key: cord-0722776-v7n5m220 authors: Forde, Justin J.; Barkin, Jodie A.; Amin, Sunil title: Reply date: 2021-01-16 journal: Gastroenterology DOI: 10.1053/j.gastro.2021.01.031 sha: 8fce1ab382f6fd752312c23cafa04ffde3d391a9 doc_id: 722776 cord_uid: v7n5m220 nan Reply. We thank Kidambi et al 1 for their interest in and insightful feedback regarding our work "Yield and Implications of Pre-Procedural COVID-19 PCR Testing on Routine Endoscopic Practice." 2 Resumption of elective endoscopy in the coronavirus disease 2019 (COVID-19) era has been challenging due to a lack of evidence-based guidance; conflicting levels of input from federal, state, and local governments; and widely variable COVID-19 prevalence rates by region. We previously reported our experience using a routine pre-procedure COVID-19 testing strategy for maintaining the safety of patients and staff. 2 During our study, outpatients with upcoming endoscopic procedures were contacted via telephone and asked a COVID-19 screening questionnaire regarding symptoms, exposures, and travel. Those with negative verbal screening underwent nasopharyngeal polymerase chain reaction (PCR) testing 48 to 72 hours before the planned procedure and, if negative, proceeded with their procedure as planned. We found 1 of 396 patients had a positive PCR test result after initial negative questionnaire screening (positive test rate 0.25%; 95% confidence interval, 0.01%-1.40%) in our intermediateprevalence area at the time of the initial study period. Given this result, we concluded that while ideal if readily available, pre-procedure COVID-19 testing of asymptomatic individuals may be relatively low-yield when coupled with screening questionnaires in a low to intermediate prevalence settings. As such, we advocated a tailored approach to testing based on available resources and disease prevalence. Our findings were particularly important for practices at an early stage in the pandemic, when resources such as PCR tests and personal protective equipment were limited. As highlighted by Kidambi et al, 1 there is a well-documented potential for asymptomatic spread of COVID-19; however, multiple studies of pre-procedure PCR COVID-19 testing have now demonstrated that asymptomatic carriers are rare in low prevalence areas. [1] [2] [3] In addition, PCR testing results may vary based on disease prevalence, prompting recent guidelines by the American Gastroenterology Association recommending against a pre-procedure testing strategy in low-or high-prevalence areas due to high false-positive or false-negative rates, respectively. 4 Since proceeding with phased reopening in May 2020, Miami-Dade County has experienced an extensively publicized increase in COVID-19 prevalence, during which time Florida encountered the highest COVID-19 cases per capita in the nation. 5 In order to further evaluate yield of routine pre-procedure COVID-19 testing of asymptomatic individuals, we continued to follow our PCR testing positivity rate within the context of our region's transition from an intermediate to high prevalence area. In a retrospective cohort study of all patients with endoscopic procedures scheduled at our facility between April 13, 2020 and July 17, 2020, the proportion of positive tests pre and at each month post societal re-opening were compared. Post reopening, we encountered 17 of 1415 positive tests (1.22%; 95% confidence interval, 0.07%-1.94%). This rate is not statistically different from our previous positivity rate when Miami was an intermediate prevalence area (0.25% vs 1.22%; P ¼ .09). There was no significant change in test positivity rates in the month after re-opening (2 of 565 ¼ 0.35%; P > .99); however, a significant change was noted during month 2 (14 of 573 ¼ 2.44%; P ¼ .01). The inflection point for significance coincided with the community test positive rate of approximately 20%. As concluded by Kidambi et al, 1 the implications of even 1 positive patient in the endoscopy unit could result in catastrophic consequences. Despite the overwhelming rise in positive COVID-19 cases in our community, we continued to perform elective and semi-elective endoscopic procedures in a manner that proved safe both for patients and staff using our continued approach of pre-procedure screening questionnaires and PCR testing in addition to physical distancing, full barrier personal protective equipment, and hand hygiene. Our positivity rates among all prevalence levels have remained acceptably low and significantly lower than the positivity rate of the surrounding population. This suggests that screening questionnaires are in fact effective tools for selecting high-risk patients. Despite disease prevalence, it has been our experience that PCR testing provides a useful and crucial adjunct to screening questionnaires by decreasing the likelihood of staff exposures to asymptomatic or pre-symptomatic patients, and we continue to advocate for pre-procedure PCR testing whenever resources permit. Our practice pattern and PCR positivity results demonstrate that an endoscopy unit can continue to operate safely in a high prevalence COVID-19 region. Ultimately, we continue to recommend an approach guided by available resources, and our findings can be cited as justification to mitigate the deleterious and potentially catastrophic effects of medical distancing on the health of our communities . 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Florida Department of Health, Division of Disease Control and Health Protection The authors declare no conflicts.