IMPACT OF COVID-19 PANDEMIC ON GASTROINTESTINAL ENDOSCOPY PROCEDURES

Background- COVID-19, an emerging coronavirus disease is a major health problem. It has markedly affected the routine medical procedures including Gastrointestinal(GI) endoscopies. Inspite of guidelines suggested by various GI societies,for safe GI endoscopy procedures in period of COVID pandemic, most of the endoscopists as well as the patients were hesitant for the endoscopy procedures.We sought to measure the impact of the same on GI endoscopy activity in Pune. Method- A pre-validated questionnaire containing 28 questions was sent across to the GI endoscopy surgeons. Responses were collected to assess the perception of GI endoscopists regarding the practice of endoscopy and the risk of self-contamination during COVID-19 Pandemic. This data was analysed using appropriate statistical applications. Result -51 GI endoscopists from Pune participated in our study; out of which 80.3% were involved in the management of COVID-19 patients outside the endoscopy the study


ISSN: 2320-5407
Int. J. Adv. Res. 9 (12), 423-428 424 confirmed a three-fold higher rate of SARS-CoV-2 infection among health care workers than the general population . [6] COVID-19 is thought to spread primarily through droplets of saliva, but airborne transmission and fecal excretion have been documented [7,8] .Periendoscopic aerosolized infections have also been reported, placing upper gastrointestinal (GI) endoscopy among the major aerosol-generating procedures [9] .In particular, while performing gastrointestinal endoscopy, there is risk of exposure to the endoscopists as well as the endoscopy team, including nurses, endoscopy technicians and anesthesia staff [10]. In addition, the high number of patients and accompanying persons visiting an endoscopy unit each day further increases the risk of contaminating the staff. [11] There remains very limited data to have insight into creating a safe model for rationing of GI endoscopy that doesnot compromise patient care.
Endoscopy requires close proximity to patients for a significant length of time, increasing the likelihood of endoscopists being exposed to infection either direct contact or through aerosol generation. Endoscopists and endoscopy staff may therefore have a higher risk of acquiring SARS-CoV-2 [12,13,14] .Several national and international gastrointestinal (GI) societies have released guidelines, to prevent nosocomial transmission and protect healthcare workers and patients, advocating performing only emergency and semiemergency endoscopic procedures and delaying elective endoscopic procedures during COVID-19 pandemic [14,15] .A review of published national and international guidelines emphasized the mandatory use of personal protective equipment (PPE) while performing endoscopies by all GI societies [15] While deferring elective procedures could assist in decreasing the peak of SARS-CoV-2, this strategy was also leading to an exponentially expanding pool of patients with delayed procedures.Moreover, the implementation of these recommendations in endoscopy units across the globe is challenging with wide variations in incidence and health care resources such as personnel, equipment and PPE [16] Based on GI society guidelines, many hospitals stopped elective endoscopic procedures, diverted healthcare providers to participate in dedicated ""COVID-19 teams" and planned a reduction in endoscopy staff. Most nonurgent endoscopic procedures have been restricted as a consequence of COVID-19, however the difference was significant (5 times larger numbers before COVID-19) with the common endoscopic procedures (Esophagogastroduodenoscopy, colonoscopy, Endoscopic Retrograde Cholangiopancreatography and Endoscopic Ultrasonography) which occur daily in most centers with Esophagogastroduodenoscopy being the most affected [17] . Previous reports from China showed marked decrease of the number of endoscopic procedures during COVID-19 compared to 6.3 times higher number of endoscopic procedures before COVID-19 [18] Due to the observed paucity of data in Indian scenario, we determine to conduct a similar study, from March 2020 to July 2021.This survey was conducted to specifically study the impact of COVID-19 on gastrointestinal endoscopy practice in Pune and also to determine the perception of risk of contamination of endoscopists and staff over the period of pandemic.

Implications-
To revise and formulate better guidelines to safeguard endoscopic practices and hence reducing the contamination of patients as well as endoscopy staff.

Methodology:-
This was a cross-sectional study.We performed a web based survey using an online questionnaire. The nature and purpose of the study was explained by the researcher and informed consent was taken from the participants. 200 practicing GI endoscopists in Pune were sent a self-administered, pre-validated questionnaire via Google forms assessing the perception of GI endoscopists regarding the practice of endoscopy and the risk of self-contamination during COVID-19 pandemic. A follow-up reminder through social networks were given 2 days before the closure of the survey responses for those who did not respond initially.We received 51 responses which were automatically retrieved in the excel sheet and analyzed.

