features of COVID 19
  • patients with symptoms of at least 5 days duration

Lung Ultrasound

We suggest against the use of lung ultrasound alone in diagnosing patients with suspected COVID-19 infection. (Very low certainty of evidence; Weak recommendation)

Chest CT Scan

We suggest against the routine use of CT scan for diagnosing COVID-19 among suspected patients with COVID-19 presenting at the emergency department if RT-PCR testing is readily available with timely results.(Very low certainty of evidence; Weak recommendation)

If RT-PCR is not available, we suggest using non-contrast chest CT scan for symptomatic patients suspected of having COVID-19 to guide early triage and management under the following conditions: (Very low certainty of evidence; Weak recommendation)

You can find the Evidence Summary here.

Updated as of 22 November 2021

We suggest the use of rapid antigen test for the diagnosis of symptomatic individuals suspected of COVID-19 as an alternative to RT-PCR if all the following conditions are met: (Low certainty of evidence; Weak recommendation)

  1. Individuals are in the early phase of illness (less than or equal to 7 days from onset of symptoms)
  2. Testing kits demonstrated sensitivity of more than or equal to 80% AND have very high specificity of more than or equal to 97%

We suggest against the use of rapid antigen test for screening purposes.  (Low certainty of evidence; Weak recommendation)

We suggest against the use of saliva as specimen for rapid antigen test in patients suspected of COVID-19 infection.  (Low certainty of evidence; Weak recommendation)

We suggest against the use of rapid antigen tests alone in asymptomatic patients suspected of COVID-19 infection.  (Low certainty of evidence; Weak recommendation)

We suggest the use of rapid antigen tests for the diagnosis of individuals suspected of COVID-19 during the setting of an outbreak provided that all the following conditions are met: (Very low certainty of evidence; Weak recommendation)

  1. Individuals are in the early phase of illness (less than or equal to 7 days from onset of symptoms); AND
  2. Testing kits demonstrated sensitivity of more than or equal to 80% AND have very high specificity of more than or equal to 97%.

There is insufficient evidence to recommend for or against the use of repeat antigen testing for screening or diagnosis of COVID-19. (Very low certainty of evidence)

 A negative rapid antigen test should be confirmed with an RT-PCR in settings or situations wherein COVID-19 is highly suspected (e.g., symptomatic or asymptomatic close contacts of probable or confirmed COVID-19 individuals).

You can find the Evidence Summary here.

There is insufficient evidence in using symptoms*, biologic factors or severity of acute COVID-19 in predicting the development of long covid symptoms. (Very low certainty of evidence)

*The most common symptoms of long COVID identified were fatigue, dyspnea, sleep disturbance, anxiety or depression, and memory impairment.

You can find the Evidence Summary here.

Updated as of October 28, 2021

CLASSIFICATIONCRITERIA
Mild COVID-19
  • No pneumonia or desaturation
  • Acute onset of fever and cough or any three (3) or more of the following:
    • Fever
    • Cough
    • Coryza
    • Sore throat
    • Diarrhea
    • Anorexia/nausea/vomiting
    • Loss of sense of smell or taste
    • General weakness/body malaise/fatigue
    • Headache
    • Myalgia
Moderate COVID-19

a. With pneumonia* BUT no difficulty of breathing or shortness of breath, RR < 30 breaths/min, oxygen saturation# >/= 94% at room air

OR

b. Without pneumonia but with risk factors for progression: elderly (60 years old and above) and/or with comorbidities

Severe COVID-19
  • With pneumonia* and ANY one of the following:
    • Signs of respiratory distress
    • Oxygen saturation# < 94% at room air
    • Respiratory rate of ≥30 breaths/minute
    • Requiring oxygen supplementation
Critical COVID-19
  • With pneumonia* and ANY one of the following:
    • Impending respiratory failure requiring high flow oxygen, non-invasive or invasive ventilation
    • Acute respiratory distress syndrome
    • Sepsis or shock
    • Deteriorating sensorium
    • Multi-organ failure
    • Thrombosis

*Pneumonia – evidence of lower respiratory disease during clinical assessement (e.g. cough, fever plus crackles) and/or imaging (CXR, ultrasound, CT scan)
#Proper recording of the O2 saturation: finger should be inserted in the oximeter for about 10-20 seconds; patient should be still and not talking.

Consensus Issues

The current COVID-19 Severity Classification is updated for better understanding and applicability. A footnote is added to clearly define pneumonia and how O2 saturation should be properly obtained. Levels of O2 saturation are specified to be in taken in room air and the elderly age group is specified to be 60 years old and above.

We recommend against the use of hydroxychloroquine / chloroquine, with or without azithromycin among patients with COVID-19 infection. (Moderate quality of evidence; Strong recommendation)

You can find the Evidence Summary here.

Updated as of 01 December 2021

We recommend against the use of azithromycin in treatment of COVID-19 regardless of disease severity. (Moderate certainty of evidence; Strong recommendation)

You can find the Evidence Summary here.

Updated as of November 8, 2021

There is insufficient evidence to recommend the use of favipiravir among patients with COVID-19 infection.(Low certainty of evidence)

You can find the Evidence Summary here.

We suggest against the use of remdesivir in patients with COVID-19 infection who have O2 saturation ≥94% and do not require oxygen supplementation. (Low quality of evidence; Conditional recommendation)

We suggest the addition of remdesivir to dexamethasone in patients with COVID-19 infection who have O2 saturation < 94% and/or requiring oxygen supplementation*. (Low quality of evidence; Conditional recommendation)

We suggest against the use of remdesivir in patients with COVID-19 infection who are already on invasive mechanical ventilation. (Low quality of evidence, conditional recommendation)

*For patients who progress to invasive mechanical ventilation while on remdesivir, the drug can be continued.

You can find the Evidence Summary here.

Updated as of October 28, 2021

We recommend the addition of tocilizumab to systemic steroids in patients showing rapid respiratory deterioration and/or requiring high doses of oxygen (high-flow nasal cannula, noninvasive or invasive mechanical ventilation) and with elevated biomarkers of inflammation (CRP). (Moderate certainty of evidence, Strong recommendation)

 We recommend against the use of tocilizumab among patients with COVID-19 infection who do not require oxygen. (Very low certainty of evidence, Strong recommendation)

You can find the Evidence Summary here.

Updated as of 18 November 2021

We recommend against the use of convalescent plasma in patients with COVID-19 infection. (Moderate certainty of evidence, Strong recommendation)

You can find the Evidence Summary here.

We recommend against the use of ibuprofen as treatment among patients with COVID-19 infection. (Very low quality of evidence; Strong recommendation)

You can find the Evidence Summary here.

There is no evidence to recommend the use of VCO as treatment among patients with COVID-19 infection.

You can find the Evidence Summary here.

