Joint Guidance from the Society of Gastrointestinal Endoscopy of India (SGEI), Indian Society of Gastroenterology (ISG), and Indian National Association for Study of the Liver (INASL) for Gastroenterologists and Gastrointestinal Endoscopists on the Prevention, Care, and Management of Patients with COVID-19

Background

Coronavirus disease 2019 (COVID-19), which is caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, known also as novel coronavirus 2019), is currently occurring as a pandemic. It first appeared in December 2019 in Wuhan city, located in the Hubei region of China, and was soon followed by a quick spread to nearby provinces of China and to its neighboring countries. As of March 26, 2020, the infection has been reported from 198 countries and has affected more than471,000 people worldwide, with more than 21,000 deaths (https://www.worldometers.info/coronavirus/).

COVID-19 most often presents with a recent-onset fever, dry cough, weakness, and sore throat. Up to 50% of patients may report shortness of breath, and a few develop acute respiratory distress syndrome. Nasal symptoms are infrequent. Asymptomatic infection can also occur; however, in the absence of a serological test, its frequency remains unclear. The case fatality rate has been reported between 1 and 3.5%, but may depend on case definition; for instance, if milder cases or asymptomatic persons are tested, diagnosed, and included in the case count, the mortality rate would appear to be low. Human-to-human transmission occurs primarily through direct contact through air droplets. The mean incubation period is 5 days (range: 0–14 days). Spread from asymptomatic persons in the late incubation period can occur; however, most of the viral spread appears to occur from symptomatic persons. Older people and the immunocompromised individuals are at particular risk of severe disease and death.

Gastrointestinal (GI) symptoms including nausea and/or diarrhea have been reported to occur in 5 to 50% of infected individuals in various series. Liver enzymes are abnormal in a quarter of cases. Viral RNA is detectable in stool and may persist for longer than the acute illness; however, whether this represents the presence of viable virus and the risk of transmission remains unclear. Meanwhile, it appears prudent to consider GI secretions as infective, capable of causing fecal–oral transmission, and associated with a potential for transmission of the virus during endoscopic procedures from patient to patient or from a patient to health care workers (HCWs).

In GI endoscopy units, several staff members including physicians and other HCW often work at a very short physical distance from patients. Furthermore, they are frequently exposed to splashes, air droplets, mucus, or saliva during GI endoscopy procedures. Endoscopy is potentially an aerosol producing procedure and the risk of exposure may be particularly high during intubation with an endoscope that can occasionally induce coughing or violent retching. Or, if unexpected respiratory adverse event occurs during endoscopy with or without the need of placement of an endotracheal tube.

The best personal protection techniques currently recommended at all times are as follows:

• Frequent and thorough handwashing (with soap and water or antiseptic handwash solutions, preferably those containing 60% alcohol).

• Avoiding touching one’s face, mouth, or nose with unwashed hands.

• Following cough and sneezing etiquette.

• Maintaining physical distance from other people and avoiding crowds.

In addition, in health care settings including in endoscopy suites, wearing surgical masks by HCWs may help prevent exposure to infectious material from an infected patient source such as splashes, saliva, or mucus. Though this practice is very useful, it may not be sufficient enough to provide complete protection from exposure to the virus and other contaminants to the wearer.

With an increasing number of COVID-19 cases in India (673 cases including 13 deaths on March 26, 2020), it is felt that GI health professionals need to be aware of the disease and how to prevent COVID-19 transmission and manage patients during the ongoing COVID-19 pandemic.

Keeping this in view, the three Indian professional bodies in the field of GI disease, namely the Society of Gastrointestinal Endoscopy of India (SGEI), Indian Society of Gastroenterology (ISG), and Indian National Association for the Study of the Liver (INASL), have come up with this guidance for gastroenterologists and GI endoscopists who are involved in providing care to patients with GI and liver disease.

Since the available scientific evidence on the disease is scanty, these recommendations are mostly based on expert opinion and knowledge derived from other pathogens with similar characteristics. However, the guidance represents what is believed to be the best current understanding and prudent clinical practice and should generally serve the gastroenterology community well.

