Personal Protective Equipment for Endoscopy in Low-Resource Settings During the COVID-19 Pandemic

Guidance From the World Gastroenterology Organisation

Abstract

Performance of endoscopic procedures is associated with a risk of infection from COVID-19. This risk can be reduced by the use of personal protective equipment (PPE). However, shortage of PPE has emerged as an important issue in managing the pandemic in both traditionally high and low-resource areas. A group of clinicians and researchers from thirteen countries representing low, middle, and high-income areas has developed recommendations for optimal utilization of PPE before, during, and after gastrointestinal endoscopy with particular reference to low-resource situations. We determined that there is limited flexibility with regard to the utilization of PPE between ideal and low-resource settings. Some compromises are possible, especially with regard to PPE use, during endoscopic procedures. We have, therefore, also stressed the need to prevent transmission of COVID-19 by measures other than PPE and to conserve PPE by reduction of patient volume, limiting procedures to urgent or emergent, and reducing the number of staff and trainees involved in procedures. This guidance aims to optimize utilization of PPE and protection of health care providers.

We aim to provide guidance with regard to the utilization of personal protective equipment (PPE) for the prevention of infection from COVID-19 in health care workers performing gastrointestinal (GI) endoscopy, with special reference to low-resource situations.

Endoscopic procedures will be indicated in some patients who are infected with COVID-19, or whose status is unknown. These procedures pose a transmission risk to the physicians, nurses, and technicians involved.¹ Prevention of infection of health care personnel and of patients attending health care facilities is important, as the infection is associated with significant morbidity and mortality.

Ideally, appropriate and optimal PPE would be used in every procedure. However, PPE shortages have emerged as a key issue in the pandemic,² even in traditionally high-resource areas. Shortage may be particularly problematic in low and medium Human Development Index (HDI) countries where, even under normal conditions, resources are limited.³

The mission of the World Gastroenterology Organisation (WGO) is focused on improving GI health in low-resource localities. WGO Cascades are guidelines formulated to outline options stratified by high, medium, and low-resource situations.⁴ This cascade will outline the ideal resources when no equipment restrictions are in place, and the options for when restrictions on ideal practice occur.

For the purposes of this document, respirator refers to N95, FFP2, FFP3, or higher levels of upper airway protection. Powered Air Purifying Respirator systems are effective but are not in widespread use.

METHODS

The Research Committee of the WGO reviewed the literature and national guidelines with special reference to low-resource countries. Nineteen clinicians and researchers, many with direct experience of treating COVID-19, from 13 countries of varying HDI were involved. A literature search was conducted on PPE and endoscopy in low-resource settings. Relevant selected literature results were shared with all members. Owing to resources and time constraints, no preliminary PICO-based statements were formulated; neither the level of evidence nor recommendations were formally graded, but the group followed a modified Delphi consensus process to produce the recommendations.

Only low, or very-low evidence was identified, which might guide recommendations in this setting. Moreover, much of the published literature on COVID-19 and endoscopy is in the form of preprints and may not have been peer-reviewed. The recommendations for low-resource settings are, therefore, based on available data reflecting poor certainty and expert opinion.

When the committee members were not unanimous on a recommendation, the issue was put to a vote with 60% in favor being taken as the threshold for acceptance of a recommendation.

Context

This guidance has been developed in the context of the acute first wave of the pandemic and for countries experiencing a significant burden of disease, community spread, and health care strain. As incidence waxes and wanes, it will be necessary to adjust PPE strategy accordingly. This has not been addressed in this report.

Recommendations

Eighteen headline recommendations and 64 subrecommendations were generated for PPE use in ideal and low-resource situations. Table 1 compares these to the recommendations of several national societies. The recommendations cover PPE conservation and use in preprocedure, intraprocedure, and postprocedure settings and are listed in Tables 2–4. The rationale behind each recommendation is also stated.

