key: cord-0767258-s28n9ytq authors: Antonelli, Giulio; Karsensten, John Gasdal; Bhat, Purnima; Ijoma, Uchenna; Osuagwu, Chukwuemeka; Desalegn, Hailemichael; Abera, Hanna; Guy, Claire; Vilmann, Peter; Dinis-Ribeiro, Mario; Ponchon, Thierry; Sabbagh, Luis Carlos; Pausawasdi, Nonthalee; Makharia, Govind; Hassan, Cesare; Veitch, Andrew; Aabakken, Lars; Ebigbo, Alanna title: Resuming endoscopy during COVID-19 pandemic: ESGE, WEO and WGO Joint Cascade Guideline for Resource Limited Settings date: 2021-03-17 journal: Endosc Int Open DOI: 10.1055/a-1400-9135 sha: 8ef6c3e935a05a2a6523e89a542fcbc1ee79fb7f doc_id: 767258 cord_uid: s28n9ytq nan increase in the burden of gastrointestinal diseases [1] [2] [3] [4] . The reopening of endoscopic services is crucial to resume elective procedures but must be balanced with the need to protect healthcare personnel who are already over-represented in terms of COVID 19 morbidity and mortality [5] [6] [7] . Resumption of partial or full endoscopy capacity depends on implementation of several interventions, such as availability of Personal Protective Equipment (PPE), COVID-19 testing, distancing and separation according to the level of infection, use of telemedicine, availability of vaccines and others. At least some of these interventions are resource-consuming, representing a limitation in developing countries [8] . The European Society of Gastrointestinal Endoscopy (ESGE), the American Society of Gastrointestinal Endoscopy (ASGE) and the British Society of Gastroenterology (BSG) have all issued position statements providing guidance and recommendations for the resumption of endoscopic activity following peaks/ waves of COVID-19 [5, 6, 9, 10] . The majority of recommendations in the position papers are based on expert opinions and early survey-based or observational evidence. Many recommendations are resource-sensitive and may be unavailable in low-resource settings due to issues such as extensive costs, personnel unavailability, lack of sufficient healthcare professional training and logistical limitations [8, 11] . At the time this paper was drafted, nearly 3 million cases and 70 000 coronavirus-related deaths had been reported in the African Continent, with the majority of states still reporting a high rate of community transmission [12] . Furthermore, the availability and the access to COVID-19 vaccination in African countries may be limited [13] . The European Society of Gastrointestinal Endoscopy (ESGE) and the World Gastroenterology Organization (WGO) have been publishing Cascade guidelines aiming to apply existing data and adapt existing guidelines for use in resource-limited settings [14] [15] [16] [17] [18] [19] . This Cascade guideline is the result of a joint effort of ESGE, WEO and WGO, aiming to standardize guidance for resumption of gastrointestinal endoscopy in the different phases of the COVID-19 pandemic also in resource limited settings. The methodology of the cascade guidelines has previously been described in an ESGE position paper [17] . Briefly, statements of the ESGE, ASGE and BSG guidelines were extracted in a dedicated sheet. Partially or totally overlapping recommendations were merged to create a single body of statements. Following this step, members of the ESGE International Affairs Working Group (IAWG), of WEO and of WGO independently categorized the statements as resource sensitive or not. Those with an agreement of 50 % or more for being resource sensitive were selected for the revision process and subsequently, adaptions were suggested for the four previously defined resource levels (▶ Table 1 ). The modified statements were then subject to a Delphi process with expert doctors from low-and medium-income Countries (LMIC), where a rate of agreement of 75 % or higher of all adaptions for all resource levels led to acceptance of the Cascade statement [17] . Experts from LMIC were contacted based upon contact lists of all three societies (ESGE, WEO, WGO). If a 75 % agreement was not reached, the statement was subject to another round of modification before a final Delphi process was carried out. All statements of the three original position papers were extracted to a dedicated excel sheet. Similar or overlapping statements were merged, and the statements were categorized in broad subsections. Overall, 46 statements resulted from this process, of which 21 statements were selected as resource sensitive by the working group. For this analysis, resource levels III and IV were merged. Three adapted cascade statementsone for each levelwere created for each of the original recommendations, making a total of 63 adapted cascade guideline statements. ▶ Table 1 Level of treatment. Core resources or fundamental services absolutely necessary for an endoscopy care system to function. By definition, a health care system lacking any basic level resource would be unable to provide endoscopic service to its patient population. It includes diagnostic