Up to 20% of Healthcare Personnel (HCP) were found to be COVID-19 infected [1] in the outbreak in Northern Italy [2] . Recommendations on patients' and HCP protection have been recommended, such as postponing procedures, triage, Personal Protective Equipment (PPE), and differentiated in-hospital pathways [3, 4] . However, several barriers against the adoption of these strategies exist, including cultural factors and shortage of medical resources and there are few reports of real-world experiences and outcomes for their adoption [5] .
The aim of this survey was to investigate the burden of COVID-19 on endoscopic activity in a highrisk area of COVID-19 outbreak, approaches to evaluating patients, adoption and compliance of HCP with protective measures, and initial possible viral transmission outcomes from endoscopy units within a large, community-based setting (both between patients and healthcare personnel and between healthcare personnel).
The study was conducted as a survey between 03/16 to 03/21, 2020. Directors of EDs in high-risk areas of northern Italy were invited by e-mail to complete a questionnaire (Supplementary Table 1, Figure 1 ).
42 endoscopy units were invited, of which 41 participated (97.6%). Most respondents (n=37, 90.2%) were high-volume endoscopy units for a total of 968 endoscopy personnel, including 323 endoscopists, 496 nurses and 149 healthcare assistants.
All endoscopy units had patients diagnosed with COVID-19 in their Hospital. All but one center 
Thirty-five (35) 
Regarding the preventive measures taken after the first Italian case (February 18 th , 2020), 5 endoscopy units (12.2%) did not take any measure, 29 
In 27 (65.9%) endoscopy units, endoscopists were relocated to other hospital departments, for example, to assist with COVID-positive patients with pneumonia or in the emergency department. 
We asked if there were cases of infection within endoscopic departments; 12 endoscopy units confirmed infections among nurses and physicians with 6 endoscopy personnel (3 nurses and 3 physicians) requiring hospitalization : none of the infections were through the endoscopic equipment, one was presumed from the environment outside the endoscopy unit, 3 presumed from contact with unrecognized infected patients early-middle February when stringent protective measure were not yet adopted by endoscopy personnel, and the remaining with a combination of presumed exposures from the external environment and/or infected colleagues/endoscopy personnel.
Our survey showed dramatic burden for endoscopy units related to COVID-19 outbreak in a highrisk area. Most routine procedures have been cancelled or postponed, limiting endoscopy to urgent cases; we outline here the variability of approaches taken in different centers. In addition, all endoscopy units are in hospitals with at least one case of COVID-19, and in more than half of the Departments, procedures were performed in infected/high-risk patients. This was offset by a reassuring availability of adequate protectors, especially N95/FFP2-3 respirators.
Most endoscopy units limited their activity to urgent cases, including also patients at high-risk of cancer, such as FIT+. This underlines a multi-center approach to how the triage of cases can be done caseby-case matching the risk of GI-cancer against that of infection [3] .
The second relevant result of our survey is the fact that at least one in every 2 endoscopy units is directly involved in emergent or urgent procedures in COVID-19 cases. Such contact is to be deemed as potentially dangerous, as upper-GI endoscopy is an aerosol-generating procedure [2] . Thus, most of the staff of endoscopy units in a red-area of COVID-19 must be ready to face the highest risk of infection. Third, despite the shortage of medical resources, most endoscopy units have availability of N95 respirators for high-risk procedures.
The third relevant result is the very limited risk of known patient to healthcare personnel transmission within the endoscopy unit setting, but the presence of possible transmission from healthcare provider to other healthcare providers, emphasizing the importance of maintaining vigilance in all contacts and settings.
Burden of COVID-19 on endoscopy units is substantial, disrupting daily routine and exposing HCP to risk of infection. 