Updated as of 06 December 2021

There is insufficient evidence to recommend the use of Lianhua in the treatment of patients with non-severe COVID-19. (Very low certainty of evidence)

You can find the Evidence Summary here.

Updated as of 06 December 2021

We recommend against the use of ivermectin for the treatment of patients with COVID-19 of any severity (Very low certainty of evidence; Strong recommendation)

You can find the Evidence Summary here.

Updated as of November 8, 2021

We suggest against the use of colchicine as treatment for COVID-19.

(Very low certainty of evidence; Weak recommendation)

You can find the Evidence Summary here.

Updated as of 06 December 2021

We recommend against the use of interferon in the treatment of COVID-19 patients (Very low certainty of evidence; Strong recommendation)

You can find the Evidence Summary here.

We suggest the use of baricitinib in addition to dexamethasone and remdesivir as treatment for hospitalized COVID-19 patients who require low-flow oxygen, high-flow oxygen, and non-invasive ventilation. (Low quality of evidence; Weak recommendation)

There is insufficient evidence to recommend baricitinib as an alternative to tocilizumab as treatment for hospitalized COVID-19 patients. (Very low quality of evidence)

You can find the Evidence Summary  here.

Updated as of 18 November 2021

There is insufficient evidence to recommend the use of inhaled corticosteroids in treatment of non-hospitalized COVID-19 patients. (Very low certainty of evidence)

You can find the Evidence Summary  here.

 

We recommend against the use of lopinavir/ritonavir as treatment for COVID-19 infection (Moderate quality of evidence; Strong recommendation)

We suggest the use of bamlanivimab and etesevimab combination therapy as treatment for mild to moderate, non-hospitalized COVID-19 patients with at least 1 risk factor* for progression to severe disease. (Low quality of evidence; Weak recommendation)

*Risk factors for severe COVID-19: age ≥65 years, body-mass index ≥35 kg/m2, cardiovascular disease (including hypertension), chronic lung disease (including asthma), chronic metabolic disease (including diabetes), chronic kidney disease (including receipt of dialysis), chronic liver disease, and immunocompromised conditions.

You can find the Evidence Summary here.

Updated as of October 28, 2021

We suggest against the use of leronlimab as treatment for COVID-19. (Very low certainty of evidence, Weak recommendation)

You can find the Evidence Summary here.

We recommend against the use of steam inhalation in the treatment of COVID-19. (Very low quality of evidence; Strong recommendation)

We recommend against the use of oseltamivir as treatment for patients with COVID-19 infection. (Very low quality of evidence; Strong recommendation)

You can find the Evidence Summary here.

We suggest against the use of baloxavir as treatment for COVID-19 infection. (Very low quality of evidence; Conditional recommendation)

You can find the Evidence Summary here.

We suggest against the use of intravenous immunoglobulin as treatment for moderate to severe COVID-19. (Very low quality of evidence; Conditional recommendation)

You can find the Evidence Summary here.

We suggest against the use of famotidine in the treatment of COVID-19. (Very low quality of evidence; Conditional recommendation)

You can find the Evidence Summary here.

There is insufficient evidence to recommend using umbilical cord-derived mesenchymal stem cell therapy among adults with severe COVID-19 (PaO2/FiO2 ratio ≤ 300 mmHg). (Very low quality of evidence)

You can find the Evidence Summary here.

We suggest against the use of tofacitinib among hospitalized COVID-19 patients. (Low quality of evidence; Weak recommendation)

You can find the Evidence Summary here.

We suggest against the use of infliximab among patients with COVID-19 infection (Very low quality of evidence; Weak recommendation)

You can find the Evidence Summary here.

Updated as of November 8, 2021

There is insufficient evidence to recommend the use of fluvoxamine among patients with COVID-19 infection. (Low certainty of evidence)

You can find the Evidence Summary here.

Updated as of 20 December 2021

We suggest the use of casirivimab-imdevimab as treatment for symptomatic, non-hospitalized patients with at least 1 risk factor* for severe COVID-19. (Moderate certainty of evidence; Weak recommendation)

We recommend against casirivimab-imdevimab as treatment for hospitalized COVID-19 patients. (Low certainty of evidence; Strong recommendation)

There is insufficient evidence to recommend casirivimab-imdevimab as treatment for asymptomatic COVID-19 patients. (Low certainty of evidence)

*Risk factors: age >50 years, obesity, cardiovascular disease (including hypertension), chronic lung disease (including asthma), chronic metabolic disease (including diabetes), chronic kidney disease (including receipt of dialysis), chronic liver disease, and immunocompromised conditions.

You can find the Evidence Summary here.

Updated as of 10 January 2022

We suggest the use of molnupiravir within 5 days of symptom onset among non-hospitalized adult patients (18 years old and older) with mild to moderate COVID-19 infection with at least one risk factor* for progression. (Low certainty of evidence, Weak recommendation)

*Risk factors for progression include: 

age >60 years, active cancer, chronic kidney disease, chronic obstructive pulmonary disease, obesity, serious heart conditions or diabetes mellitus

You can find the Evidence Summary here.

Updated as of November 8, 2021

There is insufficient evidence to recommend the use of imatinib among patients with COVID-19 infection. (Low certainty of evidence)

You can find the Evidence Summary here.

Updated as of 18 November 2021

We suggest against the use of artesunate, artemisinin or pyronaridine tetraphosphate + artesunate in the treatment of COVID-19. (Very low certainty of evidence, Weak recommendation)

You can find the Evidence Summary here.

Updated as of 06 December 2021

We suggest against the use of bevacizumab as treatment for COVID-19. (Very low certainty of evidence; Weak recommendation)

You can find the Evidence Summary here.

Updated as of 20 December 2021

We suggest against the use of regdanvimab for the treatment of mild to moderate COVID-19 (Very low certainty of evidence; Weak recommendation)

You can find the Evidence Summary here.

Updated as of 03 January 2022

We recommend the use of dexamethasone for up to 10 days among patients with severe and critical COVID-19.  (Moderate certainty of evidence, Strong recommendation)

We recommend the use of 6 mg to 12 mg per day of dexamethasone among patients with severe and critical COVID-19. (Moderate certainty of evidence, Strong recommendation)

We recommend against the use of corticosteroids among mild and moderate (non-oxygen requiring) COVID-19 patients. (Moderate certainty of evidence, Strong recommendation)

We suggest that steroid therapy be initiated as soon as diagnosed or categorized as severe or critical COVID-19. (Very low certainty of evidence, Weak recommendation)

You can find the Evidence Summary here.