TABLE 1 - Summary of Evidence From Selected National and International Societies Compared With WGO Recommendations

Society	WGO	AGA	APSDE	BSG	CAG	ESGE, ESGNA	SGEI, ISG, INASL
1. Reduce procedures	Yes	Yes	Yes	Yes	Yes	Yes	Yes
2. Reduce visits	Yes	Yes	Yes	Yes	Yes	Yes	Yes
3. Screen and stratify risk	Yes	No	Yes	No	Yes	Yes	Yes
4. Reduce risk from patients	Yes	NA	NA	Yes	NA	Yes	Yes
5. Reduce risk to patients	Yes	NA	NA	NA	NA	Yes	Yes
6. Reduce risk to staff	Yes	Yes	Yes	Yes	NA	Yes	Yes
7. Train staff in PPE use	Yes	Yes	Yes	Yes	NA	Yes	Yes
8. Hand hygiene	Yes	NA	Yes	Yes	NA	Yes	Yes
9. Respirator for upper	Yes	Yes	Yes HRC	Yes FFP3	Yes	HRC only	NA
10. Respirator for lower	Yes HR only HRC for LR	Yes	Yes HRC	Yes HR	No	HRC only	NA
11. Double glove	No	Yes	No	No	Yes HRC	Yes HRC	NA
12. Wear face shield or goggles	Yes	NA	Yes HRC	Yes upper	Yes	Yes	Yes
13. Wear scrubs, gown, and hair cover	Yes	NA	Yes	Yes	Yes	Yes	Yes
14. Wear work footwear	Yes	NA	NA	NA	NA	NA	NA
15. Ventilation of room	Yes	Yes	Yes HRC	NA	NA	Yes	Yes HRC
16. Reprocessing staff wear PPE	Yes	NA	Yes	NA	NA	Yes	NA
17. Cleaning staff wear PPE	Yes	NA	Yes HRC	NA	NA	NA	NA
18. Clean room	Yes	NA	Yes HRC	NA	NA	Yes	Yes

AGA indicates American Gastroenterological Association⁵; APSE, Asian Pacific Society for Digestive Endoscopy⁶; BSG, British Society of Gastroenterology⁷; CAG, Canadian Association of Gastroenterology⁸; ESGE, ESGNA, European Society of Gastrointestinal Endoscopy, European Society of Endoscopy Nurses and Associates⁹; HR, high resource; HRC, high risk of COVID-19; LRC, low risk of COVID-19; NA, not addressed; No, not recommended; PPE, personal protective equipment; SGEI, ISG, INASL, Society of Gastrointestinal Endoscopy of India, Indian Society of Gastroenterology, Indian Society for Study of the Liver¹⁰; WGO, World Gastroenterology Organisation; Yes, recommended.

