Dear colleagues and friends,
Welcome to another edition of the Perspectives debates. The COVID-19 crisis has directly affected our endoscopy practices, and it’s raised difficult questions about how best to balance safety with continued delivery of health care services. Dr. John Inadomi and Dr. Shahnaz Sultan address the benefits and downsides of universal testing of patients before endoscopic procedures.
Dr. Charles J. Kahi
I hope you find this debate helpful and informative for your endoscopy unit’s policies as we navigate these uncertain times. As always, I welcome your comments and suggestions for future topics at ginews@gastro.org. Stay safe!
Charles J. Kahi, MD, MS, AGAF, is a professor of medicine at Indiana University, Indianapolis. He is an associate editor for GI & Hepatology News.
Reassurance is important to both patients and providers
The COVID-19 pandemic has been a global economic, societal, and health crisis. As health care systems shifted resources to care for the overwhelming numbers of patients infected with COVID-19 and coincident with lockdown orders issued by local and state governments, elective endoscopy came to a screeching halt. The gastrointestinal professional societies issued a joint statement advocating delays of all elective endoscopies and limiting procedures to those deemed urgent or emergent.1
Dr. John M. Inadomi
Within our GI community, there was great concern raised about the degree of aerosolization and risk of virus transmission during endoscopy and colonoscopy, the type of personal protective equipment (PPE) required to minimize infection risk, and the need for negative pressure rooms or prolonged room turnover to provide adequate air exchange. Our understanding of the role of the GI tract in infection and transmission and presentation with GI symptoms, as well as the true prevalence of asymptomatic infection, was rapidly evolving. Even though our colleagues in Asia and Europe faced the COVID-19 pandemic before we did, we still had no roadmap to navigate these issues.
Public health officials emphasized that a critical step to limit the spread of infection hinged on the availability of accurate and reliable tests. However, during the initial phase of the pandemic, priority was given to patients with symptoms or exposure because of limitations of tests, sampling tools, and reagents. As testing became more available and we began to ramp up endoscopy, the American Gastroenterological Association developed a rapid review and guideline evaluating the role of testing prior to endoscopy.2 In this evidence review and guideline, the authors systematically evaluated the diagnostic accuracy of the reverse transcription polymerase chain reaction (RT-PCR) nucleic acid amplification tests (NAAT) available on the U.S. market and described a framework for how a pre-endoscopy testing strategy could help with triage and decisions around PPE use.
Specifically, they made a conditional recommendation supporting a pre-endoscopy testing strategy: “For most endoscopy centers where the prevalence of asymptomatic SARS-CoV-2 infection is intermediate (0.5%-2%), the AGA suggests implementing a pretesting strategy using information about prevalence and test performance (sensitivity/specificity) in combination with considerations about the benefits and downsides of the strategy.”2 This is a conditional recommendation based on low certainty evidence, underscoring the limitations in the evidence for diagnostic test accuracy of the currently available tests (limited sample sizes, test accuracy only for symptomatic patients, no reference standard) and limited knowledge of the true prevalence of SARS-CoV-2 infection at the population level.
The authors of the recommendations emphasized that preprocedure testing could help decrease the risk of transmission by triage – that is, delaying the procedure of patients with positive tests who could infect other patients and health care workers. In addition, for patients with negative tests, surgical masks can be considered during endoscopy to allow preservation of N95/N99 masks that are a limited resource in many settings.
Varying strategies for reopening endoscopy have been adopted by endoscopy centers and health systems. According to one survey, most of responding U.S. endoscopy centers (87%) had developed a formal COVID-19 mitigation protocol, with only 52% of the responding centers testing all patients prior to endoscopy, which highlights the large variation of policies in clinical practice.3 In making the case for a strategy of pretesting of all patients prior to endoscopy, it’s important to emphasize that the benefits of testing outweigh any downsides and that, for health care professionals and patients alike, providing reassurance about the safety of endoscopy for everyone is an important aspect to resuming endoscopy operations.
Concerns regarding acquiring COVID-19 infection in the workplace and infecting family members was and remains a source of significant stress for endoscopy unit personnel across the U.S. Recognizing these issues, many institutions initiated a program for preprocedure COVID-19 testing for all patients undergoing endoscopy. An online survey completed by 47 endoscopy unit personnel found that, after implementation of pre-endoscopy testing, fewer personnel reported anxiety regarding contracting infection (58.1% before vs. 44.7% after; P < .001), there was less concern about infecting family members (88.4% before vs. 68.4% after; P < .05), and fewer providers reported self-isolation practices (living in a room separate from family) (21.3% before vs. 10.8% after; P < .05).4
Moreover, implementation of a pre-endoscopy testing strategy could decrease patient anxiety and decrease patient reluctance to complete endoscopy. With recognition of the long-term consequences of delaying endoscopic evaluation, especially for colorectal cancer screening and surveillance, improving attendance may lessen the impact on colorectal cancer–related morbidity and mortality and other GI-related conditions.5
A pre-endoscopy testing strategy can inform PPE decisions so that N95s and power air-purifying respirators (PAPRs) are reserved for high-risk procedures (such as EGDs in COVID-19-positive patients) with use of surgical masks or extended/reused N95s for patients who test negative. In addition, preprocedure testing can improve endoscopic efficiency eliminating the need to wait for the necessary amount of air exchange between procedures in test-negative patients. In the last 6 months, the testing landscape has changed significantly with the availability of numerous platforms that allow for more efficient processing of tests and the capability of testing saliva instead of nasopharyngeal or nasal swabs. In addition to the original RT-PCR NAAT, more rapid PCR tests, and antigen tests are available. Testing is no longer a scarce resource and for this reason, we should continue our practice of testing all patients prior to endoscopy. Further studies of the false-negative/false-positive rate of various test modalities and test-timing will be important.
John M. Inadomi, MD, AGAF, is with the department of medicine at the University of Utah, Salt Lake City. He has no conflicts to declare.
References
1. Gastroenterology Professional Society Guidance on Endoscopic Procedures during the COVID-19 Pandemic. American College of Gastroenterology. 2020 Apr 1.
2. Sultan S et al. Gastroenterology. 2020 Nov;159(5):1935-48.e5.
3. Moraveji S et al. Gastroenterology. 2020 Oct 1;159(4):1568-70.e5.
4. Podboy A et al. Gastroenterology. 2020 Oct 1;1586-8.e4.
5. Dekker E et al. Gastroenterology. 2020 Dec;159(6):1998-2003.