Updated as of October 26, 2021

We recommend the use of prophylactic over therapeutic dose anticoagulation among hospitalized patients with moderate, severe or critical COVID-19 disease unless there are any contraindications. (Low certainty of evidence; Strong recommendation)

We recommend the use of standard dose prophylactic anticoagulation over intermediate dose prophylactic anticoagulation among hospitalized patients with COVID-19 disease unless there are any contraindications. (Moderate certainty of evidence; Strong recommendation)  

You can find the Evidence Summary here.

We recommend against the routine use of antibiotics in patients with severe and critical COVID-19 infection, unless with suspicion of secondary bacterial co-infection. For patients on empiric antibiotics, they should be assessed daily for the need for discontinuation, continuation or escalation based on clinical and laboratory parameters. (Very low quality of evidence; Strong recommendation)

Updated as of 01 December 2021

There is insufficient evidence to recommend the use of hemoperfusion in patients diagnosed with COVID-19. (Low certainty of evidence)

You can find the Evidence Summary here.

We suggest the use of conservative fluid management rather than liberal fluid management strategy in mechanically ventilated adult COVID-19 patients with acute respiratory distress syndrome who are adequately resuscitated*. (Low quality of evidence; Conditional recommendation)

*without tissue hypoperfusion and fluid responsiveness

Updated as of October 26, 2021

We suggest self-proning position in non-intubated patients with severe and critical COVID-19 (Very low certainty of evidence; Weak recommendation)

There is insufficient evidence to recommend the use of side lying in non-intubated patients with severe to critical COVID-19 (Very low certainty of evidence)

You can find the Evidence Summary here.

Updated as of 01 December 2021

We suggest the use of high flow nasal cannula for patients with severe to critical COVID-19 who do not respond to conventional oxygen therapy (low flow nasal cannula/face mask)  (Low certainty of evidence; Weak recommendation)

You can find the Evidence Summary here.

We suggest the use of a lung protective ventilation strategy (tidal volume 4-8 mL/kg predicted body weight and plateau pressure less than 30 cmH2O in patients with COVID-19 infection and ARDS. (Very low quality of evidence; Conditional recommendation)

There is insufficient evidence to recommend the use of a higher PEEP strategy. We suggest to individualize PEEP or employ a PEEP strategy based on respiratory mechanics (i.e., compliance) in patients with COVID-19 infection. (Low quality of evidence; Conditional recommendation)

There is insufficient evidence to recommend a driving pressure limited strategy in patients with COVID-19 infection. We suggest to keep the driving pressure ≤ 14 cmH2O. (Low quality of evidence; Conditional recommendation)

We suggest the use of rapid sequence intubation for COVID-19 patients to reduce infection among healthcare workers performing the procedure. (Very low quality of evidence; Conditional recommendation)

Updated as of 03 Jan 2022

We suggest the use of ECMO for judiciously selected COVID-19 patients with severe Acute Respiratory Distress Syndrome (ARDS) based on the Extracorporeal Life Support Organization (ELSO) criteria (Very low certainty of evidence; Weak recommendation)

You can find the Evidence Summary here.

Updated as of 01 December 2021

At present, we suggest against the use of hyperbaric oxygen therapy for the management of COVID-19 patients due to insufficient evidence. (Very low certainty of evidence, Weak recommendation)

You can find the Evidence Summary here.

We recommend against the use of etoposide among patients with COVID-19 pneumonia in cytokine storm (Very low quality of evidence; Strong recommendation)

We recommend individualized pulmonary rehabilitation with pre intervention medical clearance for long COVID patients who show residual respiratory symptoms (Moderate quality of evidence; Strong recommendation)

You can find the Evidence Summary here.

Updated as of October 26, 2021

We recommend against the use of nitric oxide among patients with COVID-19. (Low certainty of evidence; Strong recommendation)

You can find the Evidence Summary here.

Updated as of October 26, 2021

There is insufficient evidence to recommend the use of pirfenidone or nintedanib among patients with post-COVID-19 pulmonary fibrosis (Very low certainty of evidence)

You can find the Evidence Summary here.

Updated as of 03 January 2022

We suggest light over deep sedation in COVID-19 patients who are mechanically ventilated and who are anxious or agitated. (Very low certainty of evidence, Weak recommendation)

We suggest against routine use of NMB in mechanically ventilated COVID-19 ARDS patients. (Low certainty of evidence, Weak recommendation)

You can find the Evidence Summary here.

Updated as of 03 January 2022

We suggest the use of either high flow nasal cannula or non-invasive positive pressure ventilation in COVID-19 patients with hypoxemic respiratory failure, in the absence of any indication for emergent invasive mechanical ventilation.  (Low certainty of evidence, Weak recommendation)

You can find the Evidence Summary here.

Updated as of 03 December 2021

We recommend the proper use of either a well-fitted cloth mask or medical mask in the community setting. If a cloth mask will be used, we suggest that it should be made of at least two layers of cotton (e.g., t- shirt fabric) or non-woven nylon with aluminum nose bridge. (Very low certainty of evidence; strong recommendation)

You can find the Evidence Summary here.

We recommend against the use of ionizing air purifier to reduce COVID-19 transmission in the community. (Low quality of evidence; Strong recommendation)

You can find the Evidence Summary here.

We recommend against the use of footbaths for the prevention and control of COVID-19 transmission. (Very low quality of evidence; Strong recommendation)

You can find the Evidence Summary here.

We recommend against the use of misting tents or disinfection chambers for preventing and controlling COVID-19 transmission. (Very low quality of evidence; Strong recommendation)

You can find the Evidence Summary here.

We recommend against the use of UV lamps or other UV devices in any place outside of a controlled clinic or hospital setting to prevent and control COVID-19 transmission. (Low quality of evidence; Strong recommendation)

You can find the Evidence Summary here.

We suggest the use of HEPA filter as an option to improve air quality for COVID-19 prevention and control in indoor spaces with inadequate ventilation. (Low quality of evidence; Conditional recommendation)

You can find the Evidence Summary here.

In situations where there is shortage of filtering facepiece respirators (FFR), we suggest the use of Hydrogen Peroxide Vapor (HPV), Ultraviolet Germicidal Irradiation (UVGI), moist heat and peracetic acid dry fogging system (PAF) as options for N95 mask decontamination as recommended by the manufacturer based on their ability to reduce SARS-COV-2 load and infectivity while still maintaining N95 mask integrity. (Low quality of evidence; Conditional recommendation)

We recommend against the use of autoclave and alcohol as these methods alter filtering facepiece respirator’s (N95) integrity and degrade filtration efficacy. (Very low quality of evidence; Strong recommendation)

You can find the Evidence Summary here.

We recommend the use of appropriate PPE to include mask (N95 or higher standard), fluid repellent sealed well-fitting long gown, double gloves, apron, full face shield or goggles or visor, scrub hat, and disposable shoe covers or dedicated closed footwear among surgeons engaged in aerosol generating procedures of suspected or confirmed COVID-19 patients. (Very low quality of evidence; Strong recommendation)

You can find the Evidence Summary  here.