TABLE 2 - Preprocedure Recommendations

			Resources
Recommendations			Ideal	Low
1	Reduce the number of endoscopies being performed
	1.1	Triage referrals based on urgency	X	X
	1.2	Postpone non–time-sensitive procedures	X	X
	1.3	Monitor postponed procedures for status change	X	X
2	Reduce the number of patient visits to health care facilities
	2.1	Minimize patient visits to health care facilities	X	X
	2.2	Provide remote care visits	X	X
	2.3	Reschedule non–time-sensitive consults and follow-up	X	X
3	Screen all endoscopy patients for COVID-19
	3.1	Stratify by risk level	X	X
	3.2	Perform screening by questionnaire, temperature check	X	X
	3.3	Supplement clinical screening with polymerase chain reaction or rapid antigen testing	X
	3.4	In a low-incidence area, with a low-risk patient, it is acceptable to use reduced PPE		X
4	Reduce risk of patients transmitting infection in the endoscopy facility
	4.1	All patients should wear a surgical mask and disinfect hands	X	X
	4.2	Place a glass barrier between patient and interviewer	X	X
	4.3	If glass barrier is not available, interviewer should wear eye protection	X	X
	4.4	Interviewer should wear surgical mask and gloves for contact with low-risk patients, full PPE for high risk	X	X
	4.5	Caregivers and relatives should not visit the endoscopy unit	X	X
	4.6	Low-risk patients can wear a cloth mask instead of a surgical mask		X
5	Reduce risk of patients acquiring SARS-CoV-2 infection in the endoscopy facility
	5.1	Enforce physical distancing in the endoscopy facility	X	X
	5.2	Schedule procedure start times to minimize congestion	X	X
	5.3	Instruct staff to stay home if they have symptoms or unprotected contact with a COVID-19 individual	X	X
6	Reduce risk of staff acquiring SARS-CoV-2 infection in the endoscopy facility
	6.1	Minimize the number of staff in the procedure room	X	X
	6.2	Do not involve trainees in procedures for high-risk COVID-19 patients	X	X
	6.3	Ensure that all equipment is in the procedure room at the start	X	X
	6.4	Do not substitute staff during the procedure	X	X
	6.5	Minimize documentation in the procedure room	X	X
	6.6	Do not take personal items into the procedure room	X	X
7	Train all endoscopy facility staff in the correct use of PPE
	7.1	Review and observe staff practicing donning and doffing of PPE	X	X
	7.2	Ensure that all staff have been fitted for respirators	X	X
	7.3	Review and observe staff practicing meticulous hand hygiene	X	X
	7.4	Create area adjacent to the procedure room where staff will don and doff PPE safely	X	X

Headline statements apply to all.

Subrecommendations are marked as to whether they apply to ideal, low resource, or both.

PPE indicates personal protective equipment; X, recommended.

TABLE 3 - Intraprocedure Recommendations

			Resources
Recommendations			Ideal	Low
8	Practice meticulous hand hygiene
	8.1	Wash hands before and after each procedure and after any contact with potentially infectious sources	X	X
9	Endoscopist and endoscopy nurse to wear a respirator for all upper GI procedures
	9.1	Discard respirator after an upper GI procedure only in a high-risk or confirmed COVID-19 patient	X	X
	9.2	Collect used respirators that are not visibly soiled or damaged for reuse after appropriate reprocessing		X
10	Endoscopist and endoscopy nurse to wear a respirator for lower GI procedures in high-resource settings or in a high risk or confirmed COVID-19 patient in low-resource settings
	10.1	Discard respirator after a lower GI procedure only in a high-risk or confirmed COVID-19 patient	X	X
	10.2	Use a surgical mask for lower GI procedure in a low-risk patient		X
	10.3	Collect used respirators that are not visibly soiled or damaged for reuse after appropriate reprocessing		X
11	Endoscopist and endoscopy nurse to wear gloves for all GI procedures
	11.1	Wear a single pair of gloves; this should be combined with meticulous hand hygiene and correct PPE handling	X	X
	11.2	Gloves to be worn with no gap between glove and gown	X	X
12	Endoscopist and endoscopy nurse to wear eye and/or face protection for all GI procedures
	12.1	A face shield and goggles are not needed in combination	X	X
	12.2	A face shield should be disinfected after each case	X	X
	12.3	Goggles can be disposable or reusable	X	X
	12.4	Goggles should be disinfected after each list and after use in a COVID-19-infected patient	X	X
13	Endoscopist and endoscopy nurse to wear scrubs, a gown, and hair protection
	13.1	Scrubs should not be taken out of the health care facility	X	X
	13.2	Protective wear should cover the skin of the neck and the hair	X	X
	13.3	A gown should be long and waterproof	X	X
	13.4	A gown should be discarded after each case	X
	13.5	A plastic apron, discarded after each case, may be worn over a gown to allow reuse for low-risk cases		X
	13.6	Consider switching to reusable isolation gown options, wherever possible. These can be washed and disinfected in a hospital laundry		X
14	Endoscopist and endoscopy nurse to use dedicated work footwear
	14.1	Dedicated washable work boots or shoes should be kept in the endoscopy unit staff changing room	X	X
	14.2	Wear shoe covers that are long, plastic, and disposable	X	X
	14.3	Disinfect boots in a disinfectant bath by the endoscopy room exit at the end of each list	X	X
	14.4	Work footwear should not be taken out of the endoscopy facility	X	X
	14.5	Wear boots that can be disinfected if shoe covers are not available	X	X
15	Ensure adequate ventilation and air exchange in the endoscopy room
	15.1	Use a negative pressure room if available	X	X
	15.2	Use a portable, industrial-grade high-efficiency particulate air (HEPA) filter if negative pressure is unavailable	X	X
	15.3	Ensure that air conditioning is not in recycle mode	X	X
	15.4	Ventilate the endoscopy room by opening an outside window or using a fan if a negative pressure room or HEPA filter is unavailable		X
	15.5	Schedule a gap of 30 min (negative pressure room) to 60 min (normal ventilation) between cases	X	X

