8
GRADE tables from systematic reviews were cross-checked, and where relevant, risk-beneit analysis was produced by the GSC. Internal discussions were held to
evaluate the quality of the evidence presented to the GDG and needed to produce drat recommendations, beneits, harms and risks, costs of implementation, and
acceptability. Recommendations were then formulated and drated in accordance with procedures outlined in the WHO Handbook for Guideline Development,
1
and guided by the quality of evidence using the GRADE methodology.
In drating the recommendations, the WHO Secretariat used those summaries of evidence for the critical outcomes i.e. morbidity, mortality, disease progression and
sequelae, or adverse events for medicines; quality of evidence; risks and beneits of implementing the recommendations; acceptability; costs; and feasibility. he recom-
men dations were then were then ranked as strong or weak recommendation and research gaps or needs were identiied.
2.3 Consensus building and external peer review
Drat recommendations, along with the supportive evidence including summary of the evidence of the systematic reviews with risk-beneit analysis and GRADE tables
were circulated to selected expert external reviewers and some Pocket Book users for feedback
Annex 4 . his process was managed electronically through a EZcollab
site accessible to external reviewers. Results of the peer review process were used to modify the drat recommendations before presentation to the GDG panel.
To formulate the inal recommendations, these evidence summaries, with risk- beneit analysis and GRADE tables, were presented and discussed at an expert panel
meeting held at WHO headquarters in Geneva, Switzerland, in February 2011. he panel weighed the quality of evidence, risks, and beneits, including acceptability,
and placed emphasis on the values and feasibility of implementation in low-resource settings while ensuring that the recommendations are in line with international
standards of care. Although most decisions were based on the evidence from randomized clinical trials RCTs, or large efect observational cohort data, where the
panel determined that there was insuicient evidence, expert consensus was used.
TABLE 2.1
Assessment of strength of evidence
LEVEL OF EVIDENCE RATIONALE
High Further research is very unlikely to change confidence in the estimate of effect.
Moderate Further research is likely to have an important impact on confidence in the effect.
Low Further research is very likely to have an estimate of effect and is likely to change the
estimate. Very low
Any estimate of effect is very uncertain.
1
WHO Handbook for Guideline Development. Geneva, World Health Organization, March 2010.
Available at http:www.who.inthivtopicsmtctgrc_handbook_mar2010_1.pdf
. Accessed on 29 August 2011.
9
he grading of the strength of the inal recommendations, in addition to the quality of evidence, were inluenced by the balance between risks and beneits, acceptability
values and preferences, and cost and feasibility implementation in low-resource settings.
All of the inal recommendations were reached by consensus without the need for voting. he panel also provided advise on strategies to support implementation of the
recommendations through the Pocket Book and other quality-of-care tools. In deciding on the strength of the recommendations, the panel was guided by the
agreed-on assessment criteria described in Table 2.2
. he decisions were made by consensus or, where necessary, by vote.
he inal, graded recommendations and remarks made by the panel were also circulated to external reviewers, including WHO regional and country child health
staf, for comments; the results of these comments were posted on the SharePoint for discussion. Where the panel requested more information, the Secretariat provided
the information to all panel members for agreement.
2.4 Review and update of the recommendations
hese recommendations will be regularly updated as more evidence is collated and analysed on a continuous basis with major reviews and updates at least every 3 to 5
years. However, reviews of evidence will be ongoing and where new data requires update of the recommendations, online interim updates will be produced. hese
recommendations will also form part of a technical series of the evidence behind several guidelines to be produced by the Department of Maternal, Newborn, Child
and Adolescent Health over the coming years. he next major update will be done in 2014.
TABLE 2.2
Assessment criteria for the strengths of recommendations
STRENGTH OF RECOMMENDATION RATIONALE
Strong The panel is confident that the desirable effects of adherence to the
recommendation outweigh the undesirable effects. ConditionalWeak
The panel concludes that the desirable effects of adherence to a recommendation probably outweigh the undesirable effects. However:
the recommendation is only applicable to a specific group, population or setting OR where the new evidence may result in changing the
balance of risk to benefit OR where the benefits may not warrant the cost or resource requirements in all settings.
No recommendation Further research is required before any recommendation can be made.