We recommend the use of at least surgical face mask and face shield for protection against COVID-19 infection among healthcare workers in the outpatient setting not performing aerosol generating procedures. Additional PPEs such as medical gowns and gloves should be worn as part of standard precautions during the performance of other procedures. (Very low quality of evidence; Strong recommendation)
 
You can find the Evidence Summary here.

We recommend the use of the following PPE: disposable hat, medical protective mask (N95 or higher standard), goggles or face shield (anti-fog), medical protective clothing, disposable gloves and disposable shoe covers or dedicated closed footwear as an effective intervention in the prevention of COVID-19 among health care workers in areas with possible direct patient care of confirmed or probable COVID-19  patients and possible performance of aerosol generating procedures. (Moderate quality of evidence; Strong recommendation)

You can find the Evidence Summary here.

Updated as of November 5, 2021

We suggest against requiring the use of face shields in addition to face masks among the general public in non-healthcare settings. (Very low certainty of evidence; Weak recommendation)

 We recommend the addition of face shields to face masks among the general public in areas with sustained community transmission of SARS-CoV-2.  (Very low certainty of evidence; Strong recommendation)

 We recommend the use of face shield plus medical face mask and standard personal protective equipment among health care workers not directly involved in the care of COVID-19 patients in areas with sustained community transmission of SARS-COV2. (Very low certainty of evidence; Strong recommendation)

You can find the Evidence Summary here.

We suggest against the use of protective physical barrier enclosures (ex. aerosol box) for the prevention of COVID-19 among health care providers who perform aerosol generating medical procedures*. (Very low quality of evidence; Conditional recommendation)

We suggest the use of protective physical barriers in the prevention of COVID-19 in areas where physical distancing cannot be adhered to (e.g., offices, reception desk)**. (Very low quality of evidence; Conditional recommendation)

*Proper PPEs should be used by health care providers when performing aerosol-generating procedures.
**Adequate ventilation, physical distancing, use of facemasks and personal hygiene should still be maintained to prevent COVID-19 infections. Regular cleaning and disinfection of physical barriers should be practiced.

You can find the Evidence Summary here.

We recommend the practice of cleaning and disinfecting surfaces using the appropriate disinfecting chemical agents such as 0.5% sodium hypochlorite solution (bleach) or 70% alcohol to prevent COVID-19 infection.
 
For high touch surfaces and high traffic areas, such as in the workplace, disinfection should be done before shift, intermittently during shift and after the shift.
 
For household disinfection, once daily disinfection on high touch surfaces is recommended.
 
(Low quality of evidence; Strong recommendation)

We recommend the use of carbon dioxide (CO2) monitors in enclosed spaces to guide actions to improve ventilation and reduce transmission of SARS-CoV-2. (Moderate certainty of evidence; Strong recommendation)

You can find the Evidence Summary here.

Updated as of 03 December 2021

There is no evidence to recommend the use of copper-containing over non-copper-containing masks to decrease SARS-CoV-2 transmission.

You can find the Evidence Summary here.

Updated as of 28 October 2021

We recommend the use of the following vaccines to prevent symptomatic SARS-CoV-2 infection in adults: (Moderate certainty of evidence; Strong recommendation)

  1. BNT162b2 (Pfizer/BioNTech) (given as 0.3ml (30ug) intramuscular injections, in 2 doses, 21 days apart)
  2. mRNA-1273 (Moderna) (given as 0.5ml (100ug) intramuscular injections, in 2 doses, 28 days apart)
  3. ChAdOx1 (AstraZeneca) (given as 0.5 ml (5 x 106 vp) intramuscular injections, in 2 doses, at least 12 weeks apart)
  4. Gam-COVID-Vac (Gamaleya) (given as rAd-26 0.5ml intramuscular injection, then rAd-5S 0.5 ml intramuscular injection 21 days after)
  5. COV2.S (Janssen/Johnson&Johnson) (given as 0.5ml single dose intramuscular injection)

We recommend the use of CoronaVac (Sinovac) (given as 0.5ml (600SU) intramuscular injection, in 2 doses, at 28 days apart) to prevent symptomatic SARS-CoV-2 infection among healthy adults(Low certainty of evidence; Strong recommendation)

We recommend the use of BNT162b2 (Pfizer/BioNTech), mRNA-1273 (Moderna), ChAdOx1 (Astrazeneca), Gam-COVID-Vac (Gamaleya) and Ad26.COV2.S (Janssen/ Johnson&Johnson) vaccines to prevent symptomatic SARS-CoV-2 infection in older adults (>64 year old)(Low certainty of evidence; Strong recommendation)

We suggest the use of CoronaVac (Sinovac) to prevent SARS-COV-2 infection in older adults (>60 years old) (Low certainty of evidence; Weak recommendation)

We recommend the use of BNT162b2 (Pfizer/BioNTech), mRNA-1273 (Moderna), ChAdOx1 (Astrazeneca), Gam-COVID-Vac (Gamaleya), CoronaVac (Sinovac) and Ad26.COV2.S (Janssen/ Johnson&Johnson) vaccines in pregnant and lactating women after consultation with a physician. (Very low certainty of evidence; Conditional recommendation)

We recommend the use of BNT162b2 (Pfizer/BioNTech), mRNA-1273 (Moderna), ChAdOx1 (Astrazeneca), Gam-COVID-Vac (Gamaleya) and Ad26.COV2.S (Janssen/ Johnson&Johnson) vaccines to prevent SARS-CoV-2 infection in adults who have stable medical comorbidities and are at risk for severe infection(Moderate certainty of evidence; Strong recommendation)

We suggest the use of CoronaVac (Sinovac) to prevent SARS-CoV-2 infection in adults who have stable medical comorbidities and are at risk for severe infection(Very low certainty of evidence; Conditional recommendation)

We recommend the use of BNT162b2 (Pfizer/BioNTech), mRNA-1273 (Moderna), ChAdOx1 (Astrazeneca), Gam-COVID-Vac (Gamaleya),CoronaVac (Sinovac) and Ad26.COV2.S (Janssen/ Johnson&Johnson) vaccines to prevent SARS-CoV-2 infection in immunocompromised patients (i.e., diagnosed with HIV, hepatitis B and C, those with cancer undergoing chemotherapy, transplant patients receiving immune-suppression) after medical clearance from a physician. (Low certainty of evidence; Strong recommendation)

We recommend against the use of these vaccines for those who have known allergies to the contents / excipients of the vaccine, such as polysorbate (ChAdOx1 (Astrazeneca), Gam-COVID-Vac (Gamaleya) and Ad26.COV2.S (Janssen/ Johnson&Johnson)) and polyethylene glycol or PEG200 DMG (BNT162b2 (Pfizer/BioNTech) and mRNA-1273 (Moderna)). (Moderate to high certainty of evidence; Strong recommendation)

**Recommendations for vaccination in children have been updated and can be found in a separate review

We recommend against the use of melatonin as prevention for COVID-19 infection. (Very low quality of evidence; Strong recommendation)

You can find the Evidence Summary here.

