Management of gastrointestinal services in Tamil Nadu, India, during COVID-19
Authors: Arulraj Ramakrishnan, Aravindh Somasundaram, Nandhakumar Srinivasan, Sibithooran Karmegan, Sneha Madav, Krishnaveni Ramasamy, Nagaselvapandi Balasubramani, Sivakumar Venkatachalam, Jeevithan Shanmugam, Paari Vijayaragavan, Ramesh Arasaradnam
Journal: The Lancet. Gastroenterology & hepatology (2021)

In India, during the first wave of the COVID-19 pandemic, the state of Tamil Nadu become a COVID-19 hotspot between April and September, 2020, with peak infection rates in July, 2020.1The HinduCoronavirus: Tamil Nadu carries out 1 crore RT-PCR tests for COVID-19.https://www.thehindu.com/news/national/tamil-nadu/coronavirus-tamil-nadu-carries-out-1-crore-rt-pcr-tests-for-covid-19/article32999572.ece2020Date: Nov 2, 2020Date accessed: May 24, 2021Google Scholar Each year, the department of gastroenterology and hepatology at Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, treats 16 000 outpatients, admits 1600 inpatients, and carries out 3500–4000 endoscopies. Initial data showed that the case fatality rate due to COVID-19 in India2Aggarwal DK World covid meter.http://www.emedinexus.com/post/17753/Date: May 1, 2020Date accessed: January 23, 2021Google Scholar was about 3%. Our audit data showed that inpatient mortality from gastrointestinal conditions was more than 4%. Gastrointestinal cancers represent 20% of all cancers in India, and nearly one in five require immediate surgery.3India State-Level Disease Burden Initiative Cancer Cancer CollaboratorsThe burden of cancers and their variations across the states of India: the Global Burden of Disease Study 1990–2016.Lancet Oncol. 2018; 19: 1289-1306Summary Full Text Full Text PDF PubMed Scopus (272) Google Scholar As a result, and because the majority of our population had travelled (from nearby districts without public transport) after lockdown on March 24, 2020, the decision was taken to restart gastrointestinal services on April 15, 2020. We began by implementing the Asian Pacific Society for Digestive Endoscopy (APSDE) COVID-19 guidance4Chiu PWY Ng SC Inoue H et al.Practice of endoscopy during COVID-19 pandemic: position statements of the Asian Pacific Society for Digestive Endoscopy (APSDE-COVID statements).Gut. 2020; 69: 991-996Crossref PubMed Scopus (243) Google Scholar for screening (fever, travel history, occupation, cluster, close contact, evaluate for dyspnoea), with appropriate levels of personal protective equipment for the entire department (appendix p 5). An endoscopy was done only if essential and appointments for older patients and those in shielding were offered only if mandatory or an emergency. Since it was not practical to create negative pressure rooms, we took the pragmatic decision to ventilate endoscopy suites and outpatient rooms with air from the outside5Repici A Maselli R Colombo M et al.Coronavirus (COVID-19) outbreak: what the department of endoscopy should know.Gastrointest Endosc. 2020; 92: 192-197Summary Full Text Full Text PDF PubMed Scopus (393) Google Scholar to reduce indoor airborne transmission of COVID-19. We analysed outcomes at our centre from April 1 to Sept 30, 2020, and compared these with data from the same period in 2019 (appendix pp 1–2). Patients were contacted by telephone 2 weeks after endoscopy and contact with inpatient gastrointestinal services during July, 2020, to enquire about any COVID-19 symptoms, and data on symptoms among health-care workers within the gastrointestinal services were collected weekly from April to September, 2020. The number of endoscopies done in 2020 was 23·7% lower than in 2019 (1427 vs 1871; appendix pp 3, 6). In terms of procedure mix, there was a slight drop in the percentage of oesophagogastroduodenoscopies and sigmoidoscopies done in 2020 versus 2019, but the proportion of all other endoscopy procedures increased in 2020 compared with 2019 (appendix p 3). The proportion of endoscopies that resulted in a diagnosis of malignancy or inflammatory bowel disease increased significantly in 2020 versus 2019, and fewer endoscopies found no abnormalities (appendix p 3). Our therapeutic endoscopy volume increased significantly in 2020 compared with 2019 (appendix p 3). Inpatient volume was 14·4% lower in 2020 than in 2019 (681 vs 796 patients) but the percentage volume of work was similar across all diagnoses except for increased upper gastrointestinal bleeds in 2020 (appendix pp 3, 6). Mortality was higher in 2020 than in 2019, but this difference was not statistically significant (appendix p 3). There was also a slight, non-significant increase in the mean duration of stay in hospital in 2020 versus 2019 (appendix p 3). Workload at our centre appeared to vary on the basis of COVID-19 positivity in the community, with patients seeking services only when needed (appendix p 6). Of 195 patients who completed telephone follow-up following endoscopy in July, 2020, one (0·5%) reported developing COVID-19 symptoms after visiting the hospital in July, 2020, 13 days after endoscopy. No inpatients or health-care workers developed COVID-19 symptoms (appendix p 4). The main limitation of our study is that we did not