Coronavirus (COVID-19) outbreak: what the department of endoscopy should know

Abstract

Italy recorded its first case of confirmed acute respiratory illness because of coronavirus on February 18, 2020, soon after the initial reports in China. Since that time, Italy and nations throughout the world have adopted very stringent and severe measures to protect populations from spread of infection. Despite these measures, the number of infected people is growing exponentially, with a significant number of patients developing acute respiratory insufficiency. Endoscopy departments face significant risk for diffusion of respiratory diseases that can be spread via an airborne route, including aspiration of oral and fecal material via endoscopes. The purpose of this article is to discuss the measures, with specific focus on personal protection equipment and dress code modalities, implemented in our hospital to prevent further dissemination of COVID-19 infection. Italy recorded its first case of confirmed acute respiratory illness because of coronavirus on February 18, 2020, soon after the initial reports in China. Since that time, Italy and nations throughout the world have adopted very stringent and severe measures to protect populations from spread of infection. Despite these measures, the number of infected people is growing exponentially, with a significant number of patients developing acute respiratory insufficiency. Endoscopy departments face significant risk for diffusion of respiratory diseases that can be spread via an airborne route, including aspiration of oral and fecal material via endoscopes. The purpose of this article is to discuss the measures, with specific focus on personal protection equipment and dress code modalities, implemented in our hospital to prevent further dissemination of COVID-19 infection. Coronaviruses are nonsegmented, enveloped, positive-sense, single-strand RNA viruses.1Weiss S.R. Leibowitz J.L. Coronavirus pathogenesis.Adv Virus Res. 2011; 81: 85-164Crossref PubMed Scopus (586) Google Scholar Six coronavirus species are known to cause human disease. Most of them generally cause mild respiratory disease; however, fatal coronaviruses have emerged periodically in the last decades, such as severe acute respiratory syndrome coronavirus (SARS-CoV) in 2002 and the Middle East respiratory syndrome coronavirus in 2012. In December 2019 the World Health Organization China office was informed of cases of pneumonia of unknown etiology detected in Wuhan,2World Health OrganizationPneumonia of unknown cause—China.https://www.who.int/csr/don/05-january-2020-pneumonia-of-unkown-cause-china/en/Date accessed: February 14, 2020Google Scholar and a new coronavirus, called SARS-CoV-2, was extracted from lower respiratory tract samples of several patients. Since then, as of March 10, 2020 more than 100,000 cases have been confirmed worldwide,3World Health Organization. Coronavirus disease (COVID-2019) situation report—50. Available at: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200310-sitrep-50-covid-19.pdf?sfvrsn=55e904fb_2. Accessed March 10, 2020.Google Scholar with the infection spreading to many countries all over the world. Italy has one of the highest rates with more than 10,000 confirmed infections.3World Health Organization. Coronavirus disease (COVID-2019) situation report—50. Available at: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200310-sitrep-50-covid-19.pdf?sfvrsn=55e904fb_2. Accessed March 10, 2020.Google Scholar As of March 11, 2020, the World Health Organization has declared the infection a pandemic, indicating significant worldwide involvement of the disease (see https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020). The most common symptoms of SARS-CoV-2–related disease, called COVID-19, are fever, weakness, cough, and diarrhea.4National Health Commission of the People’s Republic of ChinaDiagnosis and treatment of new coronavirus pneumonia (version 5).http://www.nhc.gov.cn/Date accessed: January 30, 2020Google Scholar,5Chan Jasper F.W. Yuan S.F. Kok K.H. et al.A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person to-person transmission: a study of a family cluster.Lancet. 2020; 395: 514-523Abstract Full Text Full Text PDF PubMed Scopus (6149) Google Scholar More than half of patients report shortness of breath, with few developing acute respiratory distress syndrome. After septic shock, refractory metabolic acidosis and coagulation dysfunction can lead to death with a case fatality rate reported to be 3.5%.6World Health OrganizationNovel coronavirus (2019-nCoV) situation report.http://www.who.int/docs/default-source/coronavirus/situation-report/20200127-sitrep-7-2019–ncov.pdf?sfvrs n=98ef7 9f5_2Date accessed: March 10, 2020Google Scholar Human-to-human transmission occurs primarily through direct contact or air droplets.7Wang C. Horby P.W. Hayden F.G. et al.A novel coronavirus outbreak of global health concern.Lancet. 