In December 2019, the novel coronavirus SARS-CoV-2 was extracted from the lower respiratory tract samples of several patients with pneumonia of an unknown etiology (later identified as COVID-19) in Wuhan, China [1]. Since then, COVID-19 has rapidly disseminated worldwide. On March 11, 2020, the World Health Organization (WHO) declared that this outbreak was a pandemic [2,3]. Although person-to-person transmission occurs mainly through direct contact and air droplets [4,5], to date, most endoscopy societies have emphasized that upper and lower gastrointestinal endoscopies are aerosol-generating procedures (AGPs) [6-9]; therefore, it is possible for airborne transmission to occur during gastrointestinal endoscopy (GIE), which will also increase the risk of COVID-19 transmission. Pediatric gastroenterologists also have a much greater risk than adult gastroenterologists. For example, pediatric endoscopy procedures usually require deep sedation and general anesthesia [10-16]. Because of the breach of personal protective equipment (PPE) during the procedure, the acrylic box named “Endoshield” has been developed as an additional physical barrier tool for improving safety from the perspective of both patients and health care providers (HCPs) during AGPs. There are currently very few published reports about physical barrier boxes, such as “Endoshield”, used during AGPs. The previous studies’ goals were to prevent disease transmission during endotracheal intubation [17,18] and GIE in adults [19,20]. To date, no studies have evaluated the utility of the box in pediatric settings. Thus, here we report the first study addressing these points.

The present study was a descriptive analytical study conducted between April and June 2020 and was approved by the Faculty of Medicine’s ethical committee, Khon Kaen University (HE 641065). Informed consent was obtained from the participants’ guardians prior to enrollment.

This research presents a descriptive case series of 12 children (66.67% male) with a median age of 9 years (range, 2–11 years) who underwent emergency or urgent endoscopy according to risk stratification [8] between April and June 2020, which was during the COVID-19 outbreak. The vast majority of patients experienced life-threatening gastrointestinal bleeding requiring emergency endoscopy (8/12, 66.67%), while the rest of the patients underwent urgent endoscopy (4/12, 33.33%). All patients were screened, triaged, and stratified by symptom and exposure questionnaires for risk assessment before AGPs according to guidelines by international gastroenterology societies [6-9,21-23] and the Thai Association of Gastroenterology and Endoscopy (TAGE) [9]. All of the patients were classified into the low-risk group for COVID-19 infection; hence, they had not been tested for it. The “Endoshield” was applied and was found to be suitable for all patients’ positions (left lateral position: 9/12, 75% and supine position: 3/12, 25%). The median times for the endoscopy procedure in the left lateral position, supine position, and overall were 14.15 min (range, 10.50-15.49 min), 19.59 min (range, 16.0-39.0 min), and 15.39 min (range, 11.54-18.06 min), respectively. After completing each procedure, the patients and HCPs were followed up for symptoms via telemedicine on day 14, and none of them had any symptoms of concern (Table 2).

Recent knowledge shows that the major routes by which novel COVID-19 spreads are human-to-human transmission, including direct and indirect contact and droplets; airborne transmission is also possible, especially during aerosol generation, such as during GIEs. Due to the limitations of protective equipment, shortage of PPE, and lack of accurate and available COVID-19 tests in our country, the TAGE recommends obtaining the patient’s information to determine the risk before performing AGPs. This includes fever (body temperature >37.5°C), travel history, occupational risk, contact history with confirmed infected patients, and close contact with unfamiliar people [9]. Nevertheless, in pediatric cases, screening by symptom-based questionnaires does not represent the actual status of COVID-19 infection because most children are asymptomatic or have only mild disease [10-16]. All of the above limitations, especially the lack of protective supplies, must be overcome in crises. To prevent and minimize the spread of the disease, we used a simple, affordable, and reusable plastic box as a physical protective barrier for both patients and HCPs during AGPs, such as GIEs. The first published research in adults on physical barrier boxes involved transmission prevention during endotracheal intubation and airway procedures. Canelli et al. [18] developed a transparent plastic box to protect HCPs performing endotracheal intubations. To achieve this, they put fluorescent dye in a balloon in a mannequin’s pharynx and burst it to simulate a cough in humans; they then illuminated the area with ultraviolet light to detect the spread of the dye. They found no macroscopic dye outside the box. However, the use of a protective box also restricts the operator’s movement. Bianco et al [24] designed a box similar to that used by Canelli et al [18], an “Aerosol Box” for endotracheal intubation purposes. They retrospectively analyzed six COVID-19-positive patients who underwent emergency surgical procedures wherein a box was used while the patient was intubated. Bianco et al. discussed that the box might have some limitations, such as box size and construction [24]. For endoscopy purposes, Ljubicic et al. [20] reported using a plexiglass barrier box to improve safety during endoscopic retrograde cholangiopancreatography. Nevertheless, they did not specifically test for efficacy, but the box was similar to a previous one used for intubation purposes. In one experimental study on the effectiveness of a box to minimize droplet and aerosol spreading during GIEs, Campos et al. [19] designed an acrylic box and tested its effectiveness by using fluorescent dyes and a similar method reported by Canelli et al. [18] They proved not only its potential benefit in protecting HCPs from air droplets but also its feasibility and practicality during the procedure. In a recent publication, Sagami et al. [25] created a barrier box to prevent droplets from spreading during endoscopy. Their methodology was identical to that of Canelli et al. [18] and Campos et al. [19], whereby they used fluorescent dyes to prove its efficacy. One real patient underwent an upper GIE without conscious sedation in the left lateral position. Neither discomfort nor any change in vital signs was detected. They concluded that the box could reduce the droplets spreading during GIE. To date, no previous studies have reported differences in adult and pediatric populations. In the pediatric setting, the patients have specific characteristics, such as the necessity of general anesthesia, being small in size, and having specific conditions that affect surgical positions. Our study revealed that the median time spent on endoscopy procedures with the “Endoshield” in the supine position was slightly longer than that in the left lateral position group. This was due to the more difficult endoscopy procedures such as PEG and endoscopic esophageal dilatation in the supine position group, as shown in Table 2. The present study revealed the feasibility of a pediatric size box, namely “Endoshield”, as an adjunct tool with PPE for endoscopy. This is the first innovative device that is suitable for pediatric endoscopy. Even though our study did not prove the efficacy and safety of the box, we did prove that “Endoshield” is suitable for children of different sizes and different surgical positions and is convenient to use with anesthetic equipment. This box can be used as an additional physical protective device during pediatric endoscopy procedures as well as in those undergoing endoscopy under deep sedation. The benefit of this box is that it not only minimizes disease transmission but also works suitably in the supine position of patients, a feature that no prior studies have mentioned. Further, large and well-designed studies specific to pediatric patients that focus on the efficacy of the box to prevent transmission are warranted.