To the Editor:
We read with great interest the publications by Repici et al1 and Soetikno et al2 in Gastrointestinal Endoscopy on recommendations for endoscopic examinations during the coronavirus 2019 disease (COVID-19) pandemic. Health care workers (HCWs) are at increased risk for COVID-19 because upper GI endoscopy is a high-risk aerosol-generating procedure,2 and oral–fecal transmission may be a potential route for COVID-19.3
Recommendations have been changing rapidly and need to be updated, mainly because we are facing a scenario of sustained community transmission of COVID-19 worldwide.4 To conduct an overview of the recommendations for endoscopic procedures during the COVID-19 pandemic, we assessed the electronic sites of international and national societies of gastroenterology and GI endoscopy to review the current recommendations up to March 27, 2020. Overall, 93 international and national societies were identified, and 21 of them have elaborated specific recommendations for endoscopy during the COVID-19 pandemic. A total of 95% recommended temporarily postponing elective/nonurgent procedures; 86% recommended stratifying patients for risk of COVID-19 before the examination (questionnaire regarding symptoms and/or taking patient’s body temperature); 38% recommended reducing the number of people who accompany patients; 33% recommended requiring self-surveillance of signs and symptoms by HCWs; and 19% recommended contacting patients 14 days after the examination to check symptoms (Supplementary Fig. 1 and Supplementary Table 1, Supplementary Table 2, Supplementary Table 3, available online at www.giejournal.org).
Supplementary Figure 1.
Flow chart of identified recommendations for endoscopy during COVID-19 pandemic.
All societies recommended the use of personal protective equipment (PPE) during the examination (gloves, mask, goggles or face shield, gown, and hairnet; double gloves and use of N95 or FFP2/3 masks were recommended in highly suspected or confirmed cases), and 43% recommended that the endoscopy team must be trained in wearing and removing PPE (Table 1 ). There was not any mention of using preexposure or postexposure prophylaxis for HCW. All international societies recommended following a standardized reprocessing procedure for flexible endoscopes.
Table 1.
Recommendations for endoscopy during the COVID-19 pandemic from International/National Societies of gastroenterology/gastro-intestinal endoscopy, updated March 26, 2020
| Society; region or country | Date | Postpone nonurgent examinations | Urgent procedures | Prescreening of patients | Patients should use masks | Training for PPE use | Type of recommended PPE | Contact patients 14 days after examination | Self-surveillance by HCW |
|---|---|---|---|---|---|---|---|---|---|
| International Societies | |||||||||
| European Society of Gastrointestinal Endoscopy (ESGE); Europe | March 18, 2020 | Yes | Not reported | Yes; questionnaire | Yes for all | Yes; how to wear and to remove | Double gloves, mask (FFP2/3), goggles or face shield, gown, hairnet | Yes | Not reported |
| Sociedad Interamericana de Endoscopia Digestiva (SIED); Canada/Central and Latin America | March 18, 2020 | Yes | Not reported | Yes; questionnaire | Not reported | Not reported | Double gloves, mask (surgical), goggles or face shield, gown, hairnet | Not reported | Yes |
| World Endoscopy Organization (WEO); Global | March 24, 2020 | Yes | Upper GI bleeding, foreign body/obstruction; acute cholangitis | Yes; questionnaire | Not reported | Yes; how to wear and to remove | Gloves, mask (N95;FFP2/3), goggles or face shield, gown, hairnet | Not reported | Not reported |
| National Societies – United States | |||||||||
