AGA Rapid Review and Guideline for SARS-CoV2 Testing and Endoscopy Post-Vaccination: 2021 Update

Abstract

This guideline provides updated recommendations on the role of preprocedure testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) in individuals undergoing endoscopy in the post-vaccination period and replaces the prior guideline from the American Gastroenterological Association (AGA) (released July 29, 2020). Since the start of the pandemic, our increased understanding of transmission has facilitated the implementation of practices to promote patient and health care worker (HCW) safety. Simultaneously, there has been increasing recognition of the potential harm associated with delays in patient care, as well as inefficiency of endoscopy units. With widespread vaccination of HCWs and the general population, a re-evaluation of AGA's prior recommendations was warranted. In order to update the role of preprocedure testing for SARS-CoV2, the AGA guideline panel reviewed the evidence on prevalence of asymptomatic SARS-CoV2 infections in individuals undergoing endoscopy; patient and HCW risk of infections that may be acquired immediately before, during, or after endoscopy; effectiveness of COVID-19 vaccine in reducing risk of infections and transmission; patient and HCW anxiety; patient delays in care and potential impact on cancer burden; and endoscopy volumes. The panel considered the certainty of the evidence, weighed the benefits and harms of routine preprocedure testing, and considered burden, equity, and cost using the Grading of Recommendations Assessment, Development and Evaluation framework. Based on very low certainty evidence, the panel made a conditional recommendation against routine preprocedure testing for SARS-CoV2 in patients scheduled to undergo endoscopy. The panel placed a high value on minimizing additional delays in patient care, acknowledging the reduced endoscopy volumes, downstream impact on delayed cancer diagnoses, and burden of testing on patients.

Keywords: COVID-19; Diagnostic Test; Gastrointestinal Endoscopy; SARS-CoV2.

Figure 1

Analytic framework for preprocedural testing and outcomes. Analytic framework of downstream consequences of preprocedure testing. This framework is based on the assumption that the majority of endoscopy centers are conducting preprocedure testing during the pandemic. ∗Pre-procedure SARS-CoV2 testing in conjunction with universal symptom screening per CDC guidelines. False positive, individuals who test positive for SARS-CoV2 but do not have the infection; false negative, individuals who test negative for SARS-CoV2 but do have the infection.

Figure 2

Preferred Reporting Items for Systematic Reviews and Meta-Analyses. (PRISMA) flow diagram. PRISMA diagram of included studies and reasons for exclusion. Note that the number of total studies is lower than the sum of each category, as some studies reported on more than 1 outcome. There were no studies reporting directly on cost or vaccine effectiveness in the context of endoscopy. We therefore used existing reviews from the CDC in nonendoscopy settings with an updated search to indirectly inform our guidance as outlined in this document.

Figure 3

Implementation of a pre-endoscopic testing strategy. The AGA suggests against routine preprocedure testing for SARS-CoV2 in patients undergoing upper or lower endoscopy, irrespective of vaccination status of patients. Assumptions are that: 1. All centers have access to PPE, including face shield, eye protection, and surgical mask or N95 (or N99 or powered air-purifying respirators). 2. All centers have implemented universal screening of patients for COVID-19 symptoms, using screening checklist and have implemented universal precautions, including physical distancing, masks, and hand hygiene in the endoscopy unit. Remarks: (Conditional recommendation, very low certainty of evidence): Centers that prioritize the small potential benefit (staff and patient reassurance) over the downsides {burden of testing on patients, downstream consequences of false positives, potential delays in care, and decreased endoscopy efficiency) may choose to implement preprocedure testing strategy as outlined in Recommendation 2.