procedures (gastroscopy and colonoscopy) as well and fundamental monitoring abilities (blood pressure, basic blood biochemistry). II: Limited Second-tier resources or services that produce major improvements in outcome, such as increased survival, but that are attainable with limited financial means and modest infrastructure. It includes minor endoscopic procedures to improve major clinical outcomes (i. e. sclerotherapy/adrenaline injection, band ligation, plasma expanders, basic surgical interventions). III: Enhanced Third-tier resources or services that are optional but important. Enhanced-level resources may produce minor improvements in outcome but increase the number and quality of therapeutic options. Most procedures that improves clinical outcome are available (i. e. biliopancreatic endoscopy, electrosurgical unit, polypectomy/mucosectomy, anaesthesia back-up). High-level resources or services that may be used in some high-resource countries or be recommended in guidelines that assume unlimited resources. To be useful, maximal-level resources typically depend on the existence and functionality of all lower-level resources. Overall, 17 experts from 9 countries participated in the Delphi process expressed their degrees of agreement for each of the recommendations. Details of the participants are provided in ▶ Table 2 . A ≥ 75 % agreement was achieved for 16 of 21 proposed adaptations. Five cascade recommendations failed to achieve the ≥ 75 % agreement level. The main points of disagreement among the participants regarded the availability and use of PPE and of COVID screening and testing. In detail, the use of pre-procedural testing was said to be often unavailable even for tertiary centers, except when a high risk of transmission is suspected. In addition, an excessive time lag between testing and procedure was seen as falsely reassuring and discouraged. These statements were revised and adaptation was extended to Level II, but not to Level III as it was decided that whenever possible this strategy should be nonetheless recommended. Some participants pointed out the custom of re-using clean PPE or the washing and sterilizing of used PPE. Each original recommendation with the accepted adaptations is reported in ▶ Table 3 . Original statements were divided in the following domains: 1. General recommendations 2. Practical recommendations a) Patient and staff protection, PPE use, infection prevention and control b) COVID-19 screening and testing c) Procedure scheduling d) COVID-19 "minimized" units For the cascading, it was assumed that basic endoscopy is available at all levels of care. Limitations in PPE-availability, lack of testing capacity prior to endoscopy and infrastructural deficits regarding room space and contact tracing will impact on reopening of centers and resumption of endoscopy activity. Most centers in low and middle-resource regions perform manual reprocessing of endoscopes. This practice, if done properly with all precautionary measures, will not be expected to lead to a higher risk of COVID-19 infections in staff involved in reprocessing. Since the virus is easily destroyed by soaps and alcohol, cross contamination of patients is also unlikely. However, added to availability of endoscopy, some specific resources influenced the adaptation of the original guidelines and can be categorized as follows: The availability of PPE is a barrier for level I and II. Thus, singleuse PPE may be reutilized for more than one procedure. In the case of lack of availability of N95, the use of surgical mask is recommended. Alternatively, the use of cloth masks may be an option when surgical masks are unavailable. Methods to sterilize single-use PPE are in use in certain settings. WGO has produced guidance for use of PPE in low resource settings [20] . Due to infrastructure issues and remote location of patients from hospitals, contact between the health centre and the patients before endoscopy for triage and/or testing is often not feasible in levels I and II. In this case, it has been recommended to triage patients on the day of endoscopy at least for symptoms and signs. Similarly, a systematic policy of triage according to symptoms/signs should be recommended to healthcare professionals (HCPs). At a similar level, a policy of systematic tracing of patients after procedures is not available, and may be replaced by instructing patients to notify whenever symptoms appear in the days following the endoscopic procedure. In case patients report symptoms suggestive for COVID and no testing is available, these cases should be considered positive for COVID. Most services in developing countries are short-staffed, and this may be worsened by redeployment of endoscopy manpower to COVID areas. In addition, part of the staff should be redirected to tasks of pre-procedural risk assessment. To minimize infection risk, a possible stratification may be proposed with procedures at low-risk of viral transmission