| American College of Gastroenterology (ACG); USA | March 15, 2020 | Yes | Upper GI bleeding, foreign body/obstruction; acute cholangitis, care of cancer, prosthetic removals | Yes; questionnaire | Not reported | Yes; how to wear and to remove | Gloves, mask (type not reported), goggles or face shield, gown | Yes | Not reported |
| American Gastroenterological Association (AGA); USA∗ | March 18, 2020 | Not reported | Not reported | Not reported | Not reported | Not reported | Gloves, mask (N95), goggles or face shield, gown | Not reported | Not reported |
| American Society for Gastrointestinal Endoscopy (ASGE); USA† | March 27, 2020 | Yes | Upper GI bleeding, foreign body/obstruction; acute cholangitis, care of cancer | Yes; questionnaire, body temperature | Yes if symptoms | Yes; how to wear and to remove | Gloves, mask (N95/FFP2), goggles or face shield, gown | Yes | Not reported |
| National Societies – Canada / Central and South America | |||||||||
| Asociación Mexicana de Endoscopia Gastrointestinal; México | Not reported | Yes | Upper GI bleeding, foreign body/obstruction; acute cholangitis, care of cancer, drainage of pancreatic collection, nutritional tube | Yes; questionnaire | Yes for all | Yes; how to wear and to remove | Gloves, mask (type not reported), goggles or face shield, gown, hairnet; double gloves, special masks (N95, FFP2/3), goggles and face shield in highly suspected or confirmed cases | Not reported | Not reported |
| Canadian Association of Gastroenterology; Canadá | March 16, 2020 | Yes | Upper GI bleeding, foreign body/obstruction; acute cholangitis | Yes; questionnaire | Not reported | Not reported | Gloves, mask (surgical), goggles or face shield, gown; double gloves and special mask (N95 or FFP2/3) in highly suspected or confirmed cases | Not reported | Not reported |
| Federación Argentina de Asociaciones de Endoscopía Digestiva; Argentina | March 16, 2020 | Yes | Not reported | Yes; questionnaire | Yes if symptoms | Not reported | Gloves, mask (surgical, N95 in highly suspected or confirmed cases), goggles or face shield, gown, hairnet | Not reported | Not reported |
| Sociedad Chilena de Gastroenterología; Chile | Not reported | Yes | Not reported | Yes; questionnaire, body temperature | Not reported | Yes; how to wear and to remove | Gloves, mask (surgical), goggles or face shield, gown; double gloves and special mask (N95 or FFP2/3) in highly suspected or confirmed cases | Not reported | Yes |
| Sociedad Dominicana de Gastroenterologia; República Dominicana | March 16, 2020 | Yes | Not reported | Yes; questionnaire, body temperature | Not reported | Not reported | Not reported | Not reported | Yes |
| Sociedad Uruguaya de Endoscopía Digestiva; Uruguay | March 13, 2020 | Yes | Not reported | Yes; questionnaire, body temperature | Not reported | Not reported | Gloves, mask (surgical), goggles or face shield, gown; special mask (N95 or FFP3) in confirmed cases | Not reported | Not reported |
| Sociedade Brasileira de Endoscopia Digestiva; Brazil | March 21, 2020 | Yes | Upper GI bleeding, foreign body/obstruction; acute cholangitis, care of cancer, endoscopic ligation band; endoscopic dilatation | Yes; questionnaire | Yes for all | Yes; how to wear and to remove | Double gloves, double mask (surgical plus N95), goggles or face shield, gown, hairnet | Yes | Not reported |
| National Societies – Europe | |||||||||
| British Society of Gastroenterology (BSG); United Kingdom | March 28, 2020 | Yes | Upper GI bleeding, foreign body/obstruction; acute cholangitis, care of cancer, urgent inpatient nutrition support (PEG/NJ tube), endoscopic vacuum therapy for perforations/leaks; infected pancreatic collections | Not reported | Not reported | Yes; how to wear and to remove | Gloves, mask (FFP3), goggles or face shield, gown, hairnet | Not reported | Not reported |
