Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID- 19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active. +Model GASTRO-1552; No. of Pages 2 ARTICLE IN PRESS Gastroenterol Hepatol. 2020;xxx(xx):xxx---xxx Gastroenterología y Hepatología www.elsevier.es/gastroenterologia LETTER TO THE EDITOR Endoscopy activity in a covid-19 needs: Workforce trained in endoscopic procedures, PPE availability and testing capacity for COVID-19 [Fig. 1]. high-risk area (Barcelona): Moving The movement between the phases could be bidirectional forward (or backwards) according depending on pandemic situation. So, the phases will be to the necessary resources available dynamic returning to a previous phase or progressing to an advanced phase. Reinicio de la actividad endoscópica en un With only one team available in the unit, it will be very área de alto riesgo de covid-19 (Barcelona): risky planning to do semi-urgent endoscopy on a regular basis, considering the quarantine likelihood if health care progresión (o regresión) según los recursos workers get infected. On the other hand, to start assum- necesarios disponibles endoscopy ing more schedule of procedures, it is necessary to expand Dear Editor: the number of rooms depending on the capacity of the endoscopy unit. This may imply bringing personnel back from Endoscopy activity has been dramatically reduced to min- COVID-19 tasks. imum due to COVID-19 outbreak consequences. Endoscopy Additionally, we are suffering shortages in PPE availabil- Units are experiencing shortages in staff, personal protec- ity. PPEs are necessary for the COVID-19 era,1---3 and they tive equipment (PPE), medical equipment as respiratory should be used for every gastrointestinal endoscopy spe- ventilators and monitors, beds or even physical space. More- cially in high-risk areas. As its availability for a long time over, cleaning rooms have gained a new role of PPE (i.e. may be difficult to predict, we suggest that supplies should goggles, or face shield) disinfection from different hospital be guaranteed for at least 2 weeks before resuming more areas. For this reason, it is convenient to be prepared on how activity. to resume non-urgent and non-delayable endoscopy activity Another concern is the screening of staff and patients. and adapt to the natural evolution of pandemic. Testing capacity is not widely available right now, but it We recommend to progress to an adapted activity in a is recommended to test healthcare workers and patients. three-phase system. As circuits may differ on COVID-19 status, testing might be For that, some minimum requirements are necessary to necessary to detect asymptomatic positive cases and pre- move forward on endoscopy activity, grouped in 3 basic vent patient-to-patient, staff-to-staff, patient-to-staff and Figure 1 Dynamic phases of endoscopy activity in a high-risk area during covid-19 pandemic according to workforce, PPE avail- ability and screening test capacity. https://doi.org/10.1016/j.gastrohep.2020.05.008 0210-5705/© 2020 Elsevier España, S.L.U. All rights reserved. Please cite this article in press as: Uchima H, et al. Endoscopy activity in a covid-19 high-risk area (Barcelona): Moving forward (or backwards) according to the necessary resources available. Gastroenterol Hepatol. 2020. https://doi.org/10.1016/j.gastrohep.2020.05.008 +Model GASTRO-1552; No. of Pages 2 ARTICLE IN PRESS 2 LETTER TO THE EDITOR staff-to-patient transmission, taking into account the possi- peak of the COVID-19 pandemic. Gastroenterol Hepatol. 2020. ble false positives and false negatives due to the variability http://dx.doi.org/10.1016/j.gastrohep.2020.05.004 of the tests. 6. Lauer SA, Grantz KH, Bi Q, Jones FK, Zheng Q, Mered- Once those minimum requirements are met, we could ith HR, et al. The incubation period of coronavirus dis- move forward to a second phase, doing priority endoscopic ease 2019 (COVID-19) from publicly reported confirmed cases: estimation and application. Ann Intern Med. 2020, procedures on a regular basis according to a case-by-case http://dx.doi.org/10.7326/M20-0504 [Epub ahead of print 10 management and high/low priority as it has been recom- March 2020]. mended by ESGE,1 SEED, SEPD, AEG4,5 and other societies. Depending on the pandemic evolution, the adaptation of Hugo Uchima a,b,∗ , Marco Antonio Alvarez-Gonzalez c,d,e , endoscopy staff to second phase, and the endoscopy unit is Juan Colan-Hernandez a , Liseth Rivero-Sánchez f , reaching a full capacity with enough PPE, it will be possible David Barquero g , Joan B. Gornals h , Carme Loras i,j to gradually assume more activity. a Because epidemiology and sociopolitical measures are Endoscopy Unit, Gastroenterology Department, Hospital continuously changing, we should reassess every 1 or 2 weeks Universitari Germans Trias I Pujol de Badalona, Barcelona, (suspected incubation period6 ) our local status. And we Spain b should be prepared to move not only forward but backwards Endoscopy Unit, Teknon Medical Center, Barcelona, Spain c when needed. Endoscopy Unit, Department of Digestive Diseases, Hospital Del Mar, Barcelona, Spain d References IMIM, Hospital del Mar Medical Research Institute, Spain e Department of Medicine, Universitat Autònoma de Barcelona, Spain 1. Gralnek I, Hassan C, Beilenhoff U, Antonelli G, Ebigbo A, Pellisè f M, et al. ESGE and ESGENA Position Statement on gastrointestinal Endoscopy Unit, Department of Digestive Diseases, endoscopy and the COVID-19 pandemic. Endoscopy. 2020:52. Hospital Clinic, Barcelona, Spain g 2. Chiu PWY, Ng SC, Inoue H, Reddy DN, Hu EL, Cho Endoscopy Unit, Department of Digestive Diseases, JY, et al. Practice of endoscopy during COVID-19 pan- Hospital de Sant Joan Despí Moisès Broggi, Barcelona, demic: position statements of the Asian Pacific Society for Spain Digestive Endoscopy (APSDE-COVID statements). Gut. 2020, h Endoscopy Unit, Department of Digestive Diseases, http://dx.doi.org/10.1136/gutjnl-2020-321185. Hospital Universitari de Bellvitge-IDIBELL, Barcelona, 3. Repici A, Maselli R, Colombo M. Coronavirus (COVID-19) Spain outbreak: what the department of endoscopy should i Department of Gastroenterology, Hospital Universitari know. Gastrointest Endosc. 2020. https://www.giejournal. Mútua Terrassa, Fundació per la Recerca Mútua Terrassa, org/article/S0016-5107(20)30245-5/Abstract 4. Crespo J, Andrade R, Alberca F, Balaguer F, Barreiro- Terrassa, Catalonia, Spain j de Acosta M, Bujanda L, et al. Restablecimiento de la Centro de Investigación Biomédica en Red de actividad en los servicios de Digestivo. Recomendaciones Enfermedades Hepáticas y Digestivas (CIBERehd), Spain de la SEPD, AEEH, GETECCU y AEG. Gastroenterol Hepa- ∗ tol. 2020, http://dx.doi.org/10.1016/j.gastrohep.2020.04.001. Corresponding author. S0210-5705(20)30134-5. E-mail address: huchima.germanstrias@gencat.cat 5. Marín-Gabriel JC, Rodriguez de Santiago E. AEG-SEED position (H. Uchima). statement on resuming endoscopy practice after passing the Please cite this article in press as: Uchima H, et al. Endoscopy activity in a covid-19 high-risk area (Barcelona): Moving forward (or backwards) according to the necessary resources available. Gastroenterol Hepatol. 2020. https://doi.org/10.1016/j.gastrohep.2020.05.008