key: cord-0965005-4s9776ap
authors: Sundaram, Sridhar
title: COVID testing before every endoscopy: Is India ready for primetime?
date: 2020-05-19
journal: Gastrointest Endosc
DOI: 10.1016/j.gie.2020.05.012
sha: d8b8c95057bfb55fe99127a2971961d197e7c333
doc_id: 965005
cord_uid: 4s9776ap

nan

To the Editor,

The first case of SARS-CoV2 infection in India was reported on the January 30, 2020 from Kerala. 1 The disease since then has increased manifold to reach figures of over 45,000 infections across the country, significantly impacting healthcare with drastic changes in clinical practice. Multiple society guidelines have been published since the outbreak of the virus, with a major focus on screening and precautions for patients undergoing endoscopy.

Continuing hospital services in a smooth and effective manner while taking care of patient and caregiver safety remains a priority. COVID has had its economic impact with hospitals cutting down on elective procedures, impacting patient care and also the revenue generated. One question that has remained largely unanswered in all guidelines is whether we should routinely test for COVID before elective and semiurgent endoscopies. India is a unique healthcare setting with costs of healthcare interventions being very low. 3 Average upper GI endoscopy costs in India is between Rs. 2000 to Rs. 4000 (~30 to 60 U.S. dollars). Colonoscopy costs are between Rs. 7000 to Rs. 10000 (~100 to 140 U.S. dollars).

Meanwhile, average testing cost for Novel coronavirus PCR is Rs. 4500 (~60-65 U.S. dollars) in private laboratories. Also, the report may not be available right away considering pool testing done at various centers. The low endoscopy costs and higher PCR test costs may not justify testing for all with PCR. The population prevalence in India is approximately 3.6 per 100,000 as compared with 122 per 100,000 in the study by Corral et al. The chances of disease detection fall significantly, considering the low prevalence. The disease prevalence in high-risk pockets like Mumbai are close to 70 per 100,000 population, which is much less than the prevalence in the study previously quoted. However, an important consideration becomes the fact that disease prevalence is likely to increase further. Hence, testing for all may not be the right strategy at the moment. However, constant appraisal of the situation will guide us better for further policy decisions on testing. Adequate screening before patient assessment and endoscopy remains the cornerstone for prevention. Clinical judgement should take credence over laboratory investigations to decide necessity of investigations. The prudent use of PPE appropriate to the risk setting remains imperative and cannot be overemphasized. We designed an algorithm for restarting semiurgent and elective procedures once there is de-escalation of isolation measures (Fig. 1 ).

Our reliance on PCR makes it difficult to test all individuals, considering the logistic and financial difficulties. Serological tests with antibody testing may be the solution, where tests can be offered for all individuals. However, current first-generation ELISA tests for COVID IgM and IgG are still in the stages of evolution and require validation in our setting. 4 The caveat is also that patients may not get detected in the early stages of the disease, leading to increased infections in the hospital. The American Enterprise Institute has provided a roadmap to reopening after the coronavirus pandemic. 5 India is likely to go from phase 1 to phase 2 after lockdown measures are relaxed. Despite our slogan being "Go Corona Go," I guess the virus is here to stay. What remains crucial is to build our disease surveillance, testing, and treatment capacity to smoothen the transition. To conclude, we may still not be ready for primetime with PCR testing for all patients, largely because we may not need it in the first place at the moment.

Full-genome sequences of the first two SARS-CoV-2 viruses from India

COVID-19 polymerase chain reaction testing before endoscopy: an economic analysis

Unit cost of medical services at different hospitals in India

The Promise and Peril of Antibody Testing for COVID-19

National coronavirus response: A road map to reopening

FIGURE LEGEND FIGURE 1: Algorithm for testing before endoscopic procedures. High-risk clinical setting includes symptomatic with severe acute respiratory syndrome or Influenza-like illness or asymptomatic contact of positive patient. High-risk epidemiologic setting includes hailing from a high-prevalence area/hotspot/containment zone