| French Society of Digestive Endoscopy (SFED); France | March 11, 2020 | Yes | Not reported | Yes; questionnaire | Yes for all | Not reported | Gloves, mask (surgical; FFP2 in symptomatic patients), goggles or face shield, gown. | Not reported | Yes |
| Portuguese Society of Digestive Endoscopy (SPED); Portugal | March 15, 2020 | Yes | Not reported | Yes; Questionnaire | Not reported | Not reported | Gloves, mask (surgical), goggles or face shield, gown. Double gloves and special mask (FFP2) in confirmed cases | Not reported | Yes |
| Romanian Society of Gastrointestinal Endoscopy (SRED) | March 15, 2020 | Yes | Not reported | Yes; not reported | Not reported | Not reported | Not reported | Not reported | Not reported |
| Spanish Association of Digestive Endoscopy (SEED); Spain | March 15, 2020 | Yes | Upper GI bleeding, foreign body/obstruction; acute cholangitis, care of cancer, | Not reported | Not reported | Not reported | Gloves, mask (surgical), goggles or face shield, gown; double gloves and special mask (FFP3) in confirmed cases | Not reported | Not reported |
| National Societies – Asia-Pacific | |||||||||
| Indian Society of Gastroenterology; India | March 18, 2020 | Yes | Upper GI bleeding, foreign body/obstruction; acute cholangitis, care of cancer, urgent inpatient nutrition support (PEG/NJ tube), drainage of infected pancreatic collections | Yes; questionnaire, body temperature | Yes if symptoms | Yes; how to wear and to remove | Gloves, mask (type not reported), goggles or face shield (both in highly suspected patients), gown | Not reported | Yes |
| Gastroenterological Society of Australia (GESA); Austrália | March 20, 2020 | Yes | Not reported | Yes; questionnaire | Not reported | Yes; how to wear and to remove | Gloves, mask (surgical, N95 or FFP2/3 in highly suspected or confirmed cases), goggles or face shield, gown | Not reported | Not reported |
| Philippine Society of Gastroenterology; Philippines | March 13, 2020 | Yes | Upper GI bleeding, foreign body/obstruction; acute cholangitis, care of cancer, urgent inpatient nutrition support (PEG/NJ tube) | Yes; questionnaire, body temperature | Not reported | Not reported | Gloves, mask (surgical), goggles or face shield (both in highly suspected cases), gown, hairnet; special masks (N95), goggles and face shield in highly suspected or confirmed cases | Not reported | Yes |
Web links for all societies and recommendations are available in the supplementary material online at www.giejournal.org.
PPE, Personal protective equipment; HCW, healthcare worker(s); NJ, nasojejunal.
Recommendations based on publication by Ungaro et al, CGH https://doi.org/10.1016/j.gie.2020.03.3758 and joint GI society message from ACG, AASLD, ACG, ASGE.
Recommendations based on publication by Soetikno et al, GIE doi https://doi.org/10.1016/j.gie.2020.03.3758.
In summary, we validated the recommendations for endoscopy during the COVID-19 pandemic described by our colleagues based on an extensive and updated review of statements of international and national societies of gastroenterology and GI endoscopy worldwide. The situation is rapidly evolving, and this guidance may be updated regularly.
Disclosure
All authors disclosed no financial relationships. This work was supported by funding from INI-FIOCRUZ (Programa de Incentivo à Jovens Pesquisadores for HP grant number INI-003-FIO-19-2-5) and from University Estacio de Sa (UNESA) [Programa Pesquisa e Produtividade for GP. This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – Brasil (CAPES) (Finance Code 001 for ECCF). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Appendix
Supplementary Table 1.
Summary of recommendations for endoscopy during the COVID-19 pandemic from international/national societies of gastroenterology/gastrointestinal endoscopy, updated on March 26, 2020
