While some risk factors have been identified, the reasons for the disparities in disease progression with COVID-19 are unclear, with some patients developing progressive and severe disease while in others the course is benign. Given this sense of randomness, and in the absence of a definitive treatment, medical professionals can feel helpless. It is useful to remember how much can be done to affect the trajectory of illness, even without a 'magic bullet'. With evidence emerging that late presentation is directly associated with increased mortality, we make the case for increased vigilance in the community and earlier intervention.

ObjectivesIdentifying those individuals requiring medical care is a basic tenet of the pandemic response. Here, we examine the COVID-19 community triage pathways employed by four nations, specifically comparing the safety and efficacy of national online ‘symptom checkers’ used within the triage pathway.MethodsA simulation study was conducted on current, nationwide, patient-led symptom checkers from four countries (Singapore, Japan, USA and UK). 52 cases were simulated to approximate typical COVID-19 presentations (mild, moderate, severe and critical) and COVID-19 mimickers (eg, sepsis and bacterial pneumonia). The same simulations were applied to each of the four country’s symptom checkers, and the recommendations to refer on for medical care or to stay home were recorded and compared.ResultsThe symptom checkers from Singapore and Japan advised onward healthcare contact for the majority of simulations (88% and 77%, respectively). The USA and UK symptom checkers triaged 38% and 44% of cases to healthcare contact, respectively. Both the US and UK symptom checkers consistently failed to identify severe COVID-19, bacterial pneumonia and sepsis, triaging such cases to stay home.ConclusionOur results suggest that whilst ‘symptom checkers’ may be of use to the healthcare COVID-19 response, there is the potential for such patient-led assessment tools to worsen outcomes by delaying appropriate clinical assessment. The key features of the well-performing symptom checkers are discussed.

Introduction: Hypoxia is the main cause of morbidity and mortality in COVID-19. During the COVID-19 pandemic, some countries have reduced access to supplemental oxygen, whereas other nations have maintained and even improved access to supplemental oxygen. We examined whether variation in the nationally determined oxygen guidelines had any association with national mortality rates in COVID-19.Methods: Three independent investigators searched for, identified, and extracted the nationally recommended target oxygen levels for the commencement of oxygen in COVID-19 pneumonia from the 29 worst affected countries. Mortality estimates were calculated from three independent sources. We then applied both parametric (Pearson's R) and non-parametric (Kendall's Tau B) tests of bivariate association to determine the relationship between case fatality rate (CFR) and target SpO2, and also between potential confounders and CFR.Results: Of the 26 nations included, 15 had employed conservative oxygen strategies to manage COVID-19 pneumonia. Of them, Belgium, France, USA, Canada, China, Germany, Mexico, Spain, Sweden, and the UK guidelines advised commencing oxygen when oxygen saturations (SpO2) fell to 91% or less. A statistically significant correlation was found between SpO2 and CFR both parametrically (R = −0.53, P < 0.01) and non-parametrically (−0.474, P < 0.01).Conclusion: Our study highlights the disparity in oxygen provision for COVID-19 patients between the nations analysed. In those nations that pursued a conservative oxygen strategy, there was an association with higher national mortality rates. We discuss the potential reasons for such an association.

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As the primary surge of coronavirus disease 2019 (COVID-19) wanes in many countries, it is important to reconsider best practice. More cases, probably the majority of cases, are yet to come. Hopefully, during this next phase, we will have more time, more resources, and more experience from which to affect better outcomes. Here, we examine the compromised oxygen strategy that many nations followed. We explore the evidence related to such strategies and discuss the potential mortality impact of delaying oxygen treatment in COVID-19 pneumonia.