Catherine Bartnik MD, MPH, University of Pittsburgh Medical Center, Gastroenterology Hepatology Fellowship FIT Board Member
he outbreak of Severe Acute Respiratory Corona Virus 2 (SARSCoV-2), also known as COVID-19 is coming to a community near you. Is your healthcare system and endoscopy suite prepared to handle this rapidly spreading pathogen? As of March 13, 2020, the World Health Organization (WHO) reported 132, 758 confirmed cases worldwide among one hundred twenty-four countries 1 . Within the United States, the Centers of Disease Control (CDC) reported a total of 1,629 cases in forty-seven states, with the highest concentration of cases in California and Washington state. Presently, the mortality of this virus is estimated to be roughly 2-3% in the general population although the elderly that are greater than age 80 years old may have an estimated 10-15% mortality risk. Additional at risk populations are those who are chronically ill and also younger immunocompetent individuals have succumb to respiratory failure and have died as a result of this infection. Our immunosuppressed IBD patients have also been a concern. Fortunately, as of March 8, T
2020, there were no reported cases of COVID-19 from China’s IBD Elite Union patient registry of >20,000 IBD patients 2 . That said, there is much that remains unknown about this infectious agent and nonspecific symptoms and suboptimal detection remain a grave concern. As healthcare professionals, we must stay ahead of this outbreak and prepare ourselves and our health care delivery systems as this virus continues to spread rapidly within the United States.
Within this article, I plan to highlight a summary of this novel pathogen with respect to clinical symptoms and spread, as well as to provide a protocol tailored to gastroenterologists to decrease the risk of transmission to themselves as well as their staff and patients. As a reminder, in order for us to provide quality healthcare, we too must protect ourselves from exposure.
Recently, Guan et al. published a study in the New England Journal of Medicine describing the clinical symptoms of COVID-19, identified among hospitalized patients in Wuhan, China 3 . The most common symptoms included fever (defined as a temperature greater than 37.5C, 88.7% of 1099 cases), cough (67.8%), and shortness of breath (18.7%). Roughly 20% of individuals develop serious illness with pneumonia and acute respiratory distress syndrome requiring mechanical ventilation. While the Wuhan group reported gastrointestinal symptoms to be less common (nausea and/or vomiting at 5% and diarrhea at 3.8% of 1099 cases), the initial presentations of some patients with COVID-19 are primarily gastrointestinal. Hence, a fecal-oral route of transmission is also thought possible in addition to respiratory droplet transmission.
COVID-19 has also been implicated to play a role in liver toxicity with 2-11% of patients developing liver comorbidities 4 . Abnormal AST values identified on presentation correlated with the need of ICU care, whereas those who presented with normal aminotransferase levels were less likely to be cared for in the ICU 4 . The possible mechanism involves viral entry into cholangiocytes mediated by ACE2 receptors found throughout the gastrointestinal tract. An unpublished post mortem analysis of a patient who died from COVID-19 did not have viral inclusion bodies on liver histology in the setting of high viral titers. It is unclear if AST elevations could alternatively be explained by ischemia, hypoxia due to respiratory failure, or drug induced injury. No reported liver transplantation for acute liver failure has occurred in a COVID-19 positive patient thus far.
With respect to spread, we understand that having close contact (within 6 ft) with an infected patient or when handling their secretions increases the likelihood of transmission 1 . Therefore, infection control and prevention remain the cornerstones in curbing further disease spread. As this coronavirus has been found in stool samples of infected patients, endoscopy poses a significant risk of transmission 6 . Likewise, the sterilization and reprocessing of endoscopic equipment presents its own challenges as more frequent sterilization, in the midst of a pandemic, may place greater demand on cleansing solutions and filters depleting
available supplies. Therefore, delay of elective procedures may help conserve supplies and limit infectious transmission. When urgent or emergent cases must be conducted, then a transmission prevention protocol is of paramount priority. We may do very well to learn from fellow gastroenterologist, Professor Zhen Ding, et al in Wuhan, China who have been on the frontline and epicenter of the pandemic 7 (Figure 1).
First and foremost, the Chinese group developed a “Pre-Procedure Time Out” with the purpose to screen patients for active disease as well as to determine the appropriateness of performing an endoscopic procedure. Appropriate procedures were limited to emergent or urgent endoscopy defined as acute GI bleeding, obstructive jaundice with infection, foreign body or esophageal impaction, biliary acute pancreatitis, and feeding tube placement. Prior to rooming, each patient was screened for fever, contact history, and respiratory symptoms. Patients that screen positive for high risk of infection then underwent CBC evaluation to assess for leukopenia, as well as a CT chest to evaluate for pulmonary infection. If a patient was suspected to be infected by COVID-19, they were moved to a negative pressure room for the endoscopy. If a negative pressure room was not available, the procedure room with the optimal ventilation capability was designated for these patients to spare contamination of other rooms. Prior to the start of the procedure, a second “Procedure Time Out” was performed to address appropriate personal protection: each staff member donned a gown, mask, goggle or face shield, and gloves. At the completion of the procedure, care was taken to disinfect all surface areas within the procedure room. All members taking part in the highrisk procedure were instructed to wash their hands after appropriate removal of their personal protective equipment. The waste was then clearly labeled as biohazardous and disposed of according to biohazard protocol. Finally, the health of all personnel involved in the procedure were closely monitored.
As the clinical landscape for this pandemic evolves, we must remember not to panic but to stay calm and reassure both our patients and ourselves. We must remain vigilant, monitor our health, screen all patients regardless of the encounter, and stay informed.
For more information please see the following resources: https://www.cdc.gov/ coronavirus/2019-ncov/hcp/caringfor-patients.html
https://www.cdc.gov/ coronavirus/2019-ncov/downloads/ hcp-preparedness-checklist.pdf
References: 1. World Health Organization. Coronavirus disease (COVID-2019) situation reports (https://www.who.int/emergencies/diseases/ novel-coronavirus-2019/situation-reports). 2. Mao, R, Liang, J, Shen, J, Ghosh, S, Zhu, L, Yang, H et al. Implications of COVID-19 for patients with pre-existing digestive diseases. Lancet 2020; published online March 11, 2020. 3. Guan W-J, Ni Z-Y, Hu Y, et al. Clinical characteristics of 2019 novel coronavirus infection in China. N Engl J Med 2020; published online Feb 28. DOI:10.1056/ NEJMoa2002032 4. Zhang C, Shi L, Wang, F. Liver injury in COVID-19: management and challenges. Lancet 2020. Published online March 4, 2020. 5. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020; 395: 497–506. 6. Yeo C, Kaushal S, Yeo D. Enteric involvement of coronaviruses: is faecal–oral transmission of SARS-CoV-2 possible? Lancet Gastroenterol Hepatol 2020; published online Feb 19. DOI:10.1016/S2468-1253(20)30048-0. 7. Ding, Z. How tomanageendoscopy room during outbreak of the COVID-19 virus: Prof. Zhen Ding. Thai Association of Gastrointestinal Endoscopy. Feb 27, 2020 webinar. (https://www.youtube.com/ watch?v=tVOWgTswkWY).