We recommend against the use of Vitamin D supplementation to prevent COVID-19 infection. (Very low quality of evidence; Strong recommendation)

You can find the Evidence Summary here.

We recommend against the use of zinc supplementation to prevent COVID-19 infection. (Very low quality of evidence; Strong recommendation)

We recommend against the use of HCQ for pre-exposure prophylaxis in adults who are at high risk of exposure to COVID-19 cases. (Moderate quality of evidence; Strong recommendation)

We recommend against the use of HCQ for post-exposure prophylaxis in adults who are exposed to COVID- 19 cases. (Low quality of evidence; Strong recommendation)

We recommend against the use of lopinavir/ritonavir for chemoprophylaxis in individuals exposed to COVID-19 patients. (Very low quality of evidence; Strong recommendation)

You can find the Evidence Summary here.

There is insufficient evidence to recommend the use of saline nasal irrigation (SNI) to prevent COVID-19 in healthy individuals. (Very low quality of evidence)

You can find the Evidence Summary here.

We recommend against the use of steam inhalation in the prevention of COVID-19. (Very low quality of evidence; Strong recommendation)

You can find the Evidence Summary here.

There is insufficient evidence to recommend the use of antiseptic mouthwash or gargle to prevent COVID- 19 in healthy individuals. (Very low quality of evidence)

You can find the Evidence Summary here.

We recommend against the use of ivermectin as COVID-19 prophylaxis for the general population. (Very low quality of evidence; Strong recommendation)

We recommend against the use of ivermectin for COVID-19 as post-exposure prophylaxis for household contacts of confirmed COVID-19 patients. (Very low quality of evidence; Strong recommendation)

We recommend against the use of ivermectin for COVID-19 as prophylaxis for healthcare workers. (Very low quality of evidence; Strong recommendation)

You can find the Evidence Summary here.

Updated as of November 4, 2021

We suggest the subcutaneous use of casirivimab + imdevimab as day 4 post-exposure prophylaxis for COVID-19 close contacts*, ages 12 years and above weighing at least 40 kilograms, who are at risk for severe disease or hospitalization**. (Moderate certainty of evidence; weak recommendation)

 **This includes the following people: elderly; BMI >25; those with chronic diseases such as hypertension, diabetes, and chronic kidney disease; those who are not expected to mount an adequate immune response to the vaccine due to immunosuppressive therapy or those in an immunocompromised state.

You can find the Evidence Summary here.

Updated as of October 28, 2021

  1. We recommend the use of the CoronaVac (Sinovac), given as (given as 0.5 mL (600SU) to prevent symptomatic SARS-CoV-2 infection in:
    • Healthy Adults (Low certainty of evidence; Strong recommendation)
    • Pregnant women in their first trimester after consultation with a physician (Very Low certainty of evidence; Strong recommendation)
    • Pregnant women in their 2nd and 3rd trimester and lactating women(Very Low certainty of evidence; Strong recommendation)
    • Adults who have medical comorbidities (including chronic respiratory disease and infection, cardiovascular disease, chronic kidney disease, cerebrovascular disease, diabetes mellitus, obesity, neurologic disorder, chronic liver disease and others like sickle cell disease, thalassemia, or Down’s syndrome, as per DOH guidelines dated April 5, 2021 on the A3 Priority Group) (Low certainty of evidence; Strong recommendation)
    • Immunocompromised patients after medical clearance from a physician (the immunocompromised include those diagnosed with HIV, hepatitis B and C, those with cancer undergoing chemotherapy, transplant patients receiving immunosuppression) (Low certainty of evidence; Strong recommendation)
  1. We suggest the use of CoronaVac (Sinovac) to prevent SARS-CoV-2 infection in older adults (>60 years old). (Low certainty of evidence; Weak recommendation)
  2. We suggest against the use of CoronaVac (Sinovac) to prevent SARS-CoV-2 infection in children (3 to 17 years old) (Very Low certainty of evidence; Weak recommendation)
  3. In areas where Delta is the predominant variant of concern, we recommend the use of CoronaVac (Sinovac)(Very Low certainty of evidence; Strong recommendation)
  4. Under the current context of low vaccine coverage and inadequate vaccine supply, we recommend against booster vaccination using CoronaVac (Sinovac) in the healthy, adult population (18 years old and above) (Low certainty of evidence; Strong recommendation)
  5. For immunocompromised patients who received primary CoronaVac (Sinovac) vaccination, we recommend for heterologous booster vaccination (Very Low certainty of evidence; Strong recommendation)

You can find the Evidence Summary here.

Updated as of November 4, 2021

  1. We suggest the use of the rAd26 (Sputnik Light), given as 1011vp per 0.5ml, single dose, intramuscularly to prevent symptomatic SARS-CoV-2 infection in:
    1. Healthy adults (Low certainty, Weak recommendation)
    2. Older adults (60 years and older) (Low certainty, Weak recommendation)
    3. Adults with comorbidities (Low certainty, Weak recommendation)
  2. We suggest against the use of rAd26 (Sputnik Light) to prevent symptomatic SARS-CoV-2 infection in:
    1. Children (3-17 years) (No evidence, Weak recommendation)
    2. Pregnant and lactating women (No evidence, Weak recommendation)
    3. Immunocompromised (No evidence, Weak recommendation)
  3. In areas where Alpha, Beta or Delta is the predominant variant of concern, we suggest the use of rAd26 (Sputnik Light) to prevent COVID-19 infection. (Very Low certainty, Weak recommendation)

You can find the Evidence Summary here.

Updated as of October 21, 2021

  1. We recommend the use of BBV152 (Covaxin/Bharat), 0.5 mL/dose, in a two-dose regimen, 28 days apart for the prevention of symptomatic COVID-19 infection in healthy adults. (Moderate certainty of evidence; Strong recommendation)
  2. We suggest the use of BBV152 (Covaxin/Bharat), 0.5 mL/dose, in a two-dose regimen, 28 days apart for the prevention of symptomatic COVID-19 infection:
    1. Adults who have stable medical co-morbidities and are at high risk for severe infection (Low quality of evidence; Weak recommendation)
    2. Healthy, older adults (>60 years old) (Low certainty of evidence; Weak recommendation)
    3. Pregnant and lactating women, after discussing with a physician (No direct evidence; Weak recommendation)
    4. Immunocompromised patients, after discussing with a physician (No direct evidence; Weak recommendation)
  3. We suggest against the use of BBV152 (Covaxin/Bharat) for the prevention of COVID-19 in children and adolescents. (No evidence; Weak recommendation)
  4. We recommend against the use of BBV152 (Covaxin/Bharat) in individuals who have known allergies to its contents/excipients. (Best practice statement)

You can find the Evidence Summary here.