Headline statements apply to all.

Subrecommendations are marked as to whether they apply to ideal, low resource, or both.

GI indicates gastrointestinal; PPE, personal protective equipment; X, recommended.

TABLE 4 - Postprocedure Recommendations

			Resources
Recommendations			Ideal	Low
16	Endoscopy reprocessing staff to wear full personal protective equipment when handling used endoscopes
	16.1	Endoscopy reprocessing staff to wear gloves, gown, face shield, head cover, dedicated work footwear, and mask	X	X
	16.2	Endoscopy reprocessing staff should wear a respirator if supplies suffice	X
	16.3	Endoscopy reprocessing staff to wear a surgical mask if respirators are unavailable		X
17	Endoscopy room cleaning staff to wear full personal protective equipment in the endoscopy room
	17.1	Endoscopy room cleaning staff to wear gloves, gown, face shield, head cover, dedicated work footwear, and mask	X	X
	17.2	Endoscopy room cleaning staff may wear a respirator if supplies suffice	X
	17.3	Endoscopy room cleaning staff to wear a surgical mask if respirators are unavailable		X
18	Endoscopy room to be cleaned after each case
	18.1	Meticulously clean the endoscopy room after each case	X	X

Headline statements apply to all.

Subrecommendations are marked as to whether they apply to ideal, low resource, or both.

X indicates recommended.

Ideal situations are those where adequate amounts of all components of PPE are available and the resupply stream is secure. Low-resource situations are those where all or some components of PPE are in short supply or where supplies are insecure. The recommendations are listed for both ideal and low-resource situations. We recognize that this classification of ideal and low-resource situations is dynamic, and there may not be a clear-cut distinction between the 2. For example, an area may have adequate supplies of some components of PPE, while other components are in short supply. Low-resource settings may adopt all, or some, of the recommendations for ideal resource settings if circumstances permit.

Comparison With Other Societal Recommendations

Many national societies have prepared guidance for the use of PPE for endoscopy during the COVID-19 pandemic. To give context to the WGO guidance, the recommendations of some of these societies are summarized in Table 1 and contrasted with those of the WGO.

Preprocedure Recommendations

Reduce the Number of Endoscopies Being Performed. Not all endoscopy is urgent. A reduction in nonurgent procedures may reduce the risk of infection to patients who do not have the disease by keeping them away from health care facilities and the risk to medical personnel by reducing patient volume. This strategy will help conserve PPE, as fewer procedures will be performed. In contrast, there are several situations, such as cholangitis or acute hemorrhage, where urgent attention is needed. Triage of all procedures into urgent and nonurgent should be carried out by trained medical personnel⁵ because it requires judgement and experience. Patients whose procedures are delayed will need to be monitored or need to be able to communicate with the facility to ensure that they can be reprioritized in case their condition deteriorates.

Reduce the Number of Patient Visits to Health Care Facilities. Hospitals and health care facilities are high-risk areas for contracting COVID-19. Reducing the number of patient visits will reduce exposure of patients and staff while increasing the space to permit physical distancing for those who do need to attend. A considerable amount of care can be delivered by phone or video link.¹¹ Pre-endoscopy consultation can be performed, in some cases, before the patient attends the health care facility. Routine follow-up visits for chronic care can be delayed until the acute phase passes or is delivered remotely by telehealth to ensure patients are informed of results and treatment, unaffected by sedation.

