Article Text

Mandatory preprocedure testing for SARS-CoV-2 for all-comers may not be required for resuming endoscopic services amidst the ongoing COVID-19 pandemic
  1. Soumya Jagannath1,
  2. Ashish Agarwal1,
  3. Deepak Gunjan1,
  4. Samir Mohindra2,
  5. Vishal Sharma3,
  6. Sudipta Dhar Chowdhury4,
  7. Sanjeev Sachdeva5,
  8. Vivek A Saraswat6,
  9. Rakesh Kochhar3,
  10. Anoop Saraya1
  11. GAIN Group
    1. 1 Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, Delhi, India
    2. 2 Gastroenterology, SGPGIMS, Lucknow, Uttar Pradesh, India
    3. 3 Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
    4. 4 Christian Medical College and Hospital Vellore, Vellore, Tamil Nadu, India
    5. 5 Govind Ballabh Pant Hospital, New Delhi, Delhi, India
    6. 6 Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
    1. Correspondence to Professor Anoop Saraya, Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029, India; ansaraya{at}

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    We read with interest the study by Hayee et al 1 which reported no COVID-19 infection in healthcare workers (HCWs) or patient after 6208 outpatient GI endoscopic procedures across 18 centres in UK with the use of personal protective equipment (PPE) and infection control policies. Only 3 (0.11%) of 2611 asymptomatic patients had tested positive for SARS-CoV-2 prior to endoscopy. The study is timely and the results are gratifying given the huge perceived risk of cross-infection among HCWs and patients during the ongoing COVID-19 pandemic. The study favours resumption of outpatient diagnostics during COVID-19 recovery phase without mandatory testing. The risk may, however, vary depending on factors such as infection rate in the population and type of the procedure. We are sharing our experience of transmission of COVID-19 following endoscopy across five academic centres in India, which should strengthen their argument.

    All patients undergoing endoscopic procedures from 1 April 2020 to 31 May 2020 were included in an observational study. A detailed questionnaire was sent to the participating centres for the following information: (1) endoscopy details: type and indications of GI endoscopy and (2) infection control measures: use of PPE, mandatory policy of preprocedure testing for SARS-CoV-2 and disinfection practices. Outcome measure was new SARS-CoV-2 infection in HCWs or patient. The patients were followed up telephonically after 2 weeks of endoscopy for COVID-19 symptoms or confirmed COVID-19. HCWs were screened for symptoms and tested by reverse transcription PCR if indicated (online supplemental material).

    Supplemental material


    All the centres reported 90% reduction in endoscopy procedures similar to 95% reduction during April–May in UK.2 Four out of five centres followed a policy of selective testing if patients had high risk of SARS-CoV-2 infection (online supplemental material). Only one centre followed universal testing for all-comers. All centres used level 2 PPEs for the HCWs during endoscopy and followed recommended disinfection policies (online supplemental material).

    A total of 1549 endoscopic procedures were performed: 1064 (68.7%) oesophagogastroduodenoscopy, 224 (14.5%) colonoscopy, 177 (11.4%) Endoscopic Retrograde Cholangiopancreatography, 61 (3.9%) endoscopic ultrasound and 23 (1.4%) other procedures. Of them, 1134 (73.2%) were performed for urgent, 97 (6.3%) for semiurgent and 318 (20.5%) for elective indications (table 1).3 4

    Table 1

    Endoscopic procedures and practices in different centres during the month of April and May 2020

    Six (0.4%, 95% CI; 0.14%- 0.86% with continuity correction) patients turned out to be COVID-19 positive within 48–72 hours of the endoscopic procedure. Of 74 HCWs, 3 (4%, 95% CI; 0.8% -t 11.4% with continuity correction) developed COVID-19 infection. The risk of a HCWs getting COVID-19 positive after using adequate PPE was 0.26% per 100 endoscopies (figure 1). None of the patients developed COVID-19 after 72 hours up to 2 weeks of endoscopy. This risk of transmission should be viewed in the context of the high transmission phase (4.5%–5.1% swab positivity rate in the community)5 6 in India during that period

    Figure 1

    Distribution of type of endoscopy procedures done in April–May 2020 and risk of infection to patients and healthcare workers. EGD, esophagoduodenoscopy; ERCP, endoscopic retrograde cholangiopancreatography; EUS,endoscopic ultrasound; HCW, healthcare worker.

    The zero risk of cross-infection in the UK study could be due to multiple reasons: (1) deceleration phase of infection, (2) 42% of patients were tested based on SCOTS criteria (telephone screen questions around Symptoms, infectious Contacts, Occupational risk, Travel risk and Shielding status) and only three turned out to be positive and (iii) adherence to infection control practices. A higher rate of infection in our study could be a reflection of community-acquired infection and not necessarily due to endoscopy. It was reassuring that none of the patients developed infection similar to the UK study. These results of both the studies highlight that the risk of transmission is minimal, despite endoscopy being an aerosol-generating procedure, although with strict adherence to infection control policies, adequate use of PPE and criteria-based preprocedure testing rather than mandatory testing as advised by some guidelines such as NICE, UK.3 7 We concur with Hayee et al and recommend gradual resumption of outpatient diagnostics depending on local transmission phase of COVID-19 and report with safety guidance.

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    • Collaborators Members of GAIN Group (in alphabetical order)- All India Institute of Medical Sciences, New Delhi, India: Ashish Agarwal, Samagra Agarwal, Vineet Ahuja, Abhinav Anand, Rajat Bansal, Vikas Banyal, Kaushik Chatterjee, Anugrah Dhooria, Anshuman Elhence, Pramod Garg, Srikanth Gopi, Deepak Gunjan, Yegurla Jatin, Vikas Jindal, Bhaskar Kante, Kanav Kaushal, Saurabh Kedia, Soumya Jagannath Mahapatra, Govind Makharia, Srikant Mohta, Sandeep Kumar Mundhra, Piyush Pathak, Shubham Prasad, Mahendra Singh Rajput, Atul Rana, Anoop Saraya, Pabitra Sahu, Rahul Sethia, Shalimar, Sanchit Sharma, Amit Anurag Singh, Manas Vaishnav, Sudheer Kumar Vuyurru. Post Graduate Institute of Medical Educations and Research, Chandigarh, India: Usha Dutta, Rakesh Kochhar, Harshal S Mandavdhare, Gaurav Muktesh, Praveer Rai, Jayanta Samanta, Vishal Sharma, Jayendra Shukla. Christian Medical College, Vellore, India: Kaushik Chatterjee, Sudipta Dhar Chowdhury, Amit Kumar Dutta, John Titus George, Rajeeb Jaleel, Anjilivelil Joseph, Ebby George Simon. Sanjay Gandhi Post Graduate Institute, Lucknow, India: Ptaviva Chandra, Samir Mohindra, Vivek Saraswat, Jimil Shah. Gobind Ballabh Pant Hospital, New Delhi, India: Roshan George, Arpan Jain, Anurag Mishra, Sanjeev Sachdeva, Alok Kumar Singh.

    • Contributors SJ, AA, DG, SDC, VS, SS, RK and AS: study design, critical inputs, collection of data and manuscript writing. SM, VS and other members of GAIN study group: collection of data.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.