Striving to Protect Patients and Health Care Professionals in Endoscopy Units During Pandemics: From SARS to COVID-19

Dear Editors:

We would like to begin by commending Professor Repici and all Italian health care professionals for their hard-fought efforts in curbing the rise of coronavirus disease-2019 (COVID-)19. In their article entitled “Endoscopy units and the COVID-19 Outbreak: A Multi-Center Experience from Italy,”¹ we get a glimpse of real-world data from 41 endoscopy units in a part of the world that was heavily afflicted by the novel coronavirus.

Despite the surge of COVID-19 cases causing a huge burden to health care systems worldwide, it is reassuring that policies to enhance patient safety, avoid nosocomial outbreaks, and ensure rational use of personal protective equipment² can protect patients and health care professionals alike. All but 1 surveyed endoscopy unit decreased their normal endoscopy activity owing to COVID-19 and 70% of units adopted a triage for risk stratification. Urgent endoscopies were still being performed confirming that emergency services were not hampered even at the height of the pandemic, although it would be informative if the authors could elaborate more on the procedure types. In Italy, only 6 of 968 (0.006%) endoscopy health care professionals required hospitalization for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in the units surveyed, and none of these were attributable to endoscopy performed in COVID-19–positive patients. These numbers are even more remarkable given that 22% of these units performed procedures on COVID-19–positive patients with only surgical masks.

Despite these heartening results, there are several points we would like to highlight. First, we find the minimal number of endoscopy units prohibiting the accompaniment of caregivers slightly concerning. In Hong Kong, our public health authority has activated the Emergency Response Level since January 25, 2020; among other measures, this provision suspends visiting in all public hospitals except on compassionate grounds to mitigate the risk of cross-infection. Exceptions should be made only for patients who require specific assistance and translation services.³ It would be interesting to know the reasons behind such a low uptake for this measure in Italy. Second, the intention to follow-up patients after endoscopy seems difficult to implement in actual practice, with only one-quarter of endoscopy units doing so for suspected cases and only 1 unit doing so for asymptomatic patients. Third, approximately 70% of units were still performing screening colonoscopy for fecal immunochemical test positive patients. This issue is contentious, with the American Gastroenterological Association⁴ and European Society of Gastrointestinal Endoscopy/European Society of Gastroenterology and Endoscopy Nurses and Associates⁵ statements differing somewhat, with the former providing evidence to support a delay of ≤6 months and the latter opting for an individualized risk stratification that considers the risk of COVID-19 infection and disease-related mortality and/or morbidity. When our unit became the epicenter of the SARS outbreak back in 2003, all elective endoscopy was essentially stopped. Based on our prior experience, we now limit endoscopy only to potentially life-threatening situations, such as gastrointestinal bleeding and cholangitis, but allow some flexibility for clinical teams to decide on a case-by-case basis for time-sensitive cases such as in patients with cancer. Ultimately, whether fecal immunochemical test positive patients should have endoscopy performed would depend on the prevalence of COVID-19, local guidelines, and the available resources.

Fourth, we read with interest the significant proportion of Italian endoscopy units performing endoscopy using only surgical masks. We would like to emphasize that the sample size is small, we are unsure of the endoscopic procedures performed, and that this practice deviates from what is recommended by most guidelines.^{2 ,} 4, 5, 6 Before more evidence is made available, we believe that N95 respirators or equivalent should still be mandated. Last, policymakers should be made aware of the shortages in negative pressure facilities for endoscopy to plan ahead and enhance preparedness for future pandemics.

The holy grail for endoscopy units should be to attain zero percent infection rates among health care professionals while providing essential services to patients.⁷ To succeed, general measures such as social distancing, adequate hand hygiene, and universal masking,⁸ at least in health care settings are equally important. Future studies should explore the safety of measures such as the extended use or reuse of N95, the infective risk of different endoscopic procedures, and softer but equally important issues, such as the effects of COVID-19 on endoscopy training. Lessons learned from this study and others can pave the way and guide best practices when endoscopy and clinical services gradually return to normal in a stepwise manner.⁶

In facing COVID-19, only one thing is certain. The global community must come together in solidarity as we are all in this together. We must try our best to stay safe and healthy, to protect our patients and our loved ones. This is not a time for complacency.