Response

We thank Dr Sundaram and colleagues¹ for their interest in our article.² Comparing the implementation of a COVID-19 testing campaign before endoscopy between 2 countries (India and the United States) illustrates the complexity of this pandemic. Differences in disease prevalence, cost of endoscopy, access to polymerase chain reaction (PCR) testing, and characteristics of local healthcare systems determine the feasibility and benefit of PCR screening at a grassroots level.

Before a PCR program is considered in other healthcare systems, it is important to answer 2 key questions. First, is PCR testing cost effective? As shown by Sundaram et al,¹ when the cost of the test is higher than the primary procedure, the “test all endoscopy candidates” strategy is prohibitive. The effectiveness of COVID-19 screening is difficult to assess. Do we measure clinical benefit for the patient, do we include the benefit to the healthcare providers and system, or do we consider the benefits to family members as well? These 2 parameters have to be contrasted with the willingness to pay for each community. Overall, the benefits of testing run parallel with disease prevalence. In low-prevalence areas with limited resources, clinical screening (symptoms, fever, and exposure) is necessary to increase pretest probability and justify the costs of testing. Despite limited data measuring how COVID-19 testing has affected healthcare budgets, PCR testing comes with opportunity costs. Assigning funds to testing can divert resources from other critical healthcare needs. Will it limit HIV and tuberculosis treatments, or neglect vaccination and reproductive health campaigns? These strategies may still be a priority in low-income and middle-income countries. Performing urgent endoscopies without testing (in low-risk settings, in patients with negative history and symptoms), following adequate requirements for personal protective equipment would be an acceptable alternative.

Second, do the benefits of testing reach beyond the health system? In our study,² we measured only the direct impact of COVID-19 testing on the patient and the healthcare providers. However, if the test result is positive, this affects the community (requiring home isolation and other preventive interventions). Four months after the first cases were reported in India and the United States, identifying asymptomatic carriers remains one of our biggest challenges.³ While researchers find efficient ways to monitor exposed individuals and identify asymptomatic carriers, the question of who deserves testing will be revisited frequently. Do we test before all procedures? Should we test for lower endoscopies if risk can be reduced by the use of physical barriers? Should we test healthcare workers regularly? Triage algorithms like the one presented by Sundaram et al¹ may be particularly beneficial until we answer these and other questions.

We encourage teams across the globe to measure how clinical algorithms allow resumption of endoscopy workflow and to continue epidemiologic surveillance to monitor infections associated with endoscopy. Hopefully, countries with low disease prevalence, like India, can transition safely to the next COVID-19 phases without implementing expensive screening programs.

Disclosure

Dr Wallace is a consultant for Virgo Inc, CosmoAries Pharmaceuticals, Anx Robotica, Covidien, GI Supply, Endokey, Endostart, and Microteck; has stock and stock options in Virgo Inc; is the recipient of research grants from CosmoAries Pharmaceuticals, Fujifilm, Boston Scientific, Olympus, Medtronic, and Ninepoint Medical; and the recipient of minor food and beverage from Synergy Pharmaceuticals. Dr Corral is the recipient of a travel grant from Abbvie and of minor food and beverage from Boston Scientific and Cook Medical.