Academics have been fervently working to uncover trustworthy scientific evidence on which to base COVID-19 treatment protocols and business response recommendations. ReedGroup’s MDGuidelines, publishers of the evidence-based occupational medicine practice guidelines independently researched and developed by the American College of Occupational and Environmental Medicine (ACOEM), announced this week its publication of the very first evidence-based medicine (EBM) practice guidelines for Coronavirus (COVID-19) for occupational health. MDGuidelines has made the guideline available free of charge.
The announcement comes at a critical time as state jurisdictions fight to mitigate the pandemic’s effects on their respective economies and workforces. The ACOEM guidelines are adopted, in whole or in part, as the presumptively correct standards for treating occupational-related injuries and illnesses in two of the nation’s hardest-hit markets, California and New York.
Dr. Avrom Gart, Risico Total Managed Care’s Medical Director states, “The new ACOEM guideline on Coronavirus (COVID-19) is important to Occupational Medicine because it establishes a starting point in writing for medical providers to consider. There is too much opinion in the public domain about what could work, or should work, but nothing that provides a transparent base of evidence. At the end of the day, individuals diagnosed with COVID-19 will have to consult and listen to their doctor for the best course of care.”
A Guideline for All Stakeholders
The guideline’s intended audience includes, occupational and other physicians, health care professionals, insurers, employers, attorneys, non-occupational specialists, and all other stakeholders in worker health and workers’ compensation systems. Guidance provided in the guideline for these groups includes information pertinent to contagiousness, incubation, clinical presentation, mortality rates and more.
Employers throughout the country may be particularly interested in the employer considerations section of the guideline. The guidance provided here includes recommendations related to employee contact, general principles and recommended planning for businesses.
ACOEM’s guideline also dives into disability considerations qualifying its findings by stating that while disability will be better defined with studies to come over time, there are major concerns based on preliminary data and information from analogous diseases. In other words, we are still learning about COVID-19’s disability and recovery expectations which will need much attention.
The guideline points out that there are no quality data on disability for patients without hospitalization and estimates recovery from post-infection fatigue to take about two to three weeks for mild cases. For patients with mild to moderate pneumonia treated with oxygen supplementation, recovery is estimated to take four to eight weeks after hospitalization or clinical recovery.
The prognoses for severe pneumonia and acute respiratory distress syndrome (ARDS) are much worse. Approximately 50% of survivors may be projected to not return to work within a year of survival of the acute infection, based on prior experience from diseases that have similar symptoms as ARDS.
Hydroxychloroquine for Treatment of COVID-19
A debate around the use of hydroxychloroquine for the treatment of COVID-19 has developed in the media. Outlets have published concerns about the drug’s potentially dangerous side effects, including sudden death. The drug’s prominence in the public domain came after President Trump expressed confidence in the drug as a promising treatment option for COVID-19.
ACOEM’s new COVID-19 guidelines lists hydroxychloroquine as a “Recommended” treatment of COVID-19 for “select patients”. The recommendation’s Strength of Evidence is listed as Level C, describing the limited evidence-base with at least one randomized study of moderate quality.
The rationale for ACOEM’s recommendation of the drug for select patients is due to the quality evidence available for the efficacy of chloroquines (especially hydroxychloroquine) for the treatment of COVID-19. ACOEM qualifies that the medications are low cost, and adverse effects are minor for short courses of treatment at commonly used doses. Based on the available limited evidence, earlier treatment appears to be important for efficacy versus administering with treatment in an ICU after viral replication has ceased, according to the guideline.
Patients who may be good candidates include those who are moderately to severely affected with COVID-19. However, ACOEM found that there is no quality evidence supporting the drug’s efficacy when used after ARDS is established.
Patients with multiple comorbidities, such as diabetes, cardiovascular disease, COPD may also benefit from the use of hydroxychloroquine when administered early and the effects of COVID-19 are milder but worsening.
This along with other treatment considerations are included in the guideline. ACOEM’s recommendations, or non-recommendation, of specific treatment protocols are substantiated by the studies considered and the scoring of those studies. These elements provide the transparency required by a trustworthy EBM development process.
The Development of the COVID-19 Guideline
ACOEM’s EBM Practice Guidelines are developed in compliance with the Institute of Medicine’s (IOM) Standards for Developing Trustworthy Clinical Practice Guidelines and Appraisal of Guidelines for Research and Evaluation (AGREE). Pursuant to these standards, the development of the guidelines includes the use of various teams and panels throughout the process.
A critical part of each guidelines’ development process is the designation of the Evidence-based Practice Panel. Pertinent to COVID-19, the panel members represent expertise in occupational medicine, internal medicine, pulmonary medicine, and infectious disease. ACOEM’s complete development methodology is available on its website.
MDGuidelines’ ability to produce high-quality EBM guidelines so quickly is a monumental undertaking. Generally speaking, a trustworthy, high-quality EBM guideline can take up to two years to develop and to publish comprehensive content updates according to emerging research.
Provided that MDGuidelines and ACOEM can remain agile with updates to this guideline, this trustworthy EBM Coronavirus (COVID-19) guideline, and its subsequent updated versions, will be an immensely useful tool for users around the globe involved in health and business recovery efforts.