key: cord-252557-f89m6xv5
authors: Ong, John; Cross, Gail B; Dan, Yock Young
title: Prevention of nosocomial SARS-CoV-2 transmission in endoscopy: international recommendations and the need for a gold standard
date: 2020-04-02
journal: Gut
DOI: 10.1136/gutjnl-2020-321154
sha: 
doc_id: 252557
cord_uid: f89m6xv5

nan

Prevention of nosocomial SARS-CoV-2 transmission in endoscopy: international recommendations and the need for a gold standard Over 3000 healthcare workers (HCW) in China are suspected of having coronavirus disease 2019 (COVID-19) and over 1700 tested positive. 1 These statistics underline the need for robust preventative measures against the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Endoscopy departments are fertile grounds for viral spread because aerosolisation of bodily secretions occurs during procedures. A single viral-shedding patient with a high viral load can contaminate an entire endoscopy room with the virus that remains viable for up to 3 days, putting uninfected patients and HCWs at risk. 2 3 Singapore previously had the largest cohort of COVID-19 patients outside China in the early phases of the outbreak. Given its novelty, the effectiveness of new preventative measures implemented within our endoscopy services was unknown. To determine best practice, we conducted systematic searches of literature and official websites for gastroenterology and endoscopy societies (n=28) in the 15 most-affected countries to scrutinise recommendations and associated evidence. Methodology is available on request.

In summary, we found careful patient selection was commonly advised but protocols for screening and triaging differed (table 1). The two most important differences observed were: (1) Cough/sore throat/respiratory problems? iii.

Close contact with suspected or confirmed COVID-19 individual? (including family's exposure) iv.

High-risk area? ► Check body temperature before entering endoscopy. Classify risk: i.

Low=No symptoms, no contact risks, not from high-risk area ii.

Intermediate=One of any positive iii. High risk=symptomatic with either contact risk of from the high-risk area. PPE recommendation (general staff): ► All patients to be offered surgical face masks Contingency plan for high-risk patients detected in endoscopy: ► Not stated.

Triaging: ► Three categories: (1) Need to continue, (2) defer until further notice, (3) needs discussion. Need to continue procedures: acute upper GI bleeding, oesophageal obstruction (foreign bodies, food bolus, pinhole stricture or cancer requiring urgent stenting), endoscopic vacuum therapy for perorations/leaks, acute cholangitis or jaundice secondary to biliary obstruction, acute biliary pancreatitis, cholangitis with stone and jaundice, infected pancreatic collections, walled-off pancreatic necrosis, urgent inpatient nutrition support (enteral feeding tubes), gastrointestinal obstruction needing urgent decompression or stenting. Defer until further notice procedures: All routine symptomatic referrals, planned POEM, pneumatic dilatation for achalasia, elective PEG, stricture dilatation, APC for GAVE, RFA, pneumatic dilatation, ampullectomy, bariatric endoscopy Low-risk follow-up and repeat scopes-oesophagitis healing, gastric ulcer healing, 'poor views', check post-therapy, for example, EMR, RFA, polypectomy (unless high-risk neoplasia present), and so on. Surveillance polyp check, IBD, Barrett's (unless highrisk neoplasia present), non-urgent enteroscopy, EUS for 'benign' indications-biliary dilatation, possible stones, submucosal lesions, pancreatic cysts without high-risk features. Other ERCP cases-stones where there has been no recent cholangitis and a stent is in place; therapy for chronic pancreatitis; metal stent removal or change; ampullectomy follow-up. Flexible sigmoidoscopy should stop unless discussed with local commissioners. Patients undergoing endoscopy/ biopsy as part of clinical trials. Case-by-case decision: 2-week wait cancer referrals, FIT positive bowel screening colonoscopy, planned EMR/ESD for complex polyps or high-risk lesions, new suspected IBD, cancer staging EUS, small bowel endoscopy. (General guidance, non-exhaustive list).

Screening protocol: i.

Travel history ii.

Body temperature iii. Patients are given a symptom information sheet and asked to report any symptoms at the front desk. PPE recommendation (general staff): ► None stated Contingency plan for high-risk patients detected in endoscopy: ► Not stated. (table 2) . Only 32% (9/28) of all gastrointestinal (GI) related societies reviewed had provided guidance as of 16 March 2020. A universal gold standard was lacking. One article reported the effect of preventative measures on the incidence of new COVID-19 cases but the sample size was small and period of observation abrupt. 4 Patient screening undoubtedly is the foremost step at preventing nosocomial transmission; timely detection allows postponement of non-urgent procedures until the infection has resolved, significantly reducing transmission risk to patients and staff. However, the median incubation time of the virus is 5.1 days but can extend to 14 days (99th percentile), meanwhile patients remain asymptomatic or have subclinical symptoms and may be infectious. 5 6 This limits screening protocols reliant on symptomatology. GI symptoms of COVID-19 are also non-specific. Travel history becomes limited when COVID-19 becomes more rampant in local communities so contact screening for exposure to individuals who have symptoms of COVID-19 may be more useful. Nonetheless, data on the accuracy of questionbased screening tools were not identified.

Current limitations of screening place greater importance on risk management strategies postprocedure. Detecting 'false negatives' that slip through processes allows for the identification of HCWs and patients with infection risk after exposure to asymptomatic or subclinical carriers in the viral incubation period at the time of endoscopy. A robust contact screening programme is then necessary to contain the spread of COVID-19 among exposed staff and patient contacts. Only one guideline identified in our review has advised on postprocedure patient follow-up on day 7 and day 14 by telephone. 7 No evidence of SARS-CoV or SARS-CoV-2 transmission through endoscopy was identified. SARS-CoV-2 has been isolated in gastric, duodenal and rectal biopsies, and faecal viral RNA is detectable in half of all COVID-19 patients although there is a poor correlation to GI symptoms. 8 9 Nonetheless, reports may surface in the future and suspicion for faecal-oral transmission should remain high. US and UK guidelines regarded lower endoscopy as low risk and therefore were less stringent with PPEs compared with China or Singapore (table 2) . We have erred on the side of caution because the microbial contamination of surroundings after lower endoscopy has been reported. 10 11 Differences in recommendations may also have been influenced by resource availability and health policies. In our experience, resource allocation for staff education, decontamination and management of the physical and mental well-being of HCWs were also crucial. In conclusion, better evidence is needed to inform current practice. A postprocedure risk management programme can help prevent the nosocomial and community

Protecting Chinese healthcare workers while combating the 2019 novel coronavirus

Air, surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 (sArs-CoV-2) from a symptomatic patient

Aerosol and surface stability of sArs-CoV-2 as compared with sArs-CoV-1

the incubation period of coronavirus disease 2019 (COVID-19) from publicly reported confirmed cases: estimation and application

substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (sArs-CoV2)

COVID-19) outbreak: what the department of endoscopy should know

evidence for gastrointestinal infection of sArs-CoV-2

Ong s. COVID-19 in gastroenterology: a clinical perspective

Air suctioning during colon biopsy forceps removal reduces bacterial air contamination in the endoscopy suite

risk of bacterial exposure to the endoscopist's face during endoscopy

Disclaimer the views expressed are those of the author(s) and not necessarily those of the NHs or the Department of Health.

PostScript spread of SARS-CoV-2 and should not be neglected. 

Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review Not commissioned; internally peer reviewed.

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