Endoscopy infection control strategy during the COVID-19 pandemic: experience from a tertiary cancer center in Brazil

Pombo, Amanda A.M.; Lenz, Luciano; Paulo, Gustavo A.; Santos, Mônica A.; Tamae, Patricia K.; Santos, Alisson L.D.R.; Rezende, Daniel T.; Martins, Bruno; Kawaguti, Fabio S.; Pennachi, Caterina M.P.S.; Gusmon-Oliveira, Carla C.; Uemura, Ricardo S.; Geiger, Sebastian; Lima, Marcelo S.; Baba, Elisa R.; Figueiredo, Viviane R.; Safatle-Ribeiro, Adriana; Maluf-Filho, Fauze; Ribeiro-Júnior, Ulysses

doi:10.6061/clinics/2021/e2280

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ORIGINAL ARTICLE • Clinics 76 • 2021 • https://doi.org/10.6061/clinics/2021/e2280 copy

Endoscopy infection control strategy during the COVID-19 pandemic: experience from a tertiary cancer center in Brazil

Authorship SCIMAGO INSTITUTIONS RANKINGS

OBJECTIVES:

Strategic planning for coronavirus disease (COVID-19) care has dominated the agenda of medical services, which have been further restricted by the need for minimizing viral transmission. Risk is particularly relevant in relation to endoscopy procedures. This study aimed to describe a contingency plan for a tertiary academic cancer center, define a strategy to prioritize and postpone examinations, and evaluate the infection rate among healthcare workers (HCWs) in the endoscopy unit of the Cancer Institute of the State of São Paulo (ICESP).

METHODS:

We created a strategy to balance the risk of acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and to mitigate the effects of postponing endoscopic procedures in oncological patients. A retrospective analysis of prospectively collected data on all endoscopies between March and June 2020 compared with those during the same period in 2019 was carried out. All HCWs were interviewed to obtain clinical data and SARS-CoV-2 test results.

RESULTS:

During the COVID-19 outbreak, there was a reduction of 55% in endoscopy cases in total. Colonoscopy was the most affected modality. The total infection rate among all HCWs was 38%. None of the senior digestive endoscopists had COVID-19. However, all bronchoscopists had been infected. One of three fellows had a serological diagnosis of COVID-19. Two-thirds of all nurses were infected, whereas half of all technicians were infected.

CONCLUSIONS:

In this pandemic scenario, all endoscopy services must prioritize the procedures that will be performed. It was possible to maintain some endoscopic procedures, including those meant to provide nutritional access, tissue diagnosis, and endoscopic resection. Personal protective equipment (PPE) seems effective in preventing transmission of COVID-19 from patients to digestive endoscopists. These measures can be useful in planning, even for pandemics in the future.

COVID-19; Cancer; Endoscopy; Strategy

SOCIETY	RECOMMENDATIONS
ASGE (American Society of Gastrointestinal Endoscopy)	In the pandemic area, the indications include management of upper gastrointestinal bleeding, acute cholangitis, foreign body, and obstructions. Care (initial diagnosis, biopsy, staging, palliation of biliary and luminal obstruction) of cancer patients may also be considered urgent. Reschedule nonurgent endoscopy services. This measure is aimed at reducing the risk of infection spread from asymptomatic patients, reducing the risk of cross-infection among patients, reducing the use of PPE^* * PPE: Personal protective equipment. , and reducing unnecessary admissions to free up hospital resources.
ESGE (European Society of Gastrointestinal Endoscopy) and ESGENA (European Society of Gastroenterology and Endoscopy Nurses and Associates)	GI^ GI - Gastrointestinal. endoscopy units should strongly consider temporarily postponing elective, nonurgent endoscopy procedures, according to availability of local human resources and local policies that may depend on regional/national pandemic rules/regulations
	1. The following list of GI endoscopy procedures should always be performed
	▪ Acute upper/lower GI bleeding with hemodynamic instability ▪ Capsule/enteroscopy for urgent/emergent bleeding ▪ Anemia with hemodynamic instability ▪ Foreign body in esophagus and/or high-risk foreign body in the stomach ▪ Obstructive jaundice ▪ Acute ascending cholangitis
	2. During the current COVID-19 pandemic, the following list of GI endoscopy procedures should be postponed with no need to reschedule before 12 weeks (low priority)
	▪ Surveillance for: Barrett’s esophagus without dysplasia or low-grade dysplasia or after endoscopic treatment, gastric atrophy/intestinal metaplasia, inflammatory bowel disease - primary sclerosing cholangitis ▪ Post-endoscopic resection (including immediate endoscopy after resection), surgical resection of cancer or post-polypectomy surveillance ▪ Diagnosis/surveillance of lynch syndrome and other hereditary syndromes ▪ Diagnosis of irritable bowel syndrome-like symptoms ▪ Diagnosis of reflux disease, dyspepsia (no alarm symptoms) ▪ Screening in high-risk patients for esophageal cancer, gastric cancer, colon cancer (primary screening endoscopy) or pancreatic cancer ▪ bariatric GI endoscopy procedures (e. g., intra-gastric balloons, endoscopic sleeve gastroplasty)
	3. Each of the following GI endoscopy procedures warrant a case-by-case evaluation according to medical necessity.
SOBED (Brazilian Society of Gastrointestinal Endoscopy)	All patients who are candidates for endoscopic procedures should be considered HIGH RISK.
	Thus, part of the endoscopic examinations considered ELECTIVE should be postponed until the outbreak is controlled, which will be duly communicated in subsequent updates to this recommendation.
	There are, however, some ELECTIVE examinations that can be considered ELIGIBLE for performance during the pandemic, considering the determinations of the local CRMs (National Medical Council), the local epidemiological situation, and the ability of the endoscopy service to fully comply with the biosafety determinations recommended by ANVISA (National Health Surveillance Agency).

	03/19/2019 - 06/19/2019	03/19/2020 - 06/19/2020	Variation
Endoscopy	1114	596	-46%
Rectoscopy	133	45	-66%
Colonoscopy	589	122	-79%
Enteroscopy	4	4	0%
ERCP^* * ERCP: Endoscopic retrograde cholangiopancreatography.	41	40	-2.40%
EUS^ EUS - Endoscopic ultrasound.	29	35	+20%
TOTAL	1910	842	-56%

	03/19/2019 - 06/19/2019	03/19/2020 - 06/19/2020	Variation
Bronchoscopy	103	62	-39.80%
EBUS^* ***** EBUS center Endobronchial ultrasound.	28	14	-50%
TOTAL	131	76	-42%

Group	TOTAL	Infected workers (%)
Digestive Endoscopists	13	0 (0)
Bronchoscopists	2	2 (100)
Fellows	3	1 (33.3)
Nurses	6	4 (66.7)
Technicians	18	9 (50.0)
TOTAL	42	16 (38.1)

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E-mail: clinics@hc.fm.usp.br

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[1] *Corresponding author. E-mail: adriana.safatle@hc.fm.usp.br