Screen all Endoscopy Patients for COVID-19. Screening patients and stratifying infection risk into higher and lower will allow conservation of higher-level PPE, such as respirators. However, screening may induce a false sense of security, as even with the most rigorous screening, asymptomatic infectious patients may be classified as low risk,¹² and treated as such, with subsequent risk to health care personnel and other patients. The benefit of polymerase chain reaction testing in supplementing clinical screening is not clear, but it is used in some centers.¹³ It is unlikely that polymerase chain reaction will be an option in low-resource settings, and it does carry a false-negative risk,¹⁴ which varies with the stage of infection, and a false-positive rate, which may be problematic in low-incidence settings. Rapid antigen testing is less costly and may be a consideration even in low-resource settings.¹⁵ The specificity of rapid antigen testing is high, but sensitivity is between 50% and 85%. We define a low-risk patient as one from a low-incidence area, with no history of contact or travel, no symptoms, and no signs. Even with low-risk patients, significant PPE protection is required in the acute phase of the pandemic. Reduced PPE is scrubs, hair covering, long gown, boots, face shield or goggles, reused respirator, or surgical mask.

Reduce Risk of Patients Transmitting Infection in the Endoscopy Facility. Patients may be vectors for the disease and may infect other patients, and health care providers, both directly and by contaminating the environment. Physical barriers such as glass partitions, and masks for patients and health care providers may reduce transmission. Patients should be instructed in appropriate use of masks and hand hygiene; there is evidence that cloth masks offer some benefit¹⁶ if surgical masks are not available. Relatives and caregivers should not attend the facility if possible, as they may be infected or become infected. Fewer individuals in the facility increases social distancing, which is important in prevention of disease.¹⁷

Reduce Risk of Patients Acquiring SARS-CoV-2 Infection in the Endoscopy Facility. Health care facilities are an area where individuals with COVID-19 are treated and where the infection can be acquired. Maintaining physical distance between individuals of at least 1 m reduces the risk of transmission.¹⁷ This can be facilitated by reducing the numbers of people attending the endoscopy facility and scheduling procedures to minimize congestion. Infected health care providers, by virtue of their close contact with patients, can also spread the disease and should stay away if experiencing symptoms or are subject to local regulations requiring quarantine.

Reduce Risk of Staff Acquiring SARS-CoV-2 Infection in the Endoscopy Facility. The risk to staff can be reduced by ensuring that the procedure is performed with the smallest possible complement of essential health care staff in the procedure room. This will also help reduce infection in staff by minimizing exposure to aerosol and contaminated surfaces and by avoiding possible simultaneous large-scale quarantining of staff with subsequent personnel shortage. Removing trainees from high-risk procedures conserves PPE, reduces their risk of infection, and provides a reserve of physicians who can take over, if necessary, should attending staff become ill. Planning ahead to ensure that all necessary equipment is in the room will reduce traffic into and out of a potentially infected area. Similarly, breaks for staff should take place after procedures are completed. Charts and personal items such as phones may become contaminated and should be left outside the procedure room.¹⁸ Strict adherence to these principles has the additional advantage, for low-resource areas in particular, that minimizing the number of participating staff will conserve PPE that can then be used elsewhere.

Train all Endoscopy Facility Staff in the Correct Use of PPE. Incorrect use of PPE is common.¹⁹ PPE is only effective if the right equipment is used in the right way for the right indication. Incorrectly donned PPE, such as an incorrectly fitted respirator, reduces PPE effectiveness and increases the risk of contracting infection from COVID-19. Incorrect removal of PPE risks contaminating the user and the workspace. Correct procedures for donning and doffing are essential. All endoscopy facility staff should be supported with appropriate education and continued monitoring to ensure adherence to best PPE utilization practices. There is evidence that training may be lacking in some low-resource countries,²⁰ where PPE shortages may be most acute.