to be allocated in one day/session, and the others in different days/sessions ("COVID-minimized" days/units). Ideally, HCPs should rotate in a fixed way so that only those exposed should be removed in case of transmission. However, when organizing COVID "minimized" units/days, staff availability should be taken into account. Health facilities in levels I and II face space issues to apply social distancing. Family attendance should be avoided whenever possible. The proposal of COVID "minimized" days, where only low-risk patients and procedures are scheduled may be a more viable alternative than COVID-minimized areas in the same unit, in units where space is a limiting factor. ▶ ▶ Table 3 Adapted recommendations according to level of treatment care. Resumption of endoscopy services is critically dependent on the availability of PPE Given the lack of high-level evidence, the exclusive use of serology or rapid antigen-testing for pre-endoscopy patient triage cannot be recommended at this time. In "COVID Minimized" Units: A slower throughput of patients to reduce the risk of positive and negative patients meeting ▪ Level I: In case of unavailability of multiple rooms, lower risk procedures may be performed in separate days ("COVID minimized" days) than high-risk procedures. ▪ Level II: When two endoscopy suites are available, we suggest to create a "COVID-minimized" area, combined with separated pre-and post-endoscopy waiting areas if available. ▪ Level III: No adjustment Pre procedure COVID-19 questionnaire within 72 hours of visit on the telephone. Consider using risk stratification questionnaires including questions regarding fever, travel history, occupational exposure, contact history and clustering type). ▪ Level I: Telephone contact may be unavailable, so we suggest a risk stratification questionnaire physically on the endoscopy day. However, HCP administering the questionnaire should use highest available PPE. ▪ Level II: No adjustment, however, in the case of telephone unavailability for patients in rural areas, we suggest to refer to level I suggestion. ▪ Level III: No adjustment; however, in the case of telephone unavailability for patients in rural areas, we suggest referring to level I suggestion. ▶ Patients should be surveyed 1 to 2 weeks post procedure to record adverse events and assess interval COVID-19 symptoms or positive test results. ▪ Level I: Due to potential lack of phone and/or testing availability, patients should be educated to report to the center in case of "COVD-like" symptoms development ▪ Level II: Due to potential lack of phone and/or testing availability, patients should be educated to report to the center in case of "COVID-like" symptoms development ▪ Level III: No adjustment If positive test of staff or patient, contact tracing should be initiated ▪ Level I: In case of staff or patient positivity, local healthcare authorities should be informed and "intra-unit" contact tracing should be performed ▪ Level II: In case of staff or patient positivity, local healthcare authorities should be informed and "intra-unit" contact tracing should be performed ▪ Where possible, all outpatients being considered for endoscopy should undergo antigen testing based on molecular diagnosis (PCR or iNAAT) 1-3 days prior to their procedure ▪ Level I: Pre-endoscopy testing may not be readily available or have a long turnaround time and, as such, may not be part of routine pre-endoscopy screening ▪ Level II: Pre-endoscopy testing may not be readily available or have a long turnaround time and, as such, may not be part of routine pre-endoscopy screening ▪ Level III: No adjustment A test-and-scope strategy in asymptomatic patients, where testing is negative, might be considered to save PPE. ▪ Level I: Pre-endoscopy testing may not be readily available or have a long turnaround time and, as such, may not be part of routine pre-endoscopy screening ▪ Level II: Pre-endoscopy testing may not be readily available or have a long turnaround time and, as such, may not be part of routine pre-endoscopy screening ▪ Level III: No adjustment A test-and-scope strategy in symptomatic patients, where testing is negative, may identify patients so that gastrointestinal endoscopy procedures are not postponed. ▪ Level I: Pre-endoscopy testing may not be readily available or have a long turnaround time and, as such, may not be part of routine pre-endoscopy screening ▪ Level II: Pre-endoscopy testing may not be readily available or have a long turnaround time and, as such, may not be part of routine pre-endoscopy screening ▪ Level III: No adjustment In the case of limited molecular testing availability, testing should be reserved for those patients considered to be at high-risk for having COVID-19 infection. The high administrative burden of telephone screening ± antigen testing and telephone follow-up is likely to require endoscopy units to have additional administrative and clerical staff to deliver