We aimed to assess the ability of COVID-19 screening tools using patients’ symptoms and preprocedure COVID-19 antibody test to detect preprocedural infection and to prevent nosocomial COVID-19 at gastroenterology units.
This prospective cross-sectional study was conducted at Al Hussein University Hospital, Cairo, Egypt, between April 1 and August 1, 2020. The study was approved by the ethical committee of Faculty of Medicine, Al-Azhar University, Cairo, Egypt (Med._147Med.Research. COVID-19 Screening Before Gastrointestinal Procedures. _00000175). Informed consent was obtained from all individual participants included in the study. Among 144 patients who underwent gastrointestinal procedures, 41 patients were not tested for COVID-19 antibodies and excluded from the study. Finally, 103 patients surveyed for COVID-19 symptoms and COVID-19 rapid IgM/IgG antibodies were included.
All patients who had indications for diagnostic and/or therapeutic gastrointestinal procedures (n=103) underwent prescreening for COVID-19 symptoms. In addition, the occurrence of postprocedure COVID-19 infection was assessed among the included patients and medical staff members working in the gastrointestinal unit (n=18) to assess the efficiency of the proposed prescreening method. Patients who were not tested for COVID-19 antibodies were excluded.
Prescreening for COVID-19
Prescreening included a clinical survey for COVID-19-related symptoms and COVID-19 rapid IgM/IgG antibody testing (n=103 patients). COVID-19-related symptoms included fever ≥ 38°C, cough, dyspnea, sore throat, anosmia, loss of taste, diarrhea, fatigue, myalgia, history of recent travel, and history of contact with COVID-19-infected patients within 2 weeks before the procedure [10]. Also, complete blood count looking for lymphopenia (below 1.0 x 109/L), C-reactive protein (CRP) (positive more than 6 mg/L), and CT chest were done for all patients before procedures. Patients with COVID-19-related symptoms and/or positive COVID-19 antibodies were further tested with RT-PCR to confirm COVID-19.
Postprocedure screening for COVID-19
All patients were contacted (by phone) 14 days after the procedure and asked about the possible development of COVID-19 symptoms [11, 12]. The postprocedural diagnosis of COVID-19 infection was based on a new onset of fever ≥ 38°C and two or more new symptoms: cough, sore throat, dyspnea, anosmia, loss of taste, and diarrhea [13]. Patients with suspected symptoms of COVID-19 were referred to COVID-19 treatment centers.
All HCWs (n=18) were screened weekly for COVID-19-related symptoms. In the setting of a highly suspected COVID-19 [13], the clinical diagnosis was further confirmed by COVID-19 rapid IgM/IgG antibodies and the COVID-19 RT-PCR. Infected HCWs discharged from duty and referred for treatment.
COVID-19 detection by rapid IgM/IgG
SARS-CoV-2 antibodies were detected by a COVID-19 IgM/IgG antibody rapid diagnostic test (SGTi-flex COVID-19 IgM/IgG, Sugentech, South Korea). It is a qualitative immunoassay for the rapid detection of both anti-SARS-CoV-2-IgM and anti-SARS-CoV-2-IgG in the venous blood or plasma with a sensitivity of 92.43% and a specificity of 99.15%, as reported by the manufacturer. The results were analyzed visually after 15–20 min.
COVID-19 detection by RT-PCR
Nasopharyngeal swabs were collected for COVID-19 RT-PCR testing as described previously [14]. Briefly, probes were annealed to three target sequences specific to COVID-19: ORF1ab, nucleocapsid (N), and spike (S) primers/probes for bacteriophage MS2. Two of the three genes and the MS2 (positive control) had to be positive for a diagnosis of COVID-19.
Categorization of procedure urgency
All procedures were categorized as urgent (8–24 h), semiurgent (24 h–7 weeks), and elective (≥ 8 weeks) based on the following indications.
Indications of urgent (8–24 h) endoscopic procedures included upper GIT bleeding, food bolus impaction, lower GIT bleeding (hemodynamically unstable), acute intestinal obstruction, cholangitis with sepsis/septic shock, and biliary leakage. Urgent percutaneous transhepatic drainage (PTD) was indicated in cholangitis with sepsis/septic shock and biliary leakage.
Semiurgent (24 h to 7 weeks) endoscopic procedures were indicated in the following situations: gastric cancer diagnosis, acute-onset dysphagia, lower GIT bleeding (hemodynamically stable), partial intestinal obstruction, new-onset bloody diarrhea with negative cultures, inflammatory bowel disease flare, choledocholithiasis with/without cholangitis, biliary pancreatitis with/without cholangitis, concerns for pancreatic cancer or cholangiocarcinoma, and small-bowel bleeding. Semiurgent indications for radiofrequency ablation (RFA) and transarterial chemoembolization (TACE) included active hepatocellular carcinoma (HCC). Semiurgent liver biopsy was performed for patients with ongoing hepatitis and for those with potentially malignant liver lesions. Semiurgent pigtail insertion and PTD were indicated in patients with active hydatid cysts, choledocholithiasis with or without cholangitis, and biliary pancreatitis with or without cholangitis.
Elective (≥ 8 weeks) endoscopic procedures were performed for the following indications: ampullary adenoma, isolated weight loss, heartburn, dyspepsia/noncardiac chest pain, established dysphagia, Barrett’s esophagus, esophageal varices evaluation or follow-up banding, iron-deficiency anemia, percutaneous endoscopic gastrostomy (PEG) tube placement, chronic diarrhea, colorectal cancer screening, ulcerative colitis with dysplasia, biliary stent replacement, concerns for submucosal mass, double duct sign without a discrete mass, concerns for neuroendocrine tumor, pancreatic cyst evaluation, and small-bowel tumor. Elective pigtail insertion was performed in patients with symptomatic simple liver cysts.
Precautions to prevent infection during gastrointestinal procedures
Based on the COVID-19 RT-PCR results of the included patients, HCWs likely followed the recommended precautions to protect against infection. If patients were negative on COVID-19 RT-PCR, HCWs wore a hair net, surgical mask, face shield, single-use gown, and single pair of gloves. If patients were positive on COVID-19 RT-PCR, the HCWs wore a hair net, N-95 or FFP, 2/3 surgical mask, face shield and goggles, full-sleeve gown, a double layer of gloves, and shoe covers. All rooms were non–negative-pressure and were disinfected at the end of each procedure. All patients wore surgical masks (except during procedures).
Statistical analysis
Data were analyzed using the statistical package for social sciences, version 20.0 (SPSS Inc., Chicago, Illinois, USA). Quantitative data are expressed as the mean ± standard deviation (SD). Qualitative data are expressed as frequencies and percentages.