Intraprocedure Recommendations

All Endoscopy Staff to Practice Meticulous Hand Hygiene. There are no trials of handwashing in the prevention of COVID-19. However, based on the evidence from the prevention of other respiratory viruses,²¹ it is believed that meticulous handwashing is effective in prevention of infection from COVID-19. Contaminated hands may transfer the virus to eyes or mouth, which are portals for virus entry. Hands should be washed properly with soap for 20 seconds or cleaned with an alcohol-based disinfectant. This should be carried out before and after each procedure, after contact with potentially infectious sources, before putting on PPE, and after removal of PPE. Gloves are not a substitute for proper hand hygiene.

Endoscopist and Endoscopy Nurse to Wear a Respirator for all Upper GI Procedures. Respirator masks represent optimal mask protection.¹⁷ Given that airborne transmission may be the dominant mode of infection,²² and that all peroral endoscopy procedures, including ERCP and EUS, may generate aerosol containing the virus, it seems reasonable to use respirator-level protection. Respirators that are not damaged and have not been used on high-risk patients can be reused following disinfection by a number of methods.²³

Practical methods of disinfecting and reusing disposable respirators have been developed, including ultraviolet germicidal irradiation,²⁴ steam disinfection in a microwave oven or rice cooker,²⁵ dry heat in a blanket warmer or oven,²⁶ use of vaporized hydrogen peroxide,²⁷ or simple mask storage for 3 to 14 days between uses.²⁸ Immersion in soap and water, chlorine, or alcohol is not recommended because these methods worsen the filtering efficiency of the mask material. Elastomeric half mask respirators, which are more expensive and intended for multiple reuses, are an alternative to single-use N95 masks.²⁹ Performance of reused respirators may degrade due to changes in the filtering efficiency of the mask material, contamination of the mask and straps during doffing and donning, and loss of adequate mask fit with reuse. Respirators that are visibly contaminated should not be reused.

Dry heat at 70 to 85°C for 30 to 60 minutes does not degrade mask material filter efficiency for up to 50 disinfection cycles.^26,28 Masks should be hung by their straps and should not touch the oven surfaces or racks during heating.²⁸ Steam treatment for 3 to 5 minutes can be performed in a standard microwave oven, with the mask and its straps resting on top of a glass container that contains water and is covered with mesh from a produce bag.²⁵ This method appears effective for up to 20 disinfection cycles.²⁴ Ultraviolet germicidal irradiation requires UV-C fluorescent bulbs that produce light at a dominant wavelength of 254 nm, as well as a properly constructed rack to maintain a standard distance between the light source and the masks. The duration of treatment depends on the details of rack configuration.²⁴ Simple storage of masks in a nonairtight container (such as a paper bag) is based on the concept that the SARS-CoV-2 virus does not survive on plastic surfaces for >3 days.³⁰ Although all of these methods are plausible and supported by some experimental data, their effectiveness in real-world clinical settings has not been adequately validated.

Masks may be contaminated during doffing, and virus particles embedded in mucus or oil may be resistant to disinfection by any of the described methods. When planning to reuse respirators, care should be taken to follow recommended PPE doffing guidelines to avoid contaminating the respirator or its straps. In addition, up to half of reused respirators may fail fit tests.³¹ Users should perform a seal check after donning a respirator, to ensure that they are not inhaling unfiltered air entering around the edges of the mask.

• 100% were in favor of using a respirator for all upper procedures.
• 57% were in favor of discarding the respirator between cases in ideal resource settings.
• 36% were in favor of discarding the respirator between cases in low-resource settings.