screen our patients and staff for SARS-CoV-2 with RT-PCR; nonetheless, close monitoring of both patients and staff suggest that the small risk of SARS-CoV-2 infection observed during the first wave of the pandemic should give confidence to patients and health-care providers that the benefits of endoscopy outweigh the risks of nosocomial transmission of SARS-CoV-2. Notably, 32 patients had a CO-RADS (COVID-19 Reporting and Data System) score of 3 or more on chest CT (done for other reasons in outpatient and for screening in emergencies), of whom more than half were subsequently confirmed to have SARS-CoV-2 infection by RT-PCR (appendix p 4). These patients were otherwise asymptomatic, suggesting that no screening strategy is foolproof. However, the transmission risk from an asymptomatic patient is lower than that from a symptomatic one,6Meyerowitz EA Richterman A Gandhi RT Sax PE Transmission of SARS-CoV-2: a review of viral, host, and environmental factors.Ann Intern Med. 2021; 174: 69-79Crossref PubMed Scopus (472) Google Scholar underlining the importance of symptom screening. Patients undergoing endoscopy without RT-PCR testing might inadvertently be positive for SARS-CoV-2; however, strict disinfection of endoscopes used in patients positive for SARS-CoV-2 has been shown to result in SARS-CoV-2 being undetectable on the devices,7Boskoski I Di Gemma A Matteo MV Grilli F Cattani P Costamagna G Endoscopes used in positive and critically ill patients are SARS-CoV-2 negative at virological assessment.Gut. 2021; (published Jan 6.)https://doi.org/10.1136/gutjnl-2020-323577Crossref Scopus (5) Google Scholar suggesting that the risk of spread via endoscopy is extremely low. The infection control measures that were established during the first wave of COVID-19 (appendix p 5), together with complete staff vaccination, are helping us to dynamically manage services during the ongoing second wave of the pandemic in India—ie, service delivery is inversely proportional to infection rates in the community, with continuation of essential endoscopies but deferral of elective procedures without red flags. We have also introduced RT-PCR testing for SARS-CoV-2 before long duration endoscopies, screening all patients admitted to hospital with RT-PCR testing, and demarcation of hospital zones (red for RT-PCR-positive patients, amber for those who have been tested and are awaiting results of RT-PCR, and green for those who are RT-PCR negative). Our findings seem to justify our mitigation strategies to ensure the continuation of gastrointestinal services. Transmission dynamics are different between India and western countries,8Laxminarayan R Wahl B Dudala SR et al.Epidemiology and transmission dynamics of COVID-19 in two Indian states.Science. 2020; 370: 691-697Crossref PubMed Scopus (292) Google Scholar and our strategy might well be applicable to countries with a pandemic profile similar to that of India. We feel that a cautious approach, with meticulous screening and infection control measures, is key to mitigate the unprecedented impact of the pandemic on gastrointestinal services without risking the health of health-care workers. We declare no competing interests. AR and AS contributed equally. We thank Nalla G Palanisami, Arun N Palanisami, and other trustees of the Kovai Medical Center and Hospital for their continuous support. We thank Anjali Benchy for help in data collection and the gastroenterology team and the staff of the Kovai Medical Center and Hospital for adapting to the protocol changes. Download .pdf (.37 MB) Help with pdf files Supplementary appendix Gastrointestinal services in India during COVID-19: does governance matter?During the first wave of COVID-19 in India, when the majority of hospitals were converted into exclusive COVID centres, it was astonishing to see the performance of the Department of Gastroenterology, Kovai Medical Center and Hospital, Tamil Nadu, India.1 This hospital is part of the private sector, with an autonomous governing body responsible for making policy decisions. Although there were directives from the central government regarding functioning of hospitals during the pandemic, private hospitals could make their own decisions about priorities. Full-Text PDF Gastrointestinal services in India during COVID-19: does governance matter? – Authors' replyWe thank Gargi Sarode and Sachin Sarode for their interest in our recent Correspondence.1 As a designated COVID-19 hospital (and the largest non-governmental COVID-19 hospital in our city2), neither non-enforcement of government directives nor referral pattern (both before the pandemic and during it, we received less than 10% of referrals from private clinics, who had curtailed work during COVID-193) contributed to our results.1 Our proximity to Kerala (where the first COVID-19 case in India was reported in January, 2020), being one of the first COVID-19 hospitals in the state of Tamil Nadu, and liasion with our UK colleagues gave us an early advantage in establishing clinical governance protocols for a COVID-19-free pathway by segregating services and enabling risk mitigation strategies for health-care workers and patients. Full-Text PDF