Dealing with the COVID-19 pandemic, for all of us in the healthcare industry, has not only been a very challenging experience but also an enriching one. It has taught us how fallible we could be when dealing with a new disease. As is the practice in any pandemic, guidelines are issued by various scientific and regulatory bodies to help us manage the disease.
In this pandemic too, various guidelines have been put forth by national bodies like Indian Council of Medical Research (ICMR), Directorate General of Health Services (DGHS) and international ones like World Health Organization (WHO), Centers for Disease Control and Prevention (CDC) of the USA and others. We need to realise and be aware that these guidelines are not written in stone, they are not always gospel truths and may turn out to be erroneous as we learn more about the disease and this is what has happened in this instance too.
Just to give a few examples, initially many scientific bodies including the WHO thought that there is no human to human transmission of this virus and no aerosol spread, and therefore masking may not be needed for everyone. All of these turned out to be erroneous once we learnt more about the disease.
There were also multiple guidelines about the prevention and treatment of this disease in the initial phases, including a huge clamour for the use of hydroxychloroquine both for prevention and treatment of the disease; Vitamin D, Vitamin C and Zinc to boost your immunity; use of antibiotics like doxycycline, azithromycin, antiviral drug like Oseltamivir and antiparasitic agent Ivermectin. However, these did not withstand scientific scrutiny over a period of time and have all been withdrawn from the recommendations currently.
There were also very strong recommendation/guidelines to use Remdesivir, plasma therapy and an immunosuppressant monoclonal antibody Tocilizumab, which later on were either modified or withdrawn. Unfortunately, some of these recommendations and some misinterpretation of these recommendations led to a severe shortage of these drugs, resulting in hoarding and black marketing by unsavoury elements in the society.
Based on all these experiences, the million-dollar question that arises in one’s mind is, ‘What is the role of guidelines in a pandemic like this?’
My response to this would be that there certainly is a role for guidelines but with certain caveats, which are:
1. The guidelines issued by various scientific bodies and regulatory authorities are based on the knowledge they have at the time the guideline was issued.
2. In any new disease, the information and the knowledge about the disease could change very rapidly as we have seen in this pandemic and as new data comes up, the old guidelines maybe invalid or need to be modified/changed. Hence, frequent changes in the guidelines are required based on scientific data which is what has happened in the case of COVID-19 too.
The medical community must be aware that this is a dynamic process and should keep itself updated on the current guidelines and make the necessary changes in the management protocol accordingly.
3. We need to realise that guidelines are very important tools for uniformity in the management of a given disease at a given time but certainly not a mandate for what should be done. As a treating doctor, clinical decision on the right management of the patient should be taken along with the guidelines, in determining the appropriate management of a given individual.
4. It is also important that when we follow the guidelines it has to be done in a very specific manner and meticulous detail about the use of a specific drug, the timing, dose and duration need to be taken into consideration and deviation from this could lead to serious problems. A specific example of this was the indiscriminate use of steroids with disregard for the specifics noted in the guidelines, which unfortunately induced diabetes in some people, worsened it in others and had a role in triggering the epidemic of Mucormycosis in the aftermath of the second wave of COVID.
As long as we realise these caveats, guidelines are certainly an important tool given by the scientific and regulatory authorities to guide the healthcare workers in the right management of the disease at that particular time. But they should certainly not be considered gospel truth that will never change.