| Recommendation | Report | All |
International and USA |
Canada, Latin America |
Europe |
Asia-Pacific |
|---|---|---|---|---|---|---|
| N = 21 | N = 6 | N = 7 | N = 5 | N = 3 | ||
| Postpone nonurgent examinations | Yes | 20 (95) | 5 (83) | 7 (100) | 5 (100) | 3 (100) |
| Not reported | 1 (5) | 1 (17) | 0 ( 0) | 0 ( 0) | 0 (0) | |
| Prescreening of patients | Yes | 18 (86) | 5 (83) | 7 (100) | 3 (60) | 3 (100) |
| Not reported | 3 (14) | 1 (17) | 0 (0) | 2 (40) | 0 (0) | |
| Patients should use masks | Yes for all | 4 (19) | 1 (17) | 2 (29) | 1 (20) | 0 (0) |
| Yes if symptoms | 3 (14) | 1 (17) | 1 (14) | 0 (0) | 1 (33) | |
| Not reported | 14 (67) | 4 (67) | 4 (57) | 4 (80) | 2 (67) | |
| Reduce people who accompany patients | Yes | 8 (38) | 1 (17) | 5 (71) | 1 (20) | 1 (33) |
| Not reported | 13 (62) | 5 (83) | 2 (29) | 4 (80) | 2 (67) | |
| Train PPE use by HCW | Yes | 10 (48) | 4 (67) | 3 (43) | 1 (20) | 2 (67) |
| Not reported | 11 (52) | 2 (33) | 4 (57) | 4 (80) | 1 (33) | |
| Measure body temperature of HCW before starting work | Yes | 6 (29) | 3 (50) | 2 (29) | 0 (0) | 1 (33) |
| Not reported | 15 (71) | 3 (50) | 5 (71) | 5 (100) | 2 (67) | |
| HCW should use standard medical masks when in contact with patients before examinations | Yes for all | 5 (24) | 2 (33) | 1 (14) | 0 (0) | 2 (67) |
| Not reported | 16 (76) | 4 (67) | 6 (86) | 5 (100) | 1 (33) | |
| Use of PPE during examination | Yes | 21 (100) | 6 (100) | 7 (100) | 5 (100) | 3 (100) |
| Check patient’s temperature before, during, or after endoscopic procedure | Yes | 4 (19) | 2 (33) | 1 (14) | 0 (0) | 1 (33) |
| Not reported | 17 (81) | 4 (67) | 6 (86) | 5 (100) | 2 (67) | |
| Contact patient 14 days after GIE procedure for signs/symptoms surveillance | Yes | 4 (19) | 3 (50) | 1 (14) | 0 ( 0) | 0 ( 0) |
| Not reported | 17 (81) | 3 (50) | 6 (86) | 5 (100) | 3 (100) | |
| Self-surveillance by of HCW for symptoms | Yes | 7 (33) | 1 (17) | 2 (29) | 2 (40) | 2 (67) |
| Not reported | 14 (67) | 5 (83) | 5 (71) | 3 (60) | 1 (33) | |
| Follow standard reprocessing of endoscopes | No | 12 (57) | 4 (67) | 4 (57) | 2 (40) | 2 (67) |
| Yes | 1 (5) | 0 (0) | 0 (0) | 0 (0) | 1 (33) | |
| Not reported | 8 (38) | 2 (33) | 3 (43) | 3 (60) | 0 (0) |
Data expressed as n (%).
GIE, GI endoscopy; HCW, healthcare worker; PPE, personal protective equipment.
Supplementary Table 2.
Web links of recommendations for endoscopy during the COVID-19 pandemic from international/national societies of gastroenterology/gastrointestinal endoscopy, updated March 26, 2020
Supplementary Table 3.
Societies accessed to review the recommendations for endoscopy during the COVID-19 pandemic from international/national societies of gastroenterology/gastrointestinal endoscopy
| Society | URL | Accessed on |
|---|---|---|
| International | ||
| Asian Pacific Association of Gastroenterology (APAGE) | http://www.apage.org/index.html | March 27, 2020 |
| European Society of Gastrointestinal Endoscopy (ESGE) | https://www.esge.com/ | March 27, 2020 |
| Sociedad Interamericana de Endoscopia Digestiva (SIED) | https://siedonline.org/ | March 27, 2020 |
| World Endoscopy Organization (WEO) | http://www.worldendo.org/ | March 27, 2020 |
| USA | ||
| American Gastroenterological Association (AGA) | https://www.gastro.org/ | March 27, 2020 |
| American College of Gastroenterology (ACG) | https://gi.org/ | March 27, 2020 |
| American Society for Gastrointestinal Endoscopy (ASGE) | https://www.asge.org/ | March 27, 2020 |
| Sociedad Puertoriqueña de Endoscopia Terapéutica | Not available | |
| Europe, Middle East, and Africa | ||
| Endoscopic Group of the Austrian Society of Gastroenterology (ÖGGH) | http://www.oeggh.at/ | March 25, 2020 |
| Belgian Society of Gastrointestinal Endoscopy (BSGIE) | http://www.bsgie.be/ | March 25, 2020 |