These recommendations are divided into two sections, namely (1) those related to endoscopic procedures and (2) other important aspects of patient care in the face of the COVID-19 pandemic.

Publication History

Article published online:
06 April 2020

• Bibliography

• 1 Government of India, Ministry of Health & Family Welfare, Directorate General of Health Services (EMR Division). Guidelines on Clinical Management of COVID-19. Available at: https://www.mohfw.gov.in/pdf/GuidelinesonClinicalManagementofCOVID1912020.pdf. Accessed March 16, 2020
• 2 American Gastroenterological Association. Joint GI society message: COVID-19 clinical insights for our community of gastroenterologists and gastroenterology care providers. Available at: https://www.gastro.org/press-release/joint-gi-society-message-covid-19-clinical-insights-for-our-community-of-gastroenterologists-and-gastroenterology-care-providers. Accessed March 26, 2020
• 3 Repici A, Maselli R, Matteo R. et al. Coronavirus (COVID-19) outbreak: what the department of endoscopy should know. Gastrointest Endosc 2020 (e-pub ahead of print)
• 4 Gu J, Han B, Wang J. COVID-19: gastrointestinal manifestations and potential fecal-oral transmission. Gastroenterology 2020 (e-pub ahead of print)
• 5 Repici A, Maselli R, Matteo R. et al. Coronavirus (COVID-19) outbreak: what the department of endoscopy should know. Gastrointest Endosc 2020 (e-pub ahead of print)
• 6 Huang C, Wang Y, Li X. et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020 395 (10223): 497-506
• 7 World Endoscopy Organization. WEO ALERT: Wuhan proposal for Safety in Digestive Endoscopy. Available at: http://www.worldendo.org/2020/02/05/weo-alert-wuhan-proposal-for-safety-in-digestive-endoscopy/. Accessed March 26, 2020
• 8 Centers for Disease Control and Prevention. Interim U.S. Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease (COVID-19). Available at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html. Accessed March 26, 2020
• 9 British Society of Gastroenterology. Advice for Endoscopy Teams during COVID-19. Available at: https://www.bsg.org.uk/wp-content/uploads/2020/03/Advice-for-Endoscopy-Teams-during-COVID-ver-2-4-published-22032020FINAL-1.pdf. Accessed March 26, 2020
• 10 World Endoscopy Organization. Advice to Endoscopists. Available at: http://www.worldendo.org/wp-content/uploads/2020/03/WEO_Advice_To_Endoscopists_COVID-19_032020.pdf. Accessed March 26, 2020
• 11 Mao R, Liang J, Shen J. et al; Chinese Society of IBD, Chinese Elite IBD Union; Chinese IBD Quality Care Evaluation Center Committee. Implications of COVID-19 for patients with pre-existing digestive diseases. Lancet Gastroenterol Hepatol 2020 (e-pub ahead of print)
• 12 Das Gastroenterologie Portal. 2nd Interview COVID-19 ECCO Taskforce. Available at: http://dasgastroenterologieportal.de/Interview_der_ECCO_zu_COVID_19.html. Accessed March 26, 2020
• 13 Indian Council of Medical Research. Recommendation for empiric use of hydroxy-chloroquine for prophylaxis of SARS-CoV-2 infection. Available at: https://icmr.nic.in/sites/default/files/upload_documents/HCQ_Recommendation_22March_final_MM.pdf. Accessed March 26, 2020
• 14 Danese S, Cecconi M, Spinelli A. Management of IBD during the COVID-19 outbreak: resetting clinical priorities. Nat Rev Gastroenterol Hepatol 2020 (e-pub ahead of print)
• 15 Gautreta P, Lagiera J-C, Parola P. et al. Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an openlabel non-randomized clinical trial. Int J Antimicrob Agents 2020 (e-pub ahead of print)
• Information for transplant professionals and community members regarding 2019 novel coronavirus at the American Society of Transplantation website: https://www.myast.org/information-transplant- professionals-and-community-members- regarding-2019-novel-coronavirus