Updated as of 27 December 2021

We suggest the following homologous booster vaccination regimen for the general adult population:

  1. BNT162b2 (Low certainty of evidence; Weak recommendation)
  2. mRNA-1273 (Low certainty of evidence; Weak recommendation)
  3. ChAdOx1 (Very low certainty of evidence; Weak recommendation)
  4. Cov2.S (Very low certainty of evidence; Weak recommendation)
  5. CoronaVac (Very low certainty of evidence; Weak recommendation)
  6. BBIBP-CorV (Very low certainty of evidence; Weak recommendation)

There is insufficient evidence to recommend the following homologous booster vaccination in the general population:

  1. Gam-COVID-Vac
  2. BBV152

We suggest the following heterologous booster vaccination regimen for the general adult population: 

  1. BNT162b2 primary, mRNA-1273 booster (Very low certainty of evidence; Weak recommendation)
  2. BNT162b2 primary, Ad26.CoV2.S booster (Very low certainty of evidence; Weak recommendation)
  3. mRNA-1273 primary, BNT162b2 booster (Very low certainty of evidence; Weak recommendation)
  4. mRNA-1273 primary, Ad26.CoV2.S booster (Very low certainty of evidence; Weak recommendation)
  5. ChAdOx1 primary, BNT162b2 booster (Very low certainty of evidence; Weak recommendation)
  6. COV2.S primary, BNT162b2 booster (Very low certainty of evidence; Weak recommendation)
  7. COV2.S primary, mRNA-1273 booster (Very low certainty of evidence; Weak recommendation)
  8. CoronaVac primary, BNT162b2 booster (Very low certainty of evidence; Weak recommendation)
  9. CoronaVac primary, ChAdOx1 booster (Very low certainty of evidence; Weak recommendation)
  10. BBIBP-CorV primary, BNT162b2 booster (Very low certainty of evidence; Weak recommendation)

There is insufficient evidence to recommend the use of the heterologous booster vaccination regimens other than the combinations included above in the general adult population.

We suggest the following homologous booster vaccination for the immunocompromised population:

  1. BNT162b2 (Very low certainty of evidence; Weak recommendation)
  2. mRNA-1273 (Low certainty of evidence; Weak recommendation)

There is insufficient evidence to recommend the following homologous booster vaccination for the immunocompromised population: 

  1. ChAdOx1
  2. CoV2.S
  3. CoronaVac
  4. Gam-COVID-Vac
  5. BBV152
  6. BBIBP-CorV

We suggest the following heterologous booster vaccination regimen for the immunocompromised population:

  1. an mRNA vaccine primary, another mRNA vaccine booster (Very low certainty of evidence; Weak recommendation)
  2. an mRNA vaccine primary, ChAdOx1 booster (Low certainty of evidence; Weak recommendation)
  3. BNT162b2 primary, mRNA-1273 booster Very low certainty of evidence; Weak recommendation)
  4. BNT162b2 primary, Ad26.CoV2.S booster Very low certainty of evidence; Weak recommendation)
  5. mRNA-1273 primary, Ad26.CoV2.S booster Very low certainty of evidence; Weak recommendation)

There is insufficient evidence to recommend the use of the heterologous booster vaccination regimen other than the combinations included above in the immunocompromised population.

You can find the Evidence Summary here.

Updated as of October 22, 2021

We recommend the use of heterologous COVID-19 vaccination for those with serious adverse event to the first dose. (Very low certainty of evidence; Strong recommendation)

We suggest the use of heterologous COVID-19 vaccination in the event of the unavailability of the second dose in the recommended schedule. (Very low certainty of evidence; Weak recommendation)

You can find the Evidence Summary here.

Updated as of October 21, 2021

We recommend the use of the BNT162b2 (Pfizer/BioNTech) vaccine, [given as 0.3 mL (30 ug) intramuscular injections, in 2 doses, 21 days apart] for children 12-15 years old to prevent symptomatic SARS-CoV-2 infection. (Moderate certainty of evidence; Strong recommendation)

We suggest the use of the mRNA-1273 (Moderna) vaccine, [given as 0.5 mL (100 ug) intramuscular injections, in 2 doses, 28 days apart] for children 12-17 years old to prevent symptomatic SARS-CoV-2 infection. (Low certainty of evidence; Weak recommendation)

We suggest against the use of Coronavac (Sinovac), [given as 0.5 mL (600 SU) intramuscular injection, in 2 doses, 28 days apart] for children 3-17 years old to prevent symptomatic SARS-CoV-2 infection. (No evidence; Weak recommendation)

You can find the Evidence Summary here.

Updated as of October 28, 2021 In areas where the Delta variant is the predominant circulating variant, we recommend for the use of the following vaccine to prevent symptomatic and severe COVID-19:
  1. 2 doses of BBV152 (Covaxin/Bharat) (Moderate certainty of evidence; Strong recommendation)
  2. 2 doses of BNT162b2 (Pfizer) (Low certainty of evidence; Strong recommendation)
  3. 2 doses of mRNA-1273 (Moderna) (Low certainty of evidence; Strong recommendation)
  4. 2 doses of ChAdOx1 (Astra Zeneca) (Low certainty of evidence; Strong recommendation)
  5. 2 doses of CoronaVac (Sinovac)(Very low certainty of evidence; Strong recommendation)
In areas where the Delta variant is the predominant circulating variant, we suggest the use of the following vaccines to prevent symptomatic and severe COVID-19:
  1. Ad26.CoV2 (Janssen) (Low certainty of evidence; Weak recommendation)
  2. Gam-COVID-Vac (Sputnik V) (Low certainty of evidence; Weak recommendation
You can find the Evidence Summary here.

Updated as of 02 December 2021

  1. We recommend the use of BBIBP-CorV (Sinopharm), given as 200U (WIV04) or 4ug (HBO2) in 0.5 ml in 2 doses, 21 days apart, to prevent symptomatic and asymptomatic COVID-19 infection among healthy adults (18 to 59 years old). (Moderate certainty of evidence; Strong recommendation)
  2. We suggest the use of BBIBP-CorV to prevent severe COVID-19 infection among healthy adults (18 to 59 years old). (Low certainty of evidence; Weak recommendation)
  3. We suggest the use of BBIBP-CorV to prevent symptomatic COVID-19 infection in the following:
    1. adults with comorbidities (Very low certainty of evidence; Weak recommendation)
    2. older persons (60 years and older) (Very low certainty of evidence; Weak recommendation)
  4. There is insufficient evidence to recommend for or against the use of BBIBP-CorV to prevent COVID-19 infection among the following:
    1. Children (3-17 years old) (Very low certainty of evidence)
    2. Immunocompromised population (Very low certainty of evidence)
    3. Pregnant and lactating women (Very low certainty of evidence)
  5. In areas where the SARS-CoV-2 variants of concern are prevalent, there is insufficient evidence to recommend for or against the use of BBIBP-CorV to prevent COVID. (Very low certainty of evidence)

You can find the Evidence Summary here.