| British Society of Gastroenterology (BSG) | https://www.bsg.org.uk/ | March 27, 2020 |
| Association of Gastroenterologists of Bosnia and Herzegovina (AGBH) | Not available | |
| Bulgarian Association of Surgeons and Gastroenterologists (BASGO) | Not available | |
| Endoscopic Section of Croatian Society of Gastroenterology (HGD) | http://www.hgd.hr/ | March 25, 2020 |
| Cyprus Society of Gastroenterology (CSG) | ||
| Czech Gastroenterological Society (CSG) | http://www.endoskopiste.cz/ | March 25, 2020 |
| Danish Society for Gastroenterology and Hepatology (DSGH) | https://www.dsgh.dk/ | March 25, 2020 |
| Egyptian Society for the Study of Endoscopy and Hepatogastroenterology (ESHG) | Not available | |
| Estonian Society of Gastrointestinal Endoscopy (EGEÜ) | http://www.egeu.ee/en | March 25, 2020 |
| Finnish Society of Gastroenterology | https://www.gastroenterologiayhdistys.fi/ | March 25, 2020 |
| French Society of Digestive Endoscopy (SFED) | https://www.sfed.org/ | March 25, 2020 |
| Endoscopic Section of the German Society of Gastroenterology (DGVS) | https://www.dgvs.de/ | March 25, 2020 |
| Endoscopy Section of the Hellenic Society of Gastroenterology (HSG) | https://www.hsg.gr/ | March 25, 2020 |
| Endoscopy Section of the Hungarian Society of Gastroenterology (HSGE) | http://www.endoszkopos-szekcio.hu/ | March 25, 2020 |
| Endoscopic Section of the Iraqi Society of Gastroenterology & Hepatology (ISGH) | http://www.iraq-git.com/isgh/ | March 25, 2020 |
| Irish Society of Gastroenterology (ISG) | https://www.isge.ie/ | March 25, 2020 |
| Israel Gastroenterological Association (IGA) | https://www.gastro-israel.org.il/ | March 25, 2020 |
| Italian Society of Digestive Endoscopy (SIED) | http://www.sied.it/ | March 25, 2020 |
| Jordanian Society of Gastroenterology & Hepatology (JSGH) | Not available | |
| Latvian Association of Gastrointestinal Endoscopy (LAGE) | Not available | |
| Lebanese Society of Gastroenterology (LSGE) | http://www.lsge.org/ | March 25, 2020 |
| Libyan Society of Gastrointestinal Endoscopy (LSGE) | Not available | |
| Lithuanian Society of Gastrointestinal Endoscopy (LSGE) | Not available | |
| Luxembourg Society of Gastroenterology & Digestive Endoscopy (SLGE) | Not available | |
| Macedonian Society of Gastroenterohepatology (MSG) | Not available | |
| Gastroenterohepatology Association of Montenegro (GAM) | http://ugcg.me/en/ | March 25, 2020 |
| Moroccan Society of Digestive Endoscopy (SMED) | http://www.smed-maroc.org/# | March 25, 2020 |
| Netherlands Society of Gastroenterology (NVGE) | https://www.nvge.nl/ | March 25, 2020 |
| Norwegian Gastroenterology Society (NGA) | Not available | |
| Palestinian Society of Gastroenterology | Not available | |
| Endoscopy Group of the Polish Society of Gastroenterology (PTG-E) | http://www.ptg-e.org.pl/en | March 25, 2020 |
| Portuguese Society of Digestive Endoscopy (SPED) | https://www.sped.pt/ | March 25, 2020 |
| Romanian Society of Gastrointestinal Endoscopy (SRED) | http://www.sred.ro/ | March 25, 2020 |
| Russian Society for Digestive Endoscopy (REndO) | Not available | |
| Serbian Society of Gastrointestinal Endoscopy (SSGE) | http://www.geus.rs/ | March 25, 2020 |
| Endoscopy Section of the Slovak Gastroenterological Society | https://www.sgssls.sk/ | March 25, 2020 |
| Slovenian Society of Gastrointestinal Endoscopy (SAGH) | Not available | |
| Spanish Association of Digestive Endoscopy (SEED) | https://www.wseed.org/ | March 25, 2020 |
| Sudanese Society of Gastroenterology (SSG) | Not available | |
| Swedish Society of Gastroenterology | https://svenskgastroenterologi.se/ | March 25, 2020 |
| Swiss Society of Gastroenterology (SSG) | https://sggssg.ch/ | March 25, 2020 |
| Endoscopy Branch of the Syrian Society of Gastroenterology (SSGE) | Not available | |
