Updated November 15, 2021 (Version changelog.)

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 DOH Ahead Program through the DOST-Philippine Council for Health Research and Development (PCHRD). 

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.

Click on the interventions below to see the recommendations.

Screening and Diagnosis

We suggest an initial screen for COVID-19 by checking for any influenza-like illness symptoms and typical COVID-19 symptoms* within the past 14 days in apparently healthy adults. (Low quality of evidence; Conditional recommendation)
 
Symptoms include fever, cough, sore throat, runny nose, myalgia, headache, fatigue/malaise, diarrhea, nausea/vomiting, anosmia, ageusia, shortness of breath/dyspnea.

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 recommend the use of rapid antigen test under all these conditions in patients suspected of COVID-19 infection: (Moderate quality of evidence; Strong recommendation)

  • Symptomatic AND
  • Early phase </=7 days from onset of symptoms AND
  • Specific brands that demonstrated sensitivity ≥80% and have very high specificity (≥97-100%))

We recommend against the use of saliva as specimen for rapid antigen test in patients suspected of COVID- 19infection. (Moderate quality of evidence; Strong recommendation)

We recommend against the use of rapid antigen test alone in diagnosing COVID-19 in asymptomatic patients suspected of COVID-19 infection. (Moderate to high quality of evidence; Strong recommendation)

You can find the Evidence Summary 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.

We suggest using antibody tests with high sensitivity and specificity (e.g., total antibody or IgG assays, ELISA, ECLIA) to determine COVID-19 seroprevalence among adults (Very low quality of evidence; Conditional recommendation).

We recommend against using antibody tests detecting IgM to determine COVID-19 seroprevalence among adults (Very low quality of evidence; Strong recommendation).

We recommend against using rapid antibody tests (e.g., LFIA) to determine COVID-19 seroprevalence among adults (Very low quality of 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.

We recommend the use of symptom-based strategy for the discontinuation of isolation and return to work clearance of the following:

  1. Asymptomatic adults who are not severely immunocompromised if they fulfill the following (Very low quality of evidence; Strong recommendation):
    • remained asymptomatic throughout their infection
    • 10 days have passed from the first positive viral diagnostic test (RT-PCR or rapid antigen)
  2. Adults who had mild to moderate COVID-19 who are not severely immunocompromised if they fulfill the following (Very low quality of evidence; Strong recommendation)
    • Afebrile for at least 24 hours without use of antipyretic medications
    • Respiratory symptoms have improved (cough, shortness of breath)
    • 10 days have passed from symptom onset
  3. Adults who had severe to critical COVID-19 who are not severely immunocompromised if they fulfill the following (Very low quality of evidence; Strong recommendation)
    • Afebrile for at least 24 hours without use of antipyretic medications
    • Respiratory symptoms have improved (cough, shortness of breath)
    • 21 days have passed from symptom onset
 

A repeat negative RT-PCR test is no longer needed for discharge of immunocompetent patients with probable or confirmed COVID-19 regardless of severity, because, in most cases, it results in prolonged isolation of patients who continue to shed detectable SARS-CoV-2 RNA but are no longer infectious.

We suggest test-based strategy using RT-PCR for the discontinuation of isolation and return to work clearance of the following:
1. Severely immunocompromised adults
2. Health care workers
if they fulfill the following:

    • Afebrile for at least 24 hours without use of antipyretic medications
    • Respiratory symptoms have improved (cough, shortness of breath)
    • With at least one negative RT-PCR test of a respiratory specimen

(Very low quality of evidence; Conditional recommendation)

Severely immunocompromised: Ongoing chemotherapy for cancer, or within one year from receiving a hematopoietic stem cell or solid organ transplant; untreated HIV infection with CD4 count < 200, combined primary immunodeficiency disorder, and receipt of prednisone >20mg/day for more than 14 days, may cause a higher degree of immunocompromised and require actions such as lengthening the duration of work restrictions. Other less immunocompromising conditions include advanced old age, DM, CKD. The degree of immunocompromise is determined by the health care provider, and preventive actions are adapted to each individual and situation.

You can find the Evidence Summary  here.

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

We suggest Chest x-ray to facilitate rapid triage, infection control and clinical management among any of the following:

  • 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

(Very low quality of evidence, Conditional recommendation).

You can find the Evidence Summary  here.

We suggest against routine use the 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 and with timely results. (Very low quality of evidence, Conditional recommendation).

If RT-PCR test 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:

    • Mild COVID-19 patients who are at risk for progression

    • Moderate to severe COVID-19 patients

(Very low quality of evidence, Conditional recommendation).

You can find the Evidence Summary  here.

We suggest against the use of lung ultrasound alone in diagnosing patients with suspected COVID-19 infection. (Low quality of evidence, Conditional recommendation).

You can find the Evidence Summary  here.

