American Gastroenterological Association Releases Guidelines for COVID-19

April 6, 2020
Kenny Walter

AGA reccomends doctors wear N95 masks instead of surgical masks and 2 gloves instead of 1.

Shahnaz Sultan, MD

The American Gastroenterological Association (AGA) suggested doctors treat all patients like they have the coronavirus disease 2019 (COVID-19), while boosting personal protective equipment (PPE) regardless of the patient’s COVID-19 status.

A team of investigators, led by Shahnaz Sultan, MD, Division of Gastroenterology, Hepatology, and Nutrition, Minneapolis VA Healthcare System, released new recommendations on how doctors can better protect themselves in the face of the growing COVID-19 pandemic.

The main guidance is that in the absence of accurate and reliable testing for COVID-19, as well as the prolonged asymptomatic shedding prior to exhibiting symptoms, doctors should consider all patients as a risk.

“Data related to the spread of SARS-CoV-2 in the early phase of the pandemic have confirmed that health care professionals are at higher risk of infection than the general population,” the authors wrote. “While COVID-19 is spread primarily through droplet transmission, endoscopic procedures can lead to aerosolization and subsequent airborne transmission.”

Endoscopies generate aerosolized viral particles can stay viable for up to 3 hours based on the airflow dynamics.

Viral particles can also stay viable for 72 hours on plastic surfaces and can easily promote spread through direct contact.

New research also suggests SARS-CoV2 RNA can be shed from stool, but the risks associated with exposure is not currently known.

However, doctors performing endoscopic procedures are at a higher risk of developing an infection.

The AGA also recommends new practices for PPE for all endoscopic procedures. The new guidelines call for all healthcare workers to us N95, N00, or PAPR masks rather than surgical masks. They also recommend healthcare workers double up on gloves, rather than use single gloves as part of their PPE (RR, 0.36; 95% CI, 0.16-0.78).

Another suggestion for lowering the threat of infection is using negative pressure rooms when available.

The committee also reviewed the data on extended use and re-use of mask and did not find sufficient evidence to comment on the safety on either using masks for up to 8 hours at a time or re-using masks.

Indirect laboratory mask testing suggests the loss of durability and fit of N95 masks after wearing them 5 times.

For gastrointestinal procedures, the authors recommend triaging procedures to minimize the risk to both healthcare providers and patients and limit the spread of infection.

“We provide a framework for decision-making that is focused on the impact of the delay on patient-important outcomes,” the authors wrote. “Decisions to defer procedures should be made on a case-by-case basis using telemedicine as an adjunctive tool to help triage.”

The authors used the GRADE framework and best practices outlined by the National Academy of Medicine to develop the clinical practice guidelines.

Since outbreaks of COVID-19 began, questions have been raised regarding the gastrointestinal and liver manifestations of the viral infection and how it impacts gastrointestinal endoscopy.

The largest cohort study to date, which included 1,099 hospitalized patients with confirmed COVID-19 infection from China, reported that 5.0% of COVID-19 infected patients had nausea or vomiting and 3.8% had diarrhea.

Across different cohorts, investigators found 2.0-13.8% of patients had diarrhea, 1.0-10.1% of patients had nausea or vomiting, and 2.2% of patients in 1 particular study had abdominal pain.

The new recommendations was commissioned and approved by the AGA Institute Clinical Guidelines Committee, AGA Institute Clinical Practice Updates Committee, and the AGA Governing Board.

The new recommendations, “AGA Institute Rapid Recommendations for Gastrointestinal Procedures During the COVID-19 Pandemic,” was published online in Gastroenterology.