COVID-19 Transmission among Gastrointestinal Endoscopists

Dear Editors:

We read with interest the paper by Repici et al on the North Italian experience of gastrointestinal endoscopy practice during the coronavirus disease-2019 (COVID-19) pandemic.¹ Based on a 1-week survey among 42 endoscopy centers 1 month after the first confirmed case in Italy, the authors describe the changes in the organization and caseload of the endoscopy units related to the COVID-19 outbreak. Additionally, they report confirmed COVID-19 infections among nurses and physicians in 12 endoscopy units, and 6 health care workers (HCW) requiring hospital admission. In further report from the same survey, only 4.3% (42/968) of the HCW had a confirmed COVID-19 infection.² The authors conclude that the risk of patient to HCW transmission is limited.

Although the Italian GI-COVID19 Working Group provides a detailed investigation on the burden of COVID-19 on endoscopic activity in a high-risk area, we would like to question the message they convey on the low risk of COVID-19 transmission to HCW.

During the last week of March, at the peak of the COVID-19 circulation (from March 23–27 2020, 23 days after the 100th confirmed case) the French Society of Digestive Endoscopy (Société Française d’Endoscopie Digestive, SFED) conducted a web-based survey on the impact of the pandemic on gastrointestinal endoscopic activity. The questionnaire had 35 items, including the number of endoscopic procedures performed and their indications, and the rate of COVID-19 cases among gastroenterologists, and the use of protective measures at the beginning of the COVID-19 infection in France. The recommendations of the SFED on the protective measures for HCW in endoscopy units were published on March 10 on the SFED website.

Accounting for 21% of the 3300 French Gastroenterologists, 694 gastroenterologists took the survey. Thirty percent worked in areas with a high prevalence of COVID-19 infection (East of France and Paris area), comparable with that of Northern Italy. Thirteen percent of all gastroenterologists presented symptoms consistent with a COVID-19 infection during March 2020. A polymerase chain reaction test for COVID-19 was performed in only 37% of them, because few laboratories were able to perform the test in France at this time. The polymerase chain reaction test was performed 6 days after the onset of the symptoms and was positive in 46% of the cases. Only 54% of the endoscopists wore a surgical mask during this period. Indeed, endoscopists reported difficulty to obtain surgical masks in ≤14% of cases, FFP2 masks in 55% of cases, and glasses in 25% of cases.

In the high-incidence areas, the incidence of COVID-19 infection among endoscopists was higher than in low-incidence areas of COVID-19 infection (21.0% vs 9.5%), but still twice as high as the numbers from by Repici et al. Additionally, other reports from Northern Italy mention >10,000 positive cases among Italian HCW and 100 deaths among Italian doctors.³ Of note, most COVID-19 infections of the HCW in endoscopy units occurred at the onset of the epidemic, when protective measures had not been implemented, and our 21% infection rate is comparable with the rate to the incidence of COVID-19 infection in HCW at the onset of the outbreak in Italy.⁴

Although our survey is limited by the small proportion of respondents, the poor adherence of French endoscopists to the protective measures, and the small number of confirmed cases, the study from the ITALIAN GI-COVID19 Working Group is retrospective, and could have overlooked HCW contaminations. Gastrointestinal endoscopy remains a procedure at very high risk for COVID-19 transmission to HCW, by aerosolization of saliva droplets, possible airborne transmission, and fecal excretion of the virus: we suggest that HCW in endoscopy units scrupulously follow the recommended protective measures to prevent COVID-19 spread to patients, other HCW, and their families.