key: cord-0998008-fb89aw4a authors: Al Mahtab, Mamun; Faizul Huq, AKM; Rahman, Md Fashiur; Islam, Md Azizul; Iqbal, Syed A; Rahman, Azizur; Abdullah, Syed Abul Hassan Md; Bhuyan, Muhammad AR; Choudhury, Nuzhat; Alia, Reema A; Uddin, Mohammad H; Islam, Sunan B; Mahtab, Musarrat; Akbar, Sheikh MF title: Therapeutic Endoscopy during COVID-19 Pandemic: An Observational Study from Bangladesh date: 2020 journal: Euroasian J Hepatogastroenterol DOI: 10.5005/jp-journals-10018-1318 sha: 787c23a36da4d0e9bca49fcfcc1d5511571a6d38 doc_id: 998008 cord_uid: fb89aw4a How to cite this article: Al Mahtab M, Huq AKMF, Rahman MF, et al. Therapeutic Endoscopy during COVID-19 Pandemic: An Observational Study from Bangladesh. Euroasian J Hepato-Gastroenterol 2020;10(1): 47–49. month following execution of lockdown (from 26 March, 2020 to 26 April, 2020). In line of this, therapeutic endoscopy became 4% during lockdown period compared to their original level. Similar trend was detected in regard to therapeutic ERCP (Fig. 1) . The drastic decrease of endoscopic procedure is not a characteristic feature of Bangladesh only or our center only, but this has been found in Ganga Ram Postgraduate Institute of Medical Education and Research (GRIPMER), Delhi, India. 6 In addition to the routine endoscopy procedure described above, there are important endoscopic procedures those are indicated for treatment of patients with serious and life-threatening pathologies. These include ligation of esophageal varices (EVL) and therapeutic endoscopic retrograde cholangiopancreatography (ERCP). These maneuvers are used for saving lives and/or making critical diagnosis of intractable diseases. Within the above period during lockdown, our team performed six EVL and five ERCP as shown in Table 1 . 1 Now, everyone remains in a dilemma; should we proceed with accomplishing different Gastroenterologists procedures during pandemic of COVID-19 or we should wait for the normalization of situation. When human life is at stake and people with liver cirrhosis have been vomiting blood, EVL becomes necessary. At the same time, several professional associations have also issued special guidelines for performing endoscopic procedures during this ongoing pandemic and are discouraging routine endoscopic procedures, 7-10 which recommend routine endoscopic procedures to resume after new COVID-19 cases have declined significantly in a given geographic location for two successive weeks. The guidelines also recommend prioritizing endoscopic procedures based on urgency by physician's professional judgment. In spite of different guidelines and recommendations, accomplishing procedures has been extremely limited due to various factors, such as, (1) inadequate manpower (health personnel) available to accomplish the procedures, (2) concern of cross infection (patient to doctor and health professional to patient), movement of health professional and patients, and (3) abiding social distancing recommendations. For protection of the endoscopy personnel involved with the therapeutic endoscopy procedures, we used personal protective equipment (PPE) manufactured locally by our readymade garments industries. These are level 1 PPE, which fall short of the WHO standard. 11 However, in these difficult times of PPE shortage, this is the best that we had access to. We used N-95 8210 masks (3M, USA), hand gloves (WRP Asia Pacific Sdn Bhd, Malaysia), eye glasses (Walton High Tech. Ind. Ltd, Bangladesh), and eye shields (Walton High Tech. Ind. Ltd, Bangladesh) as part of the PPE. There was no provision of Hepafilter in our Endoscopy Suite. Several procedures were preferably performed on one day and the endoscopy personnel and the patients, following discharge, were sent for home quarantine. When we assessed the pathological status of six patients with EVL and five patients for ERCP (Table 1) , the point of interest moves to the realities of developing country and humanity of medical professional, rather than existing safety criteria. Four out of five patients in whom therapeutic ERCP was done had cholangiocarcinoma, while the other patient had carcinoma gall bladder (Table 1) . It is a matter of satisfaction that patient's lives were saved by different GI procedures during these emergencies of unknown characteristics. Even with these compromised situations in Bangladesh, at the end of follow-up after 14 days, none of the patients had any COVID-19-like symptom. Their family members were also interviewed and none revealed any COVID-19-like symptom. A recent large study from Italy has made similar observations. 12 The study reports two large series of 851 patients and 968 healthcare workers (HCW) from Northern Italy. Five out of these 851 patients who were endoscoped developed COVID-19. Of the 968 HCWs who were involved in the endoscopy suites across 41 hospitals in the region, 4.3% tested positive and 0.6% needed hospitalization with a mean duration of hospital stay of 8 days, but none required ICU support. Interestingly, 85.7% HCWs who were positive for COVID-19 acquired the infection prior to the introduction of protective measures including PPE. A major limitation of the study is that we could not do nasopharyngeal smear confirmation of the COVID-19 negativity of the patients and endoscopy personnel by polymerase chain reaction (PCR). However, these interventional approaches in GI facility may provide insights for other disciplines as to how the preparations for interventional approaches would be required during COVID-19 pandemic. The implication of the study is not limited to the field of Gastroenterology and Hepatology only. Rather, it has broad-based impact. After years of motivation, there is an upward trend for hospital delivery in rural Bangladesh. COVID-19 will have negative impact on this trend as well as on proper functioning of the internationally acclaimed expanded programme of immunization (EPI) activity of Bangladesh. As of today, it seems that COVID-19 is a seriously contagious disease with frequent mutations. A vaccine seems to be away, and even if a vaccine is found, it may not be of full satisfactory nature. Specific treatment for COVID-19 is not an option for the time being, and several drugs developed for other infectious diseases are being used for COVID-19; the utility and safety of these drugs are questionable. The present scenario indicates that we have to possibly have a co-existence with COVID-19 or some other forms of Coronavirus for longer times. The study reflects a situation that have been addressed to some extent, and proper planning and better execution would be required to have preparedness for COVID-19like situations in developing countries. WHO Declares COVID-19 a Pandemic World Health Organization declares global emergency: A review of the COVID-19 pandemic in Bangladesh-Wikipedia Telemedicine services in Bangladesh COVID-19: What should a clinician know Striving to protect patients and healthcare professionals in endoscopy units during pandemics: from SARS to COVID-19 Endoscopy during the Covid-19 outbreak: experience and recommendations from a single center in a high-incidence scenario. Dig Liver Dis Gastrointestinal effects of an attempt to "disinfect AGA/DHPA joint guidance for resumption of elective endoscopy Bangladesh hopes to start producing medical-grade PPE in six months. bdnews24 Low risk of covid-19 transmission in GI endoscopy The study was conducted at LabAid Specialized Hospital, Dhanmondi, Dhaka, Bangladesh.