Endoscopist and Endoscopy Nurse to Wear a Respirator for Lower GI Procedures Only in High-Resource Settings or in a High-risk or Confirmed COVID-19 Patient in Low-Resource Settings. Lower GI tract procedures represent a risk of contamination of both the environment and the endoscopist. The virus is detectable in the stool of infected patients.³² Aerosolization may be less than with upper procedures but may occur with removal of instruments from the biopsy channel. It is likely that the air in the endoscopy room will be contaminated¹⁸ further justifying the use of a respirator in this setting. Face shields may help extend the life of respirator stock by preventing contamination. Surgical masks and respirators differ in their efficiency.³³ Surgical masks can be used in low-risk patients in low-resource areas in preference to respirators. In a high-risk patient, or a known confirmed case of COVID-1 in a low-resource setting, use a respirator if it is available.

• 71% were in favor of using respirators in all lower GI procedures in ideal resource settings.
• 50% were in favor of using respirators in all lower GI procedures in low-resource settings.

Endoscopist and Endoscopy Nurse to Wear Gloves for all GI Procedures. For health care workers performing any GI procedure, regardless of COVID-19 status, some organizations recommend the use of double gloves compared with a single pair. There is some support for reduced contamination with double gloves³⁴ in a non-COVID setting. The outer glove is removed, then the respirator and goggles are removed using the clean glove, and then the second glove is taken off.

• 57% were in favor of double gloves in ideal resource settings.
• 50% were in favor of double gloves in low-resource settings.

Endoscopist and Endoscopy Nurse to Wear Eye and/or Face Protection for all GI Procedures. COVID-19 may be transmitted through the eyes,³⁵ and hence eye protection is necessary. Face shields and goggles do not need to be used together. Face shields will protect the mask, eyes, and face from splatter but will not protect from aerosols. Face shields are not difficult to manufacture. It is not known whether aerosolized COVID-19 is infectious through the conjunctivae. If it is, only goggles will be protective from infection through the eyes, and a face shield alone may not suffice. It is likely that the virus can be transmitted through the conjunctivae if the eyes are touched by contaminated hands. This provides additional rationale for using goggles. The shield should be disinfected between cases; however, it is not practicable to disinfect goggles between cases, and hence they should be discarded after use in a COVID-19-positive patient and discarded or disinfected at the end of the endoscopy session.

• 86% were in favor of using face shields in every case.
• 79% were in favor of disinfecting the face shield between each case.
• 86% were in favor of using goggles in every case.
• 36% were in favor of disinfecting goggles between each case.
• 21% were in favor of using a face shield and goggles together.

Endoscopist and Endoscopy Nurse to Wear Scrubs, a Gown, and Hair Protection for all GI Procedures. The objective of PPE is to create a disposable or cleanable barrier between the virus and the health provider. Contaminated clothes and skin and hair may lead to infection, as contaminated hands touch the eyes or lips. Scrubs may become contaminated and should not be taken out of the facility. A long waterproof gown will help protect the underlying scrubs and skin from contamination. If resources permit, gowns should be discarded between cases. We do not feel this is a necessity in low-resource settings where plastic aprons may be used to protect the gown from contamination and extend their use.

• 79% were in favor of discarding the gown between cases in ideal resource settings.
• 50% were in favor of discarding the gown between cases in low-resource settings.

Endoscopist and Endoscopy Nurse to Use Dedicated Work Footwear for all GI Procedures. There is ample evidence that the environment around an infected patient is contaminated. As the contaminated area includes the floor,³⁶ the virus can be tracked to other areas. This can be prevented by using disposable foot coverings or boots that can be disinfected.

Ensure Adequate Ventilation and Air Exchange in the Endoscopy Room. Ventilation of the endoscopy room is important because COVID-19 is shed into the air by infected patients. Aerosols containing the virus may be created during aerosol-generating medical procedures such as upper GI endoscopic procedures. Aerosolized virus poses a risk to medical personnel. Reducing the concentration of virus in the air and preventing contamination of the air in adjacent rooms is a reasonable objective. Negative pressure rooms may help stop the spread of aerosols containing the virus to other areas of the facility. It is reasonable to use negative pressure rooms if available, but they are not essential. Negative pressure rooms are not widely available in low-resource countries. It is important to check that the air conditioning is not in recycle mode. Opening windows and using fans to exhaust air may help reduce the concentration of virus in the air.