2020; 395: 470-473Abstract Full Text Full Text PDF PubMed Scopus (4961) Google Scholar,8Zhu N. Zhang D. Wang W. et al A novel coronavirus from patients with pneumonia in China, 2019.N Engl J Med. 2020; 382: 727-733Crossref PubMed Scopus (18375) Google Scholar The higher risk of transmission is within approximately 1 meter (about 3 feet) from the infected person; however, the maximum distance is still undetermined.9Siegel J.D. Rhinehart E. Jackson M. et al.Health Care Infection Control Practices Advisory Committee. 2007 Guideline for isolation precautions: preventing transmission of infectious agents in health care settings.Am J Infect Control. 2007; 35: S65-164Abstract Full Text Full Text PDF PubMed Scopus (1512) Google Scholar Although healthcare personnel working in endoscopy units are not directly involved in the diagnostic and therapeutic evaluation of COVID-19–positive patients, endoscopy should still be regarded as a risky procedure. This risk of exposure and subsequent infection of endoscopy personnel is, in fact, substantial in cases of patients with respiratory disease that can be spread via an airborne route.10Tang J.W. Li Y. Eames I. et al.Factors involved in the aerosol transmission of infection and control of ventilation in healthcare premises.J Hosp Infect. 2006; 64: 100-114Abstract Full Text Full Text PDF PubMed Scopus (471) Google Scholar A recent study by Johnston et al11Johnston E.R. Habib-Bein N. Dueker J.M. et al.Risk of bacterial exposure to the endoscopists face during endoscopy.Gastrointest Endosc. 2019; 89: 818-824Abstract Full Text Full Text PDF PubMed Scopus (96) Google Scholar confirmed the significant and unrecognized exposure of the endoscopist’s face to potentially infectious biologic samples during endoscopy. Endoscopy procedures demand short physical distance from patients to personnel, and according to studies performed during the global SARS outbreak of 2003, droplets from infected patients could reach persons located 6 feet (approximately 1.83 meters) or more from the source.12Wong T.W. Lee C.K. Tam W. et al.Cluster of SARS among medical students exposed to single patient, Hong Kong.Emerg Infect Dis. 2004; 10: 269-276Crossref PubMed Scopus (219) Google Scholar Finally, we do believe the risk of exposure of endoscopy personnel is not limited to upper endoscopy procedures considering the recent detection of SARS-CoV in biopsy specimens and stools, suggesting a possible fecal–oral transmission.13Gu J. Han B. Wang J. COVID-19: gastrointestinal manifestations and potential fecal-oral transmission.Gastroenterology. 2020; (S0016-5085(20)30281-X)Abstract Full Text Full Text PDF Scopus (1039) Google Scholar This could be even more relevant given that virus transmission can occur during the incubation period in asymptomatic patients. In general, establishing infection prevention measures and guidelines within an endoscopy department is essential for creating a high-quality and extremely safe environment to protect both patients and personnel. In this new era of the COVID-19 outbreak, it is imperative that these measures be implemented and maintained to avoid further unrecognized spread of the disease. The median estimated incubation period of the virus is about of 5.5 days, with a range from 0 to 14 days. Robust evidence coming from China and Italy confirms that about 80% of patients have asymptomatic or mild disease and that the median patient age is less than 60 years.4National Health Commission of the People’s Republic of ChinaDiagnosis and treatment of new coronavirus pneumonia (version 5).http://www.nhc.gov.cn/Date accessed: January 30, 2020Google Scholar,5Chan Jasper F.W. Yuan S.F. Kok K.H. et al.A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person to-person transmission: a study of a family cluster.Lancet. 2020; 395: 514-523Abstract Full Text Full Text PDF PubMed Scopus (6149) Google Scholar,7Wang C. Horby P.W. Hayden F.G. et al.A novel coronavirus outbreak of global health concern.Lancet. 2020; 395: 470-473Abstract Full Text Full Text PDF PubMed Scopus (4961) Google Scholar These data clearly show that a significant number of patients undergoing endoscopy procedure may fall in the category of asymptomatic carriers and preventive measures are necessary to avoid massive endoscopy-related diffusion of the virus. A tricky issue in this epidemic context is patient risk stratification and definition of subgroups of patients. We believe it is important to adopt a common definition of potential COVID-19 patients. According to several recently issued guidance, COVID-19 should be considered in anybody who has been in contact with confirmed SARS-CoV-2 infection or has returned from a high-risk country in the 14 days before the onset of following symptoms: fever (even without respiratory symptoms), cough, acute respiratory infection of any degree and severity (with or without fever), severe acute respiratory infection requiring hospital admission, and clinical/radiologic evidence of pneumonia. Contacts are defined as those living in the same household as a patient with a confirmed infection, those with direct or face-to-face contact (for any length of time) with an infected person or with his or her biologic fluids without wearing appropriate protective dress code, or those who have come within 2 meters (about 6½ feet) from a person with a confirmed infection. The classification