Meeting public health needs in emergencies–World Health Organization guidelines

Abstract The World Health Organization (WHO) is a leading source of trustworthy guidelines in public health, including in emergencies. In addition to standard guidelines produced in preparation for emergency response, WHO has processes and methods for issuing guidelines in the context of urgent public health need, including rapid advice guidelines (production time 2 to 3 months) and health emergency interim guidelines (days to weeks). There are numerous challenges to producing guidelines in response to an emergency in addition to the compressed timeline which necessitates truncating or modifying standard processes. There is frequently a lack of scientific data on the disease or situation at hand, especially early in the event timeline. Resources are limited, particularly the availability of WHO staff and external experts, and disease and emergency response experts may lack knowledge and experience in developing guidelines. Finally, the rapid production of new information and the resultant short shelf‐life of recommendations pose a significant challenge to keeping guidelines up to date. In order to better meet end‐users’ needs, WHO must anticipate areas of uncertainty in emergency response and proactively develop relevant guidelines, explore optimal ways of communicating gaps in knowledge in the field to guideline developers, and promote and participate in research on the sources of bias in guideline development within compressed timeframes.


INTRODUCTION
The in West Africa from 2014 to 2016 have forced WHO to reexamine its roles, organizational structure and governance, relationships with the Member States, operational efficiency, and its ability to provide timely, responsive and high-quality technical normative guidance. 3,4 In addition, WHO is facing increasing demands for timely and effective emergency response as the number of acute public health emergencies that require an operational response by WHO increases. 5,6 Since its inception in 1948, WHO has produced a vast array of technical normative guidance across a broad range of topics, including those related to emergency response. WHO guidelines are of several types (Table 1): standard guidelines follow full processes, are based on systematic reviews of the relevant evidence, and involve meetings of external experts at which recommendations are formulated based on explicit criteria and processes. Because standard guidelines take 6 months to 2 years or more to develop, WHO staff have instituted These guidelines are based on rapid, systematic reviews of the evidence on very focused topics. They usually involve an expert meeting, either virtual or in-person. A short shelf-life is anticipated so these guidelines are usually labeled "interim" with a commitment to updating.
Health emergency interim guideline (HEIG) Several days to 3-4 weeks Urgent need for technical guidance where no existing guidance exists and the recommendations can be rapidly implemented The very short timeline and the frequent paucity of structured scientific evidence necessitate ultra-rapid identification of key questions, the use of existing evidence syntheses and indirect evidence, virtual meetings, and reliance on expert opinion (which is explicit and transparent). These guidelines have a short shelf-life so are labeled "interim" with a commitment to updating.
Note that these types of guidelines and their characteristics are part of a spectrum and the information presented here represents typical situations. Timelines, methods, and characteristics will vary with each emergency in order to best meet end-users' needs.
processes and methods for developing guidelines in compressed timelines in response to urgent Member State need.
Two basic processes and document types can be developed in response to urgent public health need: rapid advice guidelines and health emergency interim guidelines (HEIGs). Although categorizations and labels are useful, these information products represent a spectrum from standard to "ultrafast" guidelines, as the development of every document is tailored to Member States' and end-user needs, and to the evidence that is available.
Rapid advice guidelines can be completed within 2 to 3 months using abbreviated and accelerated methods. These types of guidelines have well-development processes, procedures and standards as

CHALLENGES
The production of high-quality guidelines in response to public health emergencies poses a number of challenges for WHO technical units.  Second, one of the most challenging steps in guideline development, and arguably the most important, is getting the questions right.

THE FUTURE
Whether for standard guidelines, rapid advice guidelines or HEIGs, guidelines processes and methods are designed to address a key area of uncertainty. This critical step must be carefully considered, with input from the affected Member States, and from managers and field workers who are on the ground dealing with the event. Care must be taken to craft the questions such that they not only reflect the uncertainty and need, but are answerable (albeit even with expert opinion).
Third, further research is needed on the sources of bias in guideline development within compressed timeframes, in order to work toward the optimal balance between rigor (and development time) and production of a valid, impactful guideline. Finally, WHO staff responsible for guidelines in emergencies need to be trained in the principles and methods for evidence-informed decision-making and need to recognize the value of these approaches even in the most challenging of response settings. Equally importantly, guideline methodologists need to respect the constraints faced by real-world managers and frontline responders, and develop and implement processes and methods that add value, while not obstructing the urgent need for guidance in pursuit of the perfect guideline according to standards set for nonemergency situations.
WHO, as a trusted source of technical normative guidance in healthcare, produces a large number of hugely impactful information products in the context of public health emergencies. We have made tremendous progress towards optimizing efficient production, transparency, validity, and impact on health outcomes. However, challenges remain which the Organization and the international guideline development community need to continue to work diligently to address.