Using GRADE in situations of emergencies and urgencies: certainty in evidence and recommendations matters during the COVID-19 pandemic, now more than ever and no matter what

J Clin Epidemiol. 2020 Nov:127:202-207. doi: 10.1016/j.jclinepi.2020.05.030. Epub 2020 Jun 6.


Objectives: The public, policy makers, and science communities are subject to many false, uninformed, overly optimistic, premature, or simply ridiculous health claims. The coronavirus disease 2019 (COVID-19) pandemic and its context is a paramount example for such claims. In this article, we describe why expressing the certainty in evidence to support a decision is critical and why the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach matters now, perhaps more than ever and no matter what the specific topic is in relation to COVID-19. We finally also offer suggestions for how it can be used appropriately to support decision-making at global, national, and local level when emergency, urgent or rapid responses are needed.

Study design and setting: This is an invited commentary to address the objectives above building on examples from the recent COVID-19 pandemic. This includes an iterative discussion of examples and development of guidance.

Results: The GRADE approach is a transparent and structured method for assessing the certainty of evidence and when developing recommendations that requires little additional time. We describe why emergency, urgent, or rapid responses do not justify omitting this critical assessment of the evidence. In situations of emergencies and urgencies, such as the COVID-19 pandemic, GRADE can similarly be used to express and convey certainty in intervention effects, test accuracy, risk and prognostic factors, consequences of public health measures, and qualitative bodies of evidence.

Conclusions: Assessing and communicating the certainty of evidence during the COVID-19 pandemic is critical. Those offering evidence synthesis or making recommendations should use transparent ratings of the body of evidence supporting a claim regardless of time that is available or needed to provide this response.

Keywords: GRADE; Guidelines; Pandemics; Recommendations; Systematic reviews.

MeSH terms

  • COVID-19
  • Coronavirus Infections*
  • Decision Making*
  • Decision Support Techniques
  • Emergencies
  • Emergency Medical Services / organization & administration*
  • Humans
  • Pandemics*
  • Pneumonia, Viral*