Endoscopy Practices During the COVID-19 Outbreak
Recommendations from Global Endoscopy Associations
March 27, 2020
SARS-CoV-2/Novel Coronavirus-19 (COVID-19) is the novel coronavirus species responsible for the ongoing global pandemic that was first detected in Wuhan, China in December 2019. The virus is transmitted human-to-human—both asymptomatic and symptomatic—through respiratory secretions, aerosols, feces, and contaminated surfaces with viral particles detected in the aerosol state for up to 3 hours after aerosolization and up to 3 days on environmental surfaces. The virus has also been detected in the blood of COVID-19 patients. The median incubation period of the virus is around 5.5 days with a range from 0 to 14 days. Common symptoms include fever, fatigue or weakness, cough, diarrhea, and shortness of breath. In more severe cases, acute respiratory distress syndrome and septic shock have been reported, leading to death. Evidence from China and Italy suggests 80% of patients to be asymptomatic or presenting with mild disease and the median age of cases under 60 years of age. At present, more than 100,000 cases of COVID-19 infection have been confirmed worldwide with the case fatality rate hovering around 3.5%.
For healthcare personnel, the risk of infection is significant, owing to the higher likelihood of encounters with COVID-19 positive patients. Healthcare workers in endoscopy units are especially vulnerable due to the aerosol-generating nature of endoscopy procedures, exposure to potentially infectious respiratory or gastrointestinal (GI) fluids, transmission profile of the virus, and close bedside proximity of patients and staff. Particularly, since viral transmission can occur during the incubation period and a substantial number of patients undergoing endoscopy procedures may be asymptomatic carriers, it is essential for strict infection prevention measures to be implemented for the protection of patients and frontline personnel, and to prevent further community spread documented in China and Italy.
- Recommendations from the World Endoscopy Organization on infection prevention and control in digestive endoscopy based on experiences from China.
- Learnings from an Italian group regarding endoscopy performance during the COVID-19 outbreak.
Eliminating Modes of Transmission in an Endoscopy Unit
Below are high level recommendations for endoscopy practice during the COVID-19 outbreak, consolidated from the Canadian Association of Gastroenterology (CAG), American Society for Gastrointestinal Endoscopy (ASGE), World Health Organization (WHO), and Centers for Disease Control and Prevention (CDC):
- Designate procedure and recovery rooms for suspected and COVID-19 positive patients. Endoscopic procedures should be performed in a negative-pressure Airborne Infection Isolation Room that adheres to Level 3 biosafety requirements.
- Establish special handling procedures for blood samples or specimens.
- Use respiratory protection in line with CDC’s recommendations for performing aerosol-generating procedures: Personnel should wear a respirator (N95, FFP2 standard, or equivalent); impermeable gown; gloves; apron; and eye protection.
- Implement separate bathrooms for patients with suspected COVID-19 to avoid fecal-oral transmission.
- Endoscopes and reusable accessories should be reprocessed with a uniform, standardized reprocessing procedure.
- Adjust criteria for essential endoscopic procedures; only procedures that are strongly indicated for should be performed in patients with known or highly suspected COVID-19 infection.
For more resources on outpatient screening, disinfection management, use of personal protective equipment (PPE), review the following documents:
- Coronavirus outbreak: what the department of endoscopy should know from researchers and practitioners from the Humanitas Clinical and Research Center in Milan, and the ASGE
- COVID-19: Advice from the CAG for Endoscopy Facilities, as of March 16, 2020
- Considerations in performing endoscopy during the COVID-19 pandemic from the ASGE
- Sequence for Putting on PPE from the CDC