In February 2020, when a new coronavirus first started driving patients into the Hôpitaux Universitaires de Genève (HUG, Geneva University Hospitals), Switzerland’s biggest university hospital, doctors noted that some of them seemed confused.
“Patients had acute neurological symptoms, so we consulted local neurologist, whose first reactions, understandably, were, ‘wait, it’s a respiratory disease, not a neurological condition’. — but because we all worked so closely and discussed openly, just few weeks later, the neurological symptoms became clear,” said Prof. Dr Thomas Agoritsas, an internist at HUG and expert on health research methodology, who is also part of a methods core team at WHO that advises on guidelines.
From there on, things moved quickly. “We got in the mode, ‘let’s gather the data, let’s publish the data, let’s provide solutions’,” he said.
It was just one of many examples he and colleague Dr Frédérique Jacquerioz, a tropical medicine and public health specialist at HUG, can recount of how crucial collaboration within and beyond national borders and across disciplines was. It made it possible for those involved in identifying, preventing and treating the novel virus to rapidly share and shape knowledge and guidance on what was fast becoming a world-changing pandemic.
Both became involved in a HUG guideline panel of experts from all the key divisions, departments and laboratories that gathered twice a week during the peak of the crisis, then regularly after. The panel examined the evidence at each stage, and issued local recommendations on how to respond. It would go on to issue 1,084 documents over the coming months, regularly updating them with new knowledge.
That local process complemented and fed into one that was taking place at the international level, convened by the World Health Organization, to produce guidance based on the best available data and research, which would shape the response to COVID-19 across the world. The WHO-led global consultation allowed HUG experts to participate in a global network of clinicians sharing experiences and observations.
Daily discussions of HUG experts from a broad range of specialties, to share best practices. © Louis Brisset/HUG
“We work with professional experts and institutes all around the world through our clinical network. When COVID-19 happened, we could quickly activate this network, which included many people who had partnered with WHO in the past, including the doctors at HUG, to come together and share information early on within that network, and then consistently ever since,” said Dr Janet Diaz, Clinical Management lead at WHO.
Advice from the future in an unfolding pandemic
“It was really fascinating to have the consultation internally at HUG with this guidelines group, because we needed to know how to respond immediately. In the same time, it was priceless to get involved in a parallel global process, being able to share with WHO and other clinicians around the world. That gave us perspectives from countries that had more limited resources or were at a more advanced stage in the pandemic,” said Dr Jacquerioz, a long-time collaborator with the WHO on emerging infectious diseases, who, in the era of COVID-19, is in charge of the hospital’s testing centres and, more recently, its vaccination centre, and has worked in the field during the 2014 Ebola outbreak in Africa.
Dr Frédérique Jacquerioz, a tropical medicine specialist and expert in public health at HUG at the vaccination centre. ©Louis Brisset/HUG
Italy, for example, conveyed valuable clinical advice early on in March , as COVID-19 overwhelmed hospitals in its northern regions in early March 2020, when many other countries, including Switzerland, were just starting to see their first waves.
A major decision was whether and when to intubate a patient, an invasive procedure to assist breathing, which comes with risks.
“The initial thinking, clinically, was to do it as early as you can, and we should, at first sign of aggravation, intubate and transfer people to intensive care,” said Dr Agoritsas.
But clinicians in Italy and other places globally who shared experience being ‘ahead’ in the pandemic warned peers off this conventional wisdom — they had noticed that patients didn’t do well when intubated too early. Finding the right timing for this intervention was made possible through networking, discussions with colleagues across the globe to whom we had access via WHO. And, indeed, afterwards the evidence showed that there's an optimal moment, not too late, but also not too early,” he recalled.
Aligning emerging evidence to change conventional practices
As the body of evidence on COVID-19 around the world exponentially grew, close cooperation helped speed up practice change, in treating patients (as in the intubation example, or with the use of certain drugs), preventing COVID (such as whether to institute mask-wearing, or defining how long patients were contagious), supporting patients during recovery (ongoing research around long COVID), and identifying the symptoms (such as a loss in taste and smell).
“Practice change is difficult as it involves appraising risks and potential benefits, with limited certainty. As evidence gathers, we may have had clinical habits that we had to adapt because we’ve arrived at a new level of understanding. If you don’t align all the work internationally and locally, it’s hard to implement that change at the point of care,” Dr Agoritsas observed.
Equal access to living clinical guidance
International guidelines act as a reference for all involved in the race to curb the spread of COVID-19, but are particularly helpful in places that have limited capacity to keep up with the sheer volume and implications of new knowledge, and translating that information into action, all while fire-fighting on the clinical front and relaying information back to the global network.
The pace of these developments required a new approach to guidelines, which drew on the expertise and experience of Dr Agoritsas and many other methodological experts.
Professor Dr Thomas Agoritsas, HUG internist and expert on health research methodology. ©HUG
“The biggest challenge was, how to get the evidence generation into a guideline that’s transparent and trustworthy, fast. In that regard, there was another group at HUG with methodological expertise, led by Dr Thomas Agoritsas, which had a good track record in writing transparent, trustworthy guidelines, so we collaborated with his group and methodological experts from other parts of the world that helped us develop our ‘living guidelines’,” Dr Diaz explained.
“In the process, we at WHO as well as the HUG partners learnt how to use those skills at a global scale to make a guideline to be used across the world, with a global impact. This way, HUG could take into account issues emerging elsewhere that may or may not be captured in a national or local setting,” she continued. “It is a mutually beneficial process. Everyone gains and we serve populations better.”
“WHO has a central role to ensure that the information is extensively shared and different settings are taken into account. For me, it was important not just to focus on the industrialised world; during the regular WHO calls, we learnt a lot from Brazil, India and other places in Asia,” said Dr Jacquerioz.
Dr Jacquerioz is involved in the Geneva Centre for Emerging Viruses, which is on its way to becoming a WHO collaborating centre, joining five other HUG institutions that already work closely with WHO on issues including humanitarian medicine and disaster management, vaccinology and telemedicine and e-health.
A multidisciplinary response to a global threat
Mobilizing HUG’s diverse expertise and capacities was also a response to a global challenge prompting clinicians, researchers and public health practitioners around the world to shift their focus, in a multidisciplinary effort of historic proportions.
“Not working in silos was like a breath of oxygen,” Dr Agoritsas quipped. “We were working together, the infectious disease specialists, the internists, the emergency, respiratory, family doctors. I hope we won’t back to that silo world.”
“Also, as never before, we actually had the people from the clinical, academic and public health worlds structuring data, thinking of implementation strategies, brainstorming on how to best deal with a pandemic, answering questions as well dealing with the media, doing clinical work, taking care of patients. This is the strength of university hospitals like HUG, allowing that level and range of expertise and cross fertilization between specialities,” he said.
Karine Martinez, HUG director for international affairs and focal point for the collaboration with WHO, adds: “There is a complementarity and reciprocity between WHO and HUG. As a university hospital in Geneva, we see it as our duty to collaborate with WHO and share respective strengths. This is something we want to encode into the DNA of Geneva as a global health capital — strong collaborations between local institutions and international organizations, with a strong, contribution of International Geneva to global health.”
“To me, our COVID-19 experience is a perfect example of using partnerships already in place, such as the one with WHO, for addressing a crisis situation such as the pandemic,” said Dr Agoritsas.