| Tunisian Society of Gastroenterology & Digestive Endoscopy (TSG) | Not available | |
| Turkish Society of Gastroenterology (TGD) | http://www.tgd.org.tr/ | March 25, 2020 |
| Ukrainian Association of Endoscopy (UAE) | Not available | |
| Emirates Gastroenterology and Hepatology Society | Not available | |
| Yemeni Study Association for Liver, Biliary & GIT Diseases (YSALBG) | Not available | |
| Asia-Pacific | ||
| Gastroenterological Society of Australia (GESA) | https://www.gesa.org.au/resources/covid-19 | March 25, 2020 |
| Bangladesh Gastroenterology Society | http://www.bgs-bd.org/index.html | March 25, 2020 |
| Chinese Society of Gastroenterology | http://www.csge.org.cn/en#/index | March 25, 2020 |
| The Hong Kong Society of Gastroenterology | http://www.hksge.org/home.htm | March 25, 2020 |
| Indian Society of Gastroenterology | http://www.isg.org.in/ | March 25, 2020 |
| The Indonesian Society of Gastroenterology | Not available | |
| The Japanese Society of Gastroenterology | http://www.jsge.or.jp/english/index | March 25, 2020 |
| The Korean Society of Gastroentestinal Endoscopy | https://www.gie.or.kr/eng/ | March 25, 2020 |
| Macao Society of Gastroenterology & Hepatology | http://www.msgeh.com/main.html | March 25, 2020 |
| Malaysian Society of Gastroenterology & Hepatology | http://www1.msgh.org.my/ | March 25, 2020 |
| Nepalese Society of Gastroenterologists | Not available | |
| New Zealand Society of Gastroenterology | https://nzsg.org.nz/ | March 25, 2020 |
| Pakistan Society of Gastroenterology and GI Endoscopy | Not available | |
| Philippine Society of Gastroenterology | https://www.psgastro.org/ | March 25, 2020 |
| Gastroenterological Society of Singapore | https://www.gastro.org.sg/ | March 25, 2020 |
| The Chinese Taiwan Gastroenterological Society | http://www.gest.org.tw/ | March 25, 2020 |
| The Gastroenterological Association of Thailand | http://www.gastrothai.net/th/ | March 25, 2020 |
| Canada, Central America, and South America | ||
| Federación Argentina de Asociaciones de Endoscopía Digestiva | http://www.faaed.org.ar/ | March 26, 2020 |
| Sociedad Boliviana de Gastroenterología y Endoscopia Digestiva | Not available | |
| Sociedade Brasileira de Endoscopia Digestiva | https://www.sobed.org.br/ | March 26, 2020 |
| Canadian Association of Gastroenterology | https://www.cag-acg.org/ | March 26, 2020 |
| Sociedad Chilena de Gastroenterología | http://sociedadgastro.cl/ | March 26, 2020 |
| Asociación Colombiana de Endoscopía Digestiva | http://aced.org.co/ | March 26, 2020 |
| Gastroenterología y Endoscopía Digestiva de Costa Rica | http://gastroenterologoscr.com/ | March 26, 2020 |
| Sociedad Cubana de Gastroenterología | Not available | |
| Sociedad Ecuatoriana de Endoscopia Digestiva | Not available | |
| Asociación de Gastroenterología y Endoscopía de El Salvador (AGEDES) | http://agedes.org/ | March 26, 2020 |
| Asociación Guatemalteca de Gastroenterologia, Hepatología y Endoscopia Gastrointestinal | www.gastroenterologosdeguatemala.org | March 26, 2020 |
| Asociación Mexicana de Endoscopia Gastrointestinal | http://www.amegendoscopia.org.mx/ | March 26, 2020 |
| Asociación Panameña de Gastroenterología y Endoscopía Digestiva | https://gastropanama.org/ | March 26, 2020 |
| Sociedad Paraguaya de Gastroenterología y Endoscopia Digestiva | http://www.spge.org.py/ | March 26, 2020 |
| Sociedad de Gastroenterología del Perú | https://www.socgastro.org.pe/ | March 26, 2020 |
| Sociedad Dominicana de Gastroenterologia | http://sodogastro.com/esp/ | March 26, 2020 |
| Sociedad Uruguaya de Endoscopía Digestiva | http://www.sued.com.uy/inicio/es | March 26, 2020 |
| Sociedad Venezolana de Gastroenterología | https://sovegastro.org/ | March 26, 2020 |
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