Updated as of 27 December 2021

We suggest the use of NVX-CoV2373 (Novavax), given as 5ug (with 50ug Matrix M1 adjuvant) two doses, intramuscular, 21 days apart, for the prevention of symptomatic and severe SARS-CoV-2 infection in healthy adults. (Low certainty of evidence; Weak recommendation)

We suggest the use of NVX-CoV2373 (Novavax), given as 5ug (with 50ug Matrix M1 adjuvant) two doses, intramuscular, 21 days apart, for the prevention of symptomatic SARS-CoV-2 infection in older adults (>65 years old). (Low certainty of evidence; Weak recommendation)

We suggest the use of NVX-CoV2373 (Novavax), given as 5ug (with 50ug Matrix M1 adjuvant) two doses, intramuscular, 21 days apart, for the prevention of symptomatic SARS-CoV-2 infection in adults with comorbidities. (Moderate certainty of evidence; Weak recommendation)

We suggest against the use of NVX-CoV2373 (Novavax), for the prevention of symptomatic SARS-CoV-2 infection in the immunocompromised population (specifically HIV positive individuals). (Very low certainty of evidence; Weak recommendation)

We suggest against the use of NVX-CoV2373 for the prevention of symptomatic SARS-CoV-2 infection among pregnant and lactating women. (No direct evidence; Weak recommendation)

In areas where the Alpha variant is predominant, we suggest the use of the NVX-CoV2373 (Novavax) given as 5ug (with 50ug Matrix-M1 adjuvant), two doses, intramuscular, 21 days apart, to prevent symptomatic SARS-CoV-2 infection. (Low certainty of evidence; Weak recommendation)

In areas where the Beta variant is predominant, we suggest against the use of the NVX-CoV2373 (Novavax) to prevent symptomatic SARS-CoV-2 infection. (Low certainty of evidence; Weak recommendation)

There is insufficient evidence to recommend for or against the use of NVX-2373 for the prevention of symptomatic SARS-CoV-2 infection among children.

We recommend against the use of the NVX-CoV2373 (Novavax) in individuals who have known allergies to its contents/excipients, such as Matrix-M1. (Best practice statement)

You can find the Evidence Summary here.

Updated as of 27 December 2021

We suggest the use of following vaccines, after the first trimester, for the prevention of COVID-19 infection in pregnant and lactating women.

  1. BNT162b2 (Pfizer) (Low certainty of evidence; Weak recommendation)
  2. mRNA-1273 (Moderna) (Low certainty of evidence; Weak recommendation)
  3. ChAdOx1 (AstraZeneca) (No direct evidence; Weak recommendation)
  4. CoV2.S (Janssen/Johnson&Johnson) (No direct evidence; Weak recommendation)
  5. CoronaVac (Sinovac) (No direct evidence; Weak recommendation)
  6. BBIBP-CorV (Sinopharm) (No direct evidence; Weak recommendation)
  7. BBV152 (Covaxin) (No direct evidence; Weak recommendation)

We suggest against the use of the following vaccines for the prevention of COVID-19 infection in pregnant and lactating women:

  1. Gam-CoV-Vac (Sputnik V) (No direct evidence; Weak recommendation)
  2. NVX-2373 (Novavax) (No direct evidence; Weak recommendation)

You can find the Evidence Summary here.

There is insufficient evidence to recommend the use of zinc as adjunct treatment for patients with COVID- 19 infection both in the outpatient and in-patient setting. (Very low quality of evidence)

You can find the Evidence Summary here.

Updated as of 21 December 2021

There is insufficient evidence to recommend the use of vitamin C as adjunct treatment for patients with COVID-19 infection (Low certainty of evidence)

You can find the Evidence Summary here.

Updated as of 03 December 2021

There is insufficient evidence to recommend the use of Vitamin D supplementation as adjunct treatment for patients with COVID-19 infection (Very low certainty of evidence)

You can find the Evidence Summary here.

There is insufficient evidence to recommend the use of melatonin as adjunct treatment for patients with COVID-19 infection. (Very low quality of evidence)

You can find the Evidence Summary here.

There is no evidence to recommend the use of virgin coconut oil as adjunct treatment for patients with COVID-19 infection.

You can find the Evidence Summary here.

We recommend against the use of intravenous N-acetylcysteine as adjunct treatment for patients with COVID-19 infection. (Moderate quality of evidence; Strong recommendation)

You can find the Evidence Summary here.

We recommend continuing maintenance RAAS blockers for hypertension among patients with COVID-19 infection. (Moderate quality of evidence; Strong recommendation)

You can find the Evidence Summary here.

We suggest that ibuprofen may still be used as symptomatic treatment of patients with COVID-19 infection if clinically warranted. Concurrent use of ibuprofen is not associated with worsening of COVID-19 outcomes. (Very low quality of evidence; Conditional recommendation)

You can find the Evidence Summary here.

We suggest against the use of B vitamins as adjunct in the treatment of patients with COVID-19. (Very low quality of evidence; Conditional recommendation)

You can find the Evidence Summary here.

There is insufficient evidence to recommend the use of fatty acid supplements as adjunctive treatment for patients with COVID-19. (Low quality of evidence)

You can find the Evidence Summary here.

Updated as of October 29, 2021

There is no evidence to recommend Lagundi (Vitex negundo) as adjunctive treatment for patients with COVID-19 infection.

You can find the Evidence Summary here.

Updated as of October 29, 2021

There is no evidence to recommend Tawa-tawa (Euphorbia hirta) as adjunctive treatment for patients with COVID-19 infection.

You can find the Evidence Summary here.

Updated as of October 29, 2021

There is insufficient evidence to recommend statins as adjunctive treatment in patients with COVID-19. (Very low certainty of evidence)

You can find the Evidence Summary here.

Updated as of 03 December 2021

We suggest against the use of nasal spray as an adjunct to treatment of COVID-19 infection. (Low certainty of evidence, Weak recommendation)

You can find the Evidence Summary here.