of high-risk countries will be in constant evolution, but as of March 2, 2020 several countries have been categorized as highest-risk (category 1) and high-risk (category 2) as seen in Figure 1. Given the rapidly evolving epidemiology, hospitals should stay up to date through their national disease control centers. For U.S. hospitals the Centers for Disease Control and Prevention (https://www.cdc.gov/coronavirus/2019-ncov/travelers/index.html) provides up-to-date information. The World Health Organization provides similar information (https://www.who.int/health-topics/coronavirus). Once a patient is scheduled for an endoscopic procedure, the risk of COVID-19 infection should be checked and stratified individually. The day before the procedure, all patients should be called and surveyed about symptoms of a respiratory infection and potentially rescheduled according to the specific patient’s disease and condition. When the patient reaches the hospital, a nurse-directed triage protocol should be to stratify the risk of COVID-19 (Table 1), using the following questions14Razai M.S. Doerholt K. Ladhani S. et al.Coronavirus disease 2019 (COVID-19): a guide for UK GPs.BMJ. 2020; 368: m800Crossref PubMed Scopus (104) Google Scholar:•In the last 14 days have you had fever (>37.5°C or 99.5°F), cough, sore throat, or respiratory problems?•Have you had family or close contact with a suspicious or confirmed case of COVID-19?•Do you come from areas at higher risk of COVID-19?Table 1Potential SARS-CoV-2 infection risk in endoscopy patientsClassification of potential SARS-CoV-2 infection risk in patients undergoing endoscopic examinationLow risk▪No symptoms (eg, cough, fever, breathlessness, diarrhea)▪No contact with SARS-CoV-2–positive person▪Nonstay in high-risk area during the previous 14 daysIntermediate risk▪Presence of symptoms with ○No medical history for contact with SARS-CoV-2–positive person○Nonstay in high-risk area during the previous 14 days▪No symptoms but ○Contact with SARS-CoV-2–positive person○Stay in high-risk area during the previous 14 daysHigh risk∗In an emergency setting, all procedures must be considered high risk if adequate patient history cannot be assessed.▪At least 1 symptom + 1 of the following:○Contact with SARS-CoV-2–positive person○Stay in high-risk area during the previous 14 daysSARS-CoV, Severe acute respiratory syndrome coronavirus.∗ In an emergency setting, all procedures must be considered high risk if adequate patient history cannot be assessed. Open table in a new tab SARS-CoV, Severe acute respiratory syndrome coronavirus. If a patient is referred by a different healthcare facility, the same triage protocol is delivered by phone the same day of the procedure before the patient leaves the facility. This is instrumental to allow endoscopy personnel to prepare for the patient. We also suggest checking the patient’s body temperature before entering in endoscopy and to reclassify those patients with a temperature above 37.5°C (99.5°F). Based on this preliminary screening, patients can be classified as low, intermediate, and high risk, which translates to different modalities of infection control precautions. Caregivers and relatives of patients are strictly prohibited from entering the endoscopy department unless the patient requires specific assistance and translation service. We recommend regular phone follow-up with a dedicated triage at 7 and 14 days after endoscopy procedure for all patients until this infectious outbreak is completely resolved. Personal protective equipment (PPE) is worn to reduce exposure to hazards that cause workplace injuries and illnesses. PPE may include gloves, goggles, face shields, gowns, and respiratory protective equipment.15European Centre for Disease Prevention and ControlPersonal protective equipment (PPE) needs in healthcare settings for the care of patients with suspected or confirmed novel coronavirus (2019-nCoV) 2020. European Centre for Disease Prevention and Control, Stockholm, Sweden2020Google Scholar One of the most important pieces of protective equipment is the facemask, whose primary function is to keep respiratory particles from the source such as splashes, saliva, or mucus from contaminating the work environment. Medical or surgical facial masks are defined as loose-fitting, disposable devices that create a physical barrier between the mouth and nose of the wearer and potential contaminants in the immediate environment. The standard facial mask may be effective in blocking splashes and large-particle droplets but by design does not filter or block very small particles in the air that may be transmitted by coughs, sneezes, or certain medical procedures and does not provide complete protection from germs and other contaminants. On the other hand, respirators protect the wearer against potentially hazardous particles created by the work environment. More specifically the N95, filtering facepiece (FFP) 2, or FFP3 respirator is a protective device designed to achieve a very close facial fit and extremely efficient filtration of airborne particles (up to .3 μm) that can be inhaled through the nose or mouth. The edges of the