Table 1 The ten Choosing Wisely for COVID-19 recommendations

From: Choosing Wisely for COVID-19: ten evidence-based recommendations for patients and physicians

  Recommendation Comments Refs.
For the general public
1 Do use well-fitting masks appropriately, whenever in public A systematic review and meta-analysis of 10 adjusted (n = 2,647) and 29 unadjusted (n = 10,170) observational studies showed that the risk of infection was significantly reduced with facemasks (adjusted odds ratio (aOR), 0.15, and 95% confidence interval (CI), 0.07–0.34, for adjusted studies; odds ratio (OR), 0.34, and 95% CI, 0.26–0.45, for unadjusted studies). N95 masks were associated with greater reductions in risk than were surgical or other masks. Double masking is preferable to single masking unless the masks are N95. 4
2 Do avoid crowded places, especially while indoors A systematic review and meta-analysis of 9 adjusted (n = 7,782) and 29 unadjusted (n = 10,736) observational studies showed that the risk of infection was significantly reduced with physical distancing of >1 meter (aOR, 0.18, and 95% CI, 0.09–0.38, for adjusted studies; OR, 0.30, and 95% CI, 0.20–0.44, for unadjusted studies). The more the physical distancing was, the lower the chance of infection was. Maintaining adequate ventilation by opening doors and windows is an important measure for decreasing the spread of infection. 4
3 Do get tested if you have symptoms of COVID-19, and isolate yourself at home if symptoms are mild Early testing and isolation at home are advisable if someone has symptoms of COVID-19, such as fever, sore throat, cough, loss of smell and/or taste. Testing enables a test-trace-isolate strategy, which is effective in controlling further spread. If someone has these symptoms and does not have access to reliable test facilities, syndromic diagnosis can be done. Most patients can be managed at home and recover well with regular monitoring of temperature and oxygen saturation. The only interventions required are maintaining hydration (plenty of oral fluids) and acetaminophen (paracetamol) for fever and body aches. 5,6
4 Do seek medical help if you have difficulty breathing, or your oxygen saturation drops to less than 92% Patients who are breathless at rest or after exercise, or those with oxygen saturation of <92% or those with a drop of >4% in oxygen saturation after an exercise testa should seek medical help and should be appropriately triaged for medical treatment in hospital and non-hospital settings. Lying down in a prone position will help to improve oxygen saturation. 6,7
5 Do get vaccinated as soon as you are eligible, and even if you have had COVID-19 in the past Several randomized trials have demonstrated the efficacy of various approved vaccines in preventing infection with SARS-CoV-2 and serious illness and mortality due to COVID-19. Vaccination remains an extremely effective population-level strategy for the prevention and mitigation of COVID-19. This recommendation applies even if someone has had COVID-19 in the past. 8
For healthcare workers
6 Do not prescribe unproven or ineffective therapies for COVID-19 There are no data at present to support the use of favipiravir, ivermectin, azithromycin, doxycycline, oseltamivir, lopinavir–ritonavir, hydroxychloroquine, itolizumab, bevacizumab, IFN-α2b, fluvoxamine, convalescent plasma or herbal preparations in the treatment of COVID-19. None of these are currently recommended by the WHO. This list will need to be revised as new evidence emerges. 6,7,9
7 Do not use drugs like remdesivir and tocilizumab except in specific circumstances where they may be of use Tocilizumab is useful only in patients who are severely ill, are receiving steroids, have signs of inflammation, and have rapidly increasing requirements for oxygen. Use in other clinical situations is not beneficial and is probably harmful. Remdesivir has marginal efficacy in shortening the time to recovery in adults when given early to patients requiring oxygen in some trials, but not in others. It does not decrease mortality and is not indicated in other clinical situations. 6,7,9
8 Do use steroids prudently only in patients with hypoxia, and monitor blood sugar levels to keep them in the normal range Randomized trials have shown benefit with a short-duration (5- to 10-day) use of steroids such as Dexamethasone (6 mg per day) in patients with COVID-19 who require oxygen. The sicker the patient is, the greater the benefit is. Other steroid equivalents such as methylprednisolone (16 mg twice daily) or prednisolone (20 mg twice daily) may be used. Steroids do not benefit and might harm patients who do not require oxygen. There are no data to support the use of steroids for a longer duration (>10 days) or a higher dose of steroids. It is important to maintain glycemic control in patients on steroids to reduce the risk of secondary fungal infections such as mucormycosis. There is no need to taper steroids after use for 5–10 days. 6,7,9
9 Do not routinely perform investigations that do not guide treatment, such as CT scans and inflammatory biomarkers There are no data to support the routine use of CT chest scans, CT scores or inflammatory biomarkers such as ferritin, IL-6, LDH and procalcitonin to grade the severity of COVID-19 or to guide treatment protocols. 6,7
10 Do not ignore the management of critical non–COVID-19 diseases during the pandemic Several studies have shown that the care of illnesses such as cancer, tuberculosis and cardiac and renal disease, and conditions such as mental health, childbirth, perinatal care and childhood immunization, has suffered during the pandemic. This has serious implications on their outcomes. Essential healthcare services should continue to be provided during any pandemic. For example, it is estimated that suspension of cancer services will result in more deaths than those due to COVID-19 during the pandemic. 10
  1. IFN, interferon; WHO, World Health Organization; CT, computed tomography; IL, interleukin; LDH, lactate dehydrogenase. aExamples of an exercise test include a 1-minute sit-and-stand test or a 6-minute walk test.