Updated as of 9 March 2022

As an alternative specimen to nasopharyngeal swab, we recommend the use of saliva specimen for RT-PCR* among non-hospitalized children suspected of COVID-19 infection. (Moderate certainty of evidence, Strong recommendation)

*Nasopharyngeal swab is the specimen of choice for RT-PCR for the diagnosis of COVID-19 infection in children. The use of three specific saliva RT-PCR assays is recommended: Allplex 2019-nCOV assay, Cobas 6800, QuantStudio 7 system.

As an alternate specimen to nasopharyngeal swab, we suggest the use of mid-turbinate swab for RT-PCR* among non-hospitalized children suspected of COVID-19 infection. Moderate certainty of evidence, Weak recommendation)

* Nasopharyngeal swab is the specimen of choice for RT-PCR for the diagnosis of COVID-19 infection in children. The use of two specific mid-turbinate RT-PCR assays is recommended: RealStar SARS-CoV-2 RT-PCR kit or Aptima SAR-CoV-2 Assay.

 We suggest against the use of nasopharyngeal aspirate as an alternative clinical specimen among non-hospitalized children suspected of COVID-19 infection. (Moderate certainty of evidence, Weak recommendation)

You can find the Evidence Summary here.

Updated as of 2 March 2022

We suggest against the routine use of anticoagulation in children with COVID-19 infection or MIS-C. (Very low certainty of evidence, Weak recommendation)

You can find the Evidence Summary here.

Updated as of 28 February 2022

We suggest the use of systemic corticosteroids (dexamethasone) among children with severe and critical COVID-19 infection. (Very low certainty of evidence, Weak recommendation)

You can find the Evidence Summary here.

Updated as of 28 February 2022

We suggest against the routine use of intravenous immunoglobulin for children with COVID-19 infection. (Very low certainty of evidence, Weak recommendation)

You can find the Evidence Summary here.

Updated as of 9 March 2022

There is insufficient evidence to recommend the use of casirivimab plus imdevimab as treatment of non-hospitalized children with COVID-19 infection with ≥1 risk factor* for severe COVID-19. (Low certainty of evidence)

*The risk factors are obesity, cardiovascular disease (including hypertension), chronic lung disease (including asthma), chronic metabolic disease (including diabetes), chronic kidney disease (including receipt of dialysis), chronic liver disease, and immunocompromised conditions.

There is insufficient evidence to recommend the use of casirivimab plus imdevimab as treatment of hospitalized children with COVID-19 infection with ≥1 risk factor* for severe COVID-19. (Very low certainty of evidence)

*The risk factors are obesity, cardiovascular disease (including hypertension), chronic lung disease (including asthma), chronic metabolic disease (including diabetes), chronic kidney disease (including receipt of dialysis), chronic liver disease, and immunocompromised conditions.

There is insufficient evidence to recommend the use of bamlanivimab plus etesevimab as treatment of non-hospitalized children with COVID-19 infection with ≥1 risk factor* for severe COVID-19. (Low certainty of evidence)

*The risk factors are obesity, cardiovascular disease (including hypertension), chronic lung disease (including asthma), chronic metabolic disease (including diabetes), chronic kidney disease (including receipt of dialysis), chronic liver disease, and immunocompromised conditions.

There is insufficient evidence to recommend the use of sotrovimab as treatment of non-hospitalized children with COVID-19 infection. (Low certainty of evidence)

We suggest against the use of sotrovimab as treatment of hospitalized children with COVID-19 infection. (Low certainty of evidence, Weak recommendation)

We suggest against the use of amubarvimab plus romlusevimab as treatment of children with COVID-19 infection. (Low certainty of evidence, Weak recommendation)

We suggest against the use of regdanvimab as treatment of children with COVID-19 infection. (Low certainty of evidence, Weak recommendation)

You can find the Evidence Summary here.

Updated as of 2 March 2022

We suggest the use of remdesivir in hospitalized children with severe COVID-19 infection. (Very low certainty of evidence, Weak recommendation)

We suggest the use of remdesivir in non-hospitalized children with COVID-19 infection with at least one (1) risk factor* for disease progression. (Low certainty of evidence, Weak recommendation)

*The risk factors for disease progression are hypertension, cardiovascular or cerebrovascular disease, diabetes mellitus, obesity, immune compromise, chronic mild or moderate kidney disease, chronic liver disease, chronic lung disease, current cancer or sickle cell disease.

You can find the Evidence Summary here.

Updated as of 2 March 2022

We suggest the addition of tocilizumab to systemic steroids in patients with moderate to severe COVID-19 infection, particularly where there is evidence of systemic inflammation. (Very low certainty of evidence, Weak recommendation)

You can find the Evidence Summary here.

Updated as of 28 February 2022

We suggest against the routine use of vitamin C for the prevention of COVID-19 infection in children. (Very low certainty of evidence, Weak recommendation)

You can find the Evidence Summary here.

Updated as of 23 February 2022

We suggest against the routine use of vitamin D for the prevention of COVID-19 infection in children. (Very low certainty of evidence, Weak recommendation)

You can find the Evidence Summary here.

Updated as of 28 February 2022

We suggest against the routine use of zinc for the prevention of COVID-19 infection in children. (Low certainty of evidence, Weak recommendation)

You can find the Evidence Summary here.

Updated as of 23 February 2022

We suggest against the use of vitamin C as adjunctive treatment for COVID-19 infection in children. (Very low certainty of evidence, Weak recommendation)

You can find the Evidence Summary here.

Updated as of 23 February 2022

We suggest against the use of vitamin D as adjunctive treatment for COVID-19 infection in children. (Very low certainty of evidence, Weak recommendation)

You can find the Evidence Summary here.

Updated as of 28 February 2022

We suggest against the use of zinc as adjunctive treatment for COVID-19 infection in children. (Low certainty of evidence, Weak recommendation)

You can find the Evidence Summary here.

Updated as of 9 March 2022

We recommend the implementation of supportive strategies* to optimize mental health among children and adolescents during the COVID-19 pandemic. (Low certainty of evidence, Strong recommendation)

*Supportive strategies for mental health during the COVID-19 pandemic include psychological counseling, physical and leisure activities (outdoor and online exercise platforms, art and dance), mindfulness meditation training, personal and spiritual coping, strengthening social support and connecting online with peers, and health-promoting activities.

You can find the Evidence Summary here.

Updated as of 9 March 2022

We recommend a multi-layer approach using multiple non-pharmacologic interventions* in school settings to limit transmission of COVID-19 in schools. (Very low certainty of evidence, Strong recommendation)

*The non-pharmacologic interventions are wearing of masks of students, physical distancing, engineering controls (ventilation, personal hygiene and handwashing, disinfection of surfaces), administrative controls (blended learning, phased reopening, no/reduced mixing of classes, restriction of class size, minimized or staggered breaks, symptom monitoring, self-quarantine, contact tracing, and early testing).

You can find the Evidence Summary here.