To guide the decision to admit patients with COVID-19 to the hospital:
We suggest the use of the following scoring systems:

  • 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 quality of evidence; Conditional recommendation) 

There is insufficient evidence to recommend the use of the 4C Mortality Score, COVID Outcome Prediction in the Emergency Department (COPE) model, and Quick Sepsis-related Organ Failure Assessment (qSOFA) score. (Very low quality of evidence)
 
To guide in the expectant monitoring of hospitalized patients:
We suggest the use of the 4C Deterioration model. (Low quality of evidence; Conditional recommendation)

There is insufficient evidence to recommend the use of the Modified Early Warning Score (MEWS) and National Early Warning Score 2 (NEWS2) scoring systems. (Very low quality of evidence)

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

You can find the Evidence Summary  here.

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 quality 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.

Treatment

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.

We recommend against the use of azithromycin among patients with COVID-19 infection. (Moderate quality 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)

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.

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

You can find the Evidence Summary here.

We recommend against the use of ivermectin for the treatment of patients with severe and critical COVID-19 (Very low quality of evidence; Strong recommendation)

We suggest against the use of ivermectin in the treatment of patients with mild-to-moderate COVID-19 (Very low quality of evidence; Conditional recommendation)

We suggest against the use of ivermectin combined with doxycycline for the treatment of patients with COVID-19 (Very low quality of evidence; Conditional 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.

We suggest against the use of interferon in the treatment of hospitalized patients with moderate to critical COVID-19 (Very low quality of evidence; Conditional recommendation)

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 12 October 2021

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

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

*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 November 8, 2021

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

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)

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)

Critical Care and Respiratory Management

We recommend the use of dexamethasone in patients with COVID-19 infection who require supplemental oxygenation (i.e., including high-flow device, non-invasive, invasive mechanical ventilation and ECMO). (High quality of evidence; Strong recommendation)

We recommend against the use of systemic corticosteroids among patients with COVID-19 infection who do not require oxygen supplementation. (Moderate to high quality of evidence; Strong recommendation)

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)  

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)

There is insufficient evidence on the use of hemoperfusion at this time among patients with COVID-19 infection. (Very low quality 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)

We suggest the use of high-flow nasal cannula oxygenation rather than non-invasive ventilation (e.g., helmet CPAP, mask NIV) in patients with COVID-19 infection and acute hypoxemic respiratory failure who do not respond to conventional oxygen therapy. (Very low quality of evidence; Conditional recommendation)

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)

We suggest the use of VV-ECMO for judiciously selected COVID-19 patients with severe ARDS based on the ELSO criteria (Very low quality of evidence; Conditional recommendation)

There is insufficient evidence to recommend the use of hyperbaric oxygen therapy for the management of COVID-19 patients (Very low quality of evidence)

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)

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)

Non-Pharmacologic Interventions

We recommend that healthcare workers not directly taking care of COVID-19 patients, and other persons with high risk of exposure to COVID-19 should use properly fitted surgical masks instead of cloth masks. (Moderate quality of evidence; Strong recommendation)

We suggest using a cloth mask that fits snugly on the face and made of at least two layers of cotton (e.g., t- shirt fabric) or non-woven nylon with aluminum nose bridge by the general public with low risk of exposure to COVID-19 in outdoor or indoor areas to prevent COVID-19 infections (Low quality of evidence; Conditional 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)

Vaccines and Prophylactic Interventions

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 October 28, 2021

  1. Under the current context of low vaccine coverage and inadequate vaccine supply, we recommend against booster vaccination in the healthy, adult population (18 years old and above) (Very low certainty of evidence; Strong recommendation)
  2. We suggest homologous booster vaccination in the immuno-compromised population for the following vaccines:
    1. BNT162b2 (Very low certainty of evidence; Weak recommendation)
    2. mRNA-1273 (Very low certainty of evidence; Weak recommendation)
  3. For immunocompromised patients who received primary vaccination of any kind, we recommend for the use of heterologous vaccination.(Very low certainty of evidence; Strong recommendation)

NOTE: No consensus was reached on the recommendation regarding the use of homologous vaccination for immunocompromised patients who received primary vaccination with ChAdOx1 (AstraZeneca), CoronaVac (Sinovac), Gam-COVID-Vac (Sputnik) or Ad26.COV2.S (J&J/Janssen).

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.

Adjunct Interventions

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.

There is insufficient evidence to recommend the use of intravenous Vitamin C as adjunct treatment for patients with COVID-19 infection. (Low quality of evidence)

You can find the Evidence Summary here.

There is insufficient evidence to recommend the use of Vitamin D supplementation as adjunct treatment for patients with COVID-19 infection. (Low to very low quality 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.

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

We suggest the use of ABC2-SPH, CURB-65, RISE-UP, and REMS. (Low quality of evidence; Conditional recommendation)

There is insufficient evidence to recommend the use of 4C Mortality score, COPE, and qSOFA. (Very low quality of evidence)

To guide in the expectant monitoring of hospitalized patients:
We suggest the use of the 4C Deterioration. (Low quality of evidence; Conditional recommendation)

There is insufficient evidence to recommend the use of MEWS and NEWS2 models. (Very 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.

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.

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)