key: cord-0943610-2m2j9w7q
authors: Srinivasan, Sachin; Sundaram, Suneha; Emura, Fabian; Reddy, Nageshwar; Faigel, Douglas O.; Repici, Alessandro; Parasa, Sravanthi; Sharma, Prateek
title: Ongoing Global Impact of the COVID-19 Pandemic on Endoscopy: A Subsequent International Survey of 121 Centers From 35 Countries (BRIEF REPORT)
date: 2021-09-23
journal: Gastroenterology
DOI: 10.1053/j.gastro.2021.09.042
sha: 6a5ce75119568ee3fecb0b083e07fb378334413b
doc_id: 943610
cord_uid: 2m2j9w7q

nan

 Sachin Srinivasan: acquisition of data; analysis and interpretation of data; drafting of the manuscript, statistical analysis  Sravathi Parasa: study concept and design; acquisition of data, critical revision of the manuscript for important intellectual content  Suneha Sundaram: analysis and interpretation of data, drafting of the manuscript  Nageshwar Reddy: acquisition of data, critical revision of the manuscript for important intellectual content  Douglas O. Faigel: acquisition of data, critical revision of the manuscript for important intellectual content  Alessandro Repici: acquisition of data, critical revision of the manuscript for important intellectual content  Fabian Emura: acquisition of data, critical revision of the manuscript for important intellectual content  Prateek Sharma: study concept and design; acquisition of data, critical revision of the manuscript for important intellectual content -19) is a global pandemic with over 120 million cases and 2.6 million deaths as of March 2021 1 . It has had a significant impact on the health care system with drastic reductions in elective and non-essential procedures. Previous surveys have shown a significant reduction in procedure volumes at the height of the pandemic 2 . Since then, readily available testing for COVID-19 and use of personal protective equipment (PPE) has enabled routine pre-procedure testing and the safe conduct of endoscopy in many countries 3 . GI societies have put forth recommendations to help guide endoscopy centers to resume services in a safe manner [4] [5] [6] [7] . However, each country has unique challenges -rates of infection, local policy, availability of testing and PPE-that pose as barriers to resumption of services. We conducted this survey-based study to understand the ongoing impact of COVID-19 on endoscopy units and trainees worldwide.

A web-based survey was developed by the World Endoscopy Organization. 21 questions focused on the endoscopy units' baseline information, volumes, COVID-19 testing practices and outcomes, pandemic's impact on volumes and barriers to resumption of services. The survey was sent on Oct 15, 2020, and responses were collected through December 15, 2020.

(Supplementary material 1). All participants provided informed consent and Institutional Review Board exemption was obtained.

121 endoscopy units included 3,618 personnel-36% endoscopists, 47% nurses, and 17% technicians-from 35 countries across 6 continents completed the survey (Figure 1 ). Centers reported a total of 1,029,000 endoscopic procedures performed in the year before COVID-19, 45% lower and 55% upper endoscopic procedures (median 5,000 (IQR 1,950-10,000)). The median number of endoscopists, nurses, and technicians was 8 (IQR 4-15), 6 (IQR 3-15), and 3 (IQR 1-8) respectively.

Of the 121 endoscopy units, 43% reported testing for COVID-19 on all patients before endoscopy, 43% reported no testing and 14% reported only testing occasionally. 90% of units utilized PCR-based or other antigen tests and 10% utilized antibody-based (ELISA/finger stick rapid antibody) tests. An average of 1396 (SD: 4402) tests were completed by each endoscopy unit (median, 275 (50, 1000)). 1.3% of patients tested were positive for COVID-19 ( Figure 1A ). 32% of endoscopy units required a negative test before performing an endoscopy, 10% required the patient to be asymptomatic for 72 hours, 31% required both and 27% reported no further testing or waiting requirements.

Only 19% of participating units tested all endoscopy personnel while 55% tested symptomatic personnel. Of the remaining, 22% performed only symptomatic screenings and 4% neither tested nor screened personnel. Cumulatively, 10% of endoscopy personnel tested J o u r n a l P r e -p r o o f positive for COVID-19 since the start of the pandemic, 0.9% were hospitalized and 0.25% died from COVID-19 (geographical distribution Figure 1B) .

The surveyed endoscopy units reported a mean reduction of procedure volumes by 58% initially and 54% at the time of this survey. At each respective first peak, Africa (72%) reported the highest reduction followed by Europe (68%), Asia (62%), North America (59%), South America (59%), and Oceania (42%). At the time of this survey, North America reported the highest mean reduction in endoscopy volumes (60%) while all other continents had shown some evidence of recovery.

Of the 73 units with training programs, trainee endoscopy volumes reduced on average by 64% at the start of the pandemic and 54% at the time of survey. At the pandemic's onset, average reduction in trainee volumes were: Africa (90%), Europe (76%), North America (75%), Asia (67%), South America (63%), and Oceania (53%). All continents showed improvements by December 2020.

Only 14% of the centers reported no barriers to resuming endoscopy. Barriers cited by centers included safety concerns (52%), institutional policy (40%), limited COVID-19 testing (32%), limited endoscopy staff (30%), and limited PPE (23%). Regarding PPE practices, 71% of centers reported using N95/PAPRs for all endoscopic procedures, 9% used them only for upper endoscopic procedures, 12 % used only if a patient tested positive and 9% used them if a patient was not tested for COVID-19.

The current survey includes data from 121 endoscopy centers from 35 countries after COVID-19 testing has become more available and various GI societies have published guidelines to help endoscopy centers resume services safely [4] [5] [6] [7] . Although most GI societies recommend patient testing, 57% reported not testing or only testing occasionally. In tested patients, only 1.3% were positive. Recognizing that it may be difficult to test all patients in resource limited settings, these results rationalize an argument to scale down testing to high-risk groups only (screen positive patients). Only 10% of the endoscopy personnel tested positive and <1% were hospitalized or died from COVID-19 that was lower than that reported in our earlier report where 13.5% of the personnel tested positive and 7.9% were hospitalized2. These results along with other published studies suggest that the risk of transmission from endoscopy itself is relatively low when using appropriate PPE.

All continents, except Oceania, reported over 50% reduction in endoscopy volumes at their first peak of the pandemic. This could be attributed to the relatively low prevalence of the COVID-19 cases in Oceania. At the time of this survey, most continents had also shown improvement. Reduction of endoscopy volumes were noted for trainees. We did not explore specific reasons for reduced trainee volumes, but conceivably, the safety of trainees and local policy would have mandated this.

In this large international survey, we report that there is an ongoing impact of COVID-19 on outpatient endoscopy worldwide. The improving trend with signs of recovery of endoscopy volume necessitate continued guidance from GI societies on safe reopening and addressing the backlog of cases. COVID-19 testing is readily available in most places, but outcomes are similar in places where there is limited testing as well, suggesting that following local guidelines is key. The low positive rate in asymptomatic individuals raise the question if continued testing of all patients is cost effective. In addition, the percentage of personnel reporting infection has remained relatively low. With vaccines now available, further recovery of endoscopy services is expected. 

COVID-19 Map. Johns Hopkins Coronavirus Resource Center

AGA/DHPA joint guidance for resumption of elective endoscopy