Managing therapeutic uncertainty in the COVID-19 pandemic: rapid evidence syntheses and transparent decision-making

The outbreak of the COVID-19 pandemic posed challenges to the practice of evidence-informed decision-making. Soon after the index case was identified in South Africa, the first local clinical guidelines were developed, reliant on preliminary evidence. Quick decisions were essential to inform practice and procurement at a time of exceptional global demand for medicine supply. This chapter describes how a rapid review mechanism was implemented to enable the development of evidence-informed and context-specific clinical treatment and prevention recommendations for COVID-19 in South Africa. The chapter reflects on the extent to which there is evidence for the implementation of these recommendations in clinical practice, using medicinesutilisation data from the public sector. In order to manage the ‘infodemic’ of research evidence of variable quality, a robust mechanism of rapid evidence review, transparent decision-making, and dissemination of trustworthy, accurate and context-specific recommendations was developed. Rapid evidence syntheses were produced by a sub-committee of the National Essential Medicines List Committee, supported by the South African GRADE Network and SAMRC Cochrane Centre. A generic rapid review protocol was developed, relying on GRADE principles and an evidence-to-decision framework. Consensus recommendations informed the National Department of Health/National Institute for Communicable Diseases clinical guidelines. Reviews were published on the National Department of Health website to advance transparency and were updated as new evidence emerged. Medicinesutilisation data showed increased use of corticosteroids, but there was also evidence of increased use of medicines not recommended. Further investment in technical capacity and support is needed to strengthen implementation, monitoring, and evaluation of clinical guidelines.