this. ▪ Level I: In case of unavailability of additional staff, existing staff may be reorganised to undertake pre-and post-endoscopic screening ▪ Level II: In case of unavailability of additional staff, existing staff may be reorganised to undertake pre-and post-endoscopic screening ▪ Level III: No adjustment Reprocessing staff should be donning personal protective equipment (PPE) that includes gloves, gown, face shield, bonnet and mask (N95 if available). Since the societies recommendations were published, development and rollout of the first COVID-19 vaccines have commenced world-wide [21, 22] . It is likely that more vaccine candidates will be available and the WHO has indicated a strong need to prioritise access to LMIC where populations are most vulnerable [23] . Most countries that have commenced a vaccination program have targeted vulnerable populations first, and health workers second, as initial vaccine recipients. The successful rollout of vaccines in LMIC may further enable rapid opening of endoscopy facilities, and minimise risk to staff and patients, and is strongly encouraged. However, as immunisation efficacy may be variable, and new COVID-19 strains continue to be discovered, recommendations for PPE and infection control remain unchanged, even for vaccinated staff and patients. In conclusion, when summarizing international societies' recommendations regarding the resumption of endoscopy during COVID-19 pandemic, almost half of these resulted to be critically dependent on sensitive resources, primarily personal protective equipment. Using a previously validated methodology, we have adapted resource sensitive recommendations to resource limited settings, with particular regard to PPE, limited infrastructure, staff shortage and triage procedures. The cascade adaptations presented here are in conjunction with return strategies reported previously, and which mainly included pre-screening and risk stratification based on questionnaires and temperature measurement [8] . Strategies for multiple use of PPE, especially N95 masks and water-resistant longsleeved gowns, have also been described, and may form an important part of return strategies in resource-poor regions. COVID-19 infection rates, with temporary surges in disease activity, will most likely persist; nevertheless, the risk of infection for endoscopy staff must be weighed against the benefits for patients presenting for endoscopy. Unlike in most European countries with elective endoscopic activity centered around screening programs, the indications for endoscopic procedures in resource-poor regions are usually symptom-driven, and often include alarm symptoms such as bleeding or dysphagia [17] . As such, resumption and maintenance of endoscopic activity is crucial for mortality and prognosis of gastrointestinal disorders in such settings. Reuse strategies for PPE, on-site triage of patients as well as introduction of "COVID-minimized ▶ Linear patient flow through the unit, (no crossing of COVID positive and negative pathways, separate entrance and exit) ▪ Level I: Due to unavailability of multiple rooms, lower risk procedures may be performed in separate days ("COVID minimized" days) than high-risk procedures. ▪ Level II: When two endoscopy suites are available, we suggest to create a "COVID-minimized" area, combined with separated pre-and post-endoscopy waiting areas if available. ▪ Level III: No adjustment Keeping known /suspected COVID patients out of "COVID-minimized" units (e. g. scope in theatre or at the bedside) ▪ Level I: Known or suspected COVID patients should be scoped separately (e. g. end of the day or "hot days"). ▪ Level II: Known or suspected COVID patients should be scoped separately (e. g. end of the day or "hot days"). ▪ Level III: No adjustment Smaller units, or where there are few units in a region, could have "COVIDminimized" and "hot" days of the week, or could prioritize inpatients and COVID-positive patients in separate rooms, prioritised to the afternoon to allow deep cleaning and settling of the rooms overnight ▪ Level I: No adjustment ▪ Level II: No adjustment ▪ Level III: No adjustment Staff will also require enhanced viral screening to maintain "COVID-minimized" units. e. g. pre-work symptoms and fever-free confirmation; staff rotation to work between "hot" and "COVID-minimized" parts of a hospital or sites should be avoided. ▪ Level I: Due to shortage of trained endoscopy staff, separation between "COVID-minimized" staff and "hot" staff may not be possible. HCP should report any possible exposure or COVID-like symptoms. ▪ Level II: Due to shortage of trained endoscopy staff, separation between "COVID minimized" staff and "hot" staff may not be possible. HCP should report any possible exposure or COVID-like symptoms. days" have formed the framework of the cascade adaptations to guide HCP in resource-poor settings through the COVID-19 pandemic. 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