respirator are designed to form a seal around the nose and mouth. As a general measure, as of March 4, 2020 the World Health Organization recommends respiratory protection for providers with use of the standard medical mask. This means that all personnel not directly in close contact with patients (those in charge of endoscope disinfection, etc) need to constantly wear the medical mask for the time they stay in the hospital. All patients entering the endoscopy unit should be invited to wear a surgical mask. In addition, those classified as intermediate risk or high risk should wear a surgical mask and gloves. The surgical mask has to be removed just before commencing the procedure. Because most endoscopic procedures are performed with the patient under conscious or deep sedation, we adopted the policy to replace the mask again once the patient has recovered from sedation sufficiently to maintain oxygen saturation above 90% on room air. All staff involved in the endoscopy department are invited to follow standardized precautions as a measure for optimal infection control among employers. We recommend that personnel keep a reasonable distance from every patient during all steps taken before beginning endoscopic procedures (informed consent signature, vital signs recording, patient instructions for the procedure, etc). It is mandatory to wash hands with soap and water or alcohol-based hand rub before and after all patient interaction, contact with potentially infectious sources, and before putting on and on removal of PPE, including gloves. The minimal composition of a set of PPE for personnel in endoscopy should be modified on the basis of risk stratification, as shown in Figure 2. In a time when shortage of devices may happen, we strongly discourage the reuse of any disposable device. In case of shortages, alternatives to respirators should be considered, including other classes of FFP respirators, elastomeric half-mask, and full face-piece air-purifying respirators. The U.S. Centers for Disease Control and Prevention provide detailed, graphic instructions on proper use of PPE in the setting of COVID-19 (see https://www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf). The first PPE to be donned is the hairnet. Always check that the equipment has not expired because this will compromise their integrity. Then, proper hand hygiene should be performed using an alcohol-based solution. The second PPE to be worn is the gown; in case of a gown with back closure, a second operator should assist in closing up the back. After the gown, donning a filtering face-piece (N95, FFP2, or FFP3) respirator is recommended; it is crucial to perform a fitting test after the equipment has been put on the face. In case of shortage of filtering face-piece respirators, the use of a surgical mask as substitution is recommended. Once the respirator has been correctly positioned, the is for are should 2 of gloves, 1 of the up to the (eg, surgical and 1 of gloves, the the of the the removal of the PPE is an essential and crucial of the procedure that needs to be to prevent from because the PPE could by be The are removed first because they are considered to be of alcohol-based hand should be considered before the gloves. Once the are hand hygiene should be performed a new of should be worn to prevent and to the procedure Once the new of are the gown should be using a second operator to assist for with back protection should be removed When or face shields, the which can be by droplets or should be of respiratory protection it is important not to the respirator during its After the should be taken The last PPE to be removed are the of which may be After hand hygiene should be Despite for Endoscopy to perform endoscopic procedures in a et in Endoscopy for infection control during endoscopy.Gastrointest Endosc. Full Text Full Text PDF PubMed Scopus Google Scholar in most endoscopy around the world this is not it is to at least 1 endoscopic room with a to be for all patients with respiratory When this is not we recommend endoscopy on patients who are high risk or for SARS-CoV-2 in located the endoscopy department as as this is to perform any endoscopy procedure and The guidelines for infection control in the endoscopy unit can be and are in at the European of Endoscopy et of and endoscopic in gastrointestinal of the European of Endoscopy and European of and PubMed Scopus Google Scholar recommend that all and should be with a standardized procedure. for this purpose should be according to the European The must be as and against and of and virus transmission have been reported in the medical but have been to and When all guidelines are strictly the risk of transmission of any of is extremely to This is we have and personnel on the of strictly following endoscope policy as a safe and efficient to prevent the spread of infection. endoscopy department should have a to the of including and agents for and the procedure at the of The should include of all in the procedure room to all and by proper et in Endoscopy for infection control during endoscopy.Gastrointest Endosc. 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