Postprocedure Recommendations

Endoscopy Reprocessing Staff to Wear Full PPE When Handling Used Equipment. Reprocessing staff are exposed to contaminated scopes and should wear PPE that includes gloves, gown, face shield, and surgical mask. A surgical mask may suffice, as aerosol should be less than in the procedure room. Although there are no data to support a requirement for the use of respirators in the reprocessing room, their use should be considered, if available.³⁷

Endoscopy Room Cleaning Staff to Wear Full PPE in the Endoscopy Room. Staff are exposed to potentially contaminated scopes, surfaces, and environment when cleaning endoscopy rooms after procedures and they, too, should wear PPE including head covering, gown, surgical mask, face shield, foot coverings, and glove. The amount of virus in the air should be reduced compared with during the procedure, but cleaning staff should, at least, wear a surgical mask when the areas are being cleaned, as it can take atleast 30 to 60 minutes for the room air to be cleared of aerosol.

Endoscopy Room to be Cleaned After Each Case. The area where a procedure has been performed on a COVID-19-infected patient, the recovery area and washrooms will be contaminated.¹⁸ Meticulous cleaning of all surfaces is required.

DISCUSSION

Shortages of PPE have emerged as a key issue in management of the COVID-19 pandemic. The importance of adequate PPE is illustrated by reports of infection in health care providers.³⁸ Even traditionally high-resource countries have struggled to provide sufficient PPE.² These challenges are exacerbated in low-income countries where scarcity of PPE requires that high-level PPE is used only when it can be of maximal benefit. Therefore, we wished to provide guidance on the optimal use of PPE in low-resource settings.

The evidence base on which to base this advice is lacking. We relied primarily on indirect evidence from the literature and on expert opinion. However, input was gathered from experts in the field, from both low and high-income countries. When disagreements were present, a vote was taken, and the results of the voting have been presented.

We had the advantage of reviewing the recommendations from several national societies before formulating our position. These recommendations are shown in Table 1 and compared with those of the WGO. Our report is more comprehensive than several of these, as we were able to build on aspects of these reports. We specifically sought to address the issues with reference to low-resource countries.

Following literature review and initial discussion among the committee, it was apparent that there was very limited room to compromise on the basics of PPE used in procedures, such as masks, gloves, eye protection, and gowns. Therefore, we chose to take a holistic approach to PPE and extend the guidance to preprocedural, intraprocedural, and postprocedural conditions. We have stressed the need to conserve PPE and to reduce infection burden through measures such as handwashing, physical distancing, and reduction of patient volume.

The 18 headline recommendations are common to both resource situations. Only 10 (16%) of the 64 subrecommendations are unique to low-resource settings, and only 3 (5%) of the recommendations uniquely apply to ideal resource settings.

The respiratory tract seems to be the primary portal for acquisition of COVID-19.²¹ Airway protection of health care providers by the use of masks is central to prevention of infection. Unfortunately, while many components of PPE such as boots or face shields are readily available or can be improvised, respirator-level masks cannot be easily made. Shortage of respirators has emerged as one of the key items of concern. Recognizing this, we have made a number of recommendations when we feel that surgical masks, which are in greater supply, can be used rather than respirators. We have addressed the issue of reusing and extending the use of available respirators.

We set a threshold of 60% for acceptance of a recommendation. There was a high level of agreement within the committee but also, as can be seen from the voting results, several areas where this group of experienced clinicians and researchers was divided. This illustrates the difficulties of formulating policies in the absence of objective evidence. Further research may allow greater flexibility, and further definition, of safe practice in low-resource situations. At current levels of knowledge, we believe that a high level of PPE is required to practice endoscopy safely regardless of resource realities. We hope that the recommendations will allow endoscopic procedures to be performed safely while optimizing the use of available local PPE resources.