Sampling Method
Previous study report stated that 98.7% of GI endoscopy surgeons had to cancel their procedures due to the Covid-19 pandemic [8] .Considering this data with 95% confidence interval and 10% allowable error, the estimated sample size is 48.

Stastical Analysis
For the statistical analysis a Microsoft Office Excel® spreadsheet was used, since only a descriptive analysis was performed. Data were presented as frequencies for categorical variables and medians (IQR) for continuous variables

Results:-
There were 51 GI endoscopists who responded to the survey, with a mean age of 37 years.46 GI endoscopists worked in a private setup , 4 in government hospitals and 3 in non profit hospitals.
Among the 58.82% (30/51) of the responders providing telephone consultations for gastrointestinal symptoms, 80% made <10 phone consultations per day and 3% made >30 phone consultations per day.Nevertheless, 88.2 % responders ultimately cancelled the consultations, as clinical examination was neededfor deciding further plan of treatment. (Fig 1)

Discussion:-
This study definitely gives an idea of the impact and the changes in endoscopy practices, in response to the COVID-19 pandemic, across Pune.In our survey, we observed a major reduction (87%) of GI endoscopy activity in Pune during pandemic.Similarly, reports from New York mention an 80-90% procedural volume reduction and 91.2% reduction in France [11]. M Goenka et al, reported that endoscopy units in India performed <10% of their usual volumes [19]. In addition to the health hazard, human and logistics resources, reallocation in the midst of the pandemic led to this endoscopic "lockdown." We observed that 80.3% of responders and 58.82% of endoscopy staff was requisitioned in COVID 19 healthcare activities, reducing the working manpower of endoscopy units.

DIFFICULTY OBTAINING PPE
Difficulty obtaining PPE Also, the recent guidelines published by various societies recommended categorizing endoscopic procedures into emergency, urgent, and routine endoscopies based on indications, with cancellation and/or postponement of routine endoscopies until the current threat due to COVID-19 was reduced. In our study 78% of the study"s responders only performed emergent endoscopies during the pandemic. 19.60% responders performed endoscopy in COVID 19 positive patients, in our survey.Deferring semi-urgent cases could delay the diagnosis of cancers, and few other illnesses and loss of window of therapeutic intervention (endoscopicallyresectable lesions can become unresectable due to spread). Although multiple GI societies have provided a road map, clinical judgment should prevail, and every case should be individualized to prioritize for endoscopic procedures.
Telehealth is defined as the provision of healthcare remotely by means of a variety of telecommunication tools, including telephones, smartphones, and mobile wirelessdevices, with or without a video connection [20]. It proved to be a valuable tool in providing health care with maintaining safety on either side during pandemic.In our study, 58.82% of GI endoscopists provided telephone consultations for gastrointestinal symptoms.However, remote consultation cannot be an option when physical examination or direct patient contact is required.
The American Gastroenterological Society has stated that for eradication of SARS-CoV-2,standard manual cleaning followed by high-level disinfection could be effective.Although there is a theoretical risk of endoscopes acting as potential vectors for viral infections, so far,there is no published report of SARS-CoV-2 transmission via endoscopes [21] .86.27% of responders used 2% glutarldehyde for disinfecting the endoscope before using it for the next patient.
Given the inherent nature of the procedure, endoscopists are almost always in a "high transmission zone" (within 3 feet of the patients).Johnston et al. reported that during endoscopy, the endoscopists face has significant exposure to potentially infectious biologic samples [22].
Symptoms compatible with COVID-19 infection were reported by 12.8 % of theGI endoscopistsin France [11]. Chen et al. reported that 5.7% gastroenterologists or their colleagues developed work related COVID-19 infections [24]. This could be due to difficulty in obtaining PPE, as reported by our responders.86.6% GI endoscopists believed that they had been contaminated at work.Furthermore, an increased degree of anxiety and burnout were noted among endoscopists . [21] This study has few limitations.It was a web based survey and we could not collect datafrom all endoscopists across Pune due to few limitations and hospital policies.So a limited number of responders with an over representation of private setup and possible bias cannot be ignored.
Hence, this survey cannot be generalized as a representing sample for all.

Conclusion:-
COVID-19 pandemic has seriously affected GI endoscopy practice. COVID 19 infection rate was also remarkable in endoscopists and endoscopy staff. As the screening of patients with GI problems was hampered, there was definitive delay in diagnosis and treatment. Nevertheless, endoscopy centers should adapt and make changes in their practice to face future pandemic, emphasizing safety of staff without delaying patient care.