The coronavirus disease 2019 (COVID-19) pandemic is having a profound impact on the world. As of May 18, 2020, there were 4,889,287 confirmed cases and 322,683 deaths globally.1Johns Hopkins Universityhttps://coronavirus.jhu.edu/map.htmlGoogle Scholar The health care system is wrestling with a virus that threatens to overwhelm hospital capacity while simultaneously confronting an unprecedented reduction in elective and nonessential care.2Centers for Medicare & Medicaid Serviceshttps://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-pageGoogle Scholar,3Iacobucci G. BMJ. 2020; 368: m1106Crossref PubMed Scopus (197) Google Scholar A survey by the American Cancer Society showed that 50% of cancer patients and survivors reported some impact to their health care due to the COVID-19 epidemic.4Cancer Action Network, American Cancer Societyhttps://www.fightcancer.org/sites/default/files/National%20Documents/Survivor%20Views.COVID19%20Polling%20Memo.Final_.pdfGoogle Scholar Forbes et al5Forbes N. et al.Gastroenterology. 2020; 159: 772-774.e13Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar, 6Connor M.J. et al.BJU Int. 2020; 125: E3-E4Crossref PubMed Scopus (0) Google Scholar recently conducted a survey to evaluate the changes in gastrointestinal and endoscopy practices in North America. However, the impact of this epidemic on endoscopy units globally has not been studied. A web-based survey was developed by leaders of the World Endoscopy Organization. The questionnaire included 16 questions focused on the endoscopy units’ baseline volumes, the impact on procedure numbers during the peak of the COVID-19 epidemic, the use of personal protection equipment (PPE), and whether any endoscopy personnel contracted the infection. The survey was sent April 23, 2020, and responses were collected through May 12, 2020. The detailed questionnaire is provided in Supporting Document 1. All participants provided informed consent for the collection, handling, and storage of data. For this survey, Institutional Review Board exemption was provided by Swedish Medical Center, Seattle, Washington. Descriptive statistics were used to analyze responses. Continuous variables are reported as mean ± SD or median and interquartile range (IQR), and categorical variables are summarized as frequency and percentage. Data were compared across continents and tertiles of pre–COVID-19 volume using 1-way analysis of variance for continuous and the χ2 test for categorical variables. All statistical analyses were performed using SAS 9.4 software (SAS Institute Inc, Cary, NC). From April 23 to May 12, 2020, 252 endoscopy units globally responded to the survey, performing 2,069,447 endoscopic procedures in a year (at baseline). These endoscopy units represent 2810 endoscopists, 3024 endoscopy nurses, and 1334 endoscopy technicians from 55 countries across 6 continents. The median number of endoscopic procedures performed annually among the endoscopy units was 5000 (IQR, 2000–9000), number of endoscopists in each center was 7 (IQR, 3–13), number of endoscopy nurses was 6.5 (IQR, 3–15), and number of technicians was 3 (IQR, 1–6). Compared with baseline, endoscopy units reported an average 83% reduction in total endoscopy volumes during the COVID-19 pandemic. There was an 82% reduction in upper endoscopy procedures (esophagogastroduodenoscopy, endoscopic ultrasonography, and endoscopic retrograde cholangiopancreatography) and an 85% reduction in lower endoscopy (flexible sigmoidoscopy and colonoscopy) (Figure 1B). These reductions in endoscopy volumes were consistent across all continents except for Oceania (Australia and New Zealand), which continued to perform approximately 41% of procedures compared with baseline (P = .008 for comparison with other continents) (Figure 1A). For upper endoscopy, the use of PPE was as follows: N95/powered air-purifying respirator (PAPR) in 78.6% of cases, surgical masks in 65.9%, gloves in 96%, gown in 92.1%, and goggles in 83.7%. The use of N95 by continent is shown in Figures 1C and 1D (grouped by baseline case volume). Endotracheal intubation was used in approximately 12% of the upper endoscopy procedures. With regard to PPE use for lower endoscopy: N95/PAPR was used in 68.7% of cases, surgical masks in 77.2%, gloves in 96%, gowns in 91.3%, and goggles in 77% (Supplementary Table 1). Use of N95/PAPR masks was significantly higher for upper compared with lower endoscopy (P < .001). Results of PPE use stratified by baseline procedure volumes is summarized in Supplementary Table 2, with no significant difference in PPE use noted among centers based on these volumes (characteristics of participating endoscopy units based on baseline total number of procedures were performed in tertiles). A total of 34 endoscopy units (13.5%) reported severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)–positive cases among their endoscopy personnel, with 48.6% of these cases in Europe. Only 7.9% of the positive cases required hospitalization. Endoscopy units that performed a higher procedure volume at baseline reported a higher rate of SARS-CoV-2 infection: 27.1% in the third tertile vs 13.5% in the first tertile (P < .001). In addition to the analyses above, we assessed the geographic distribution of our sample to display survey data using ArcGIS Pro 2.5 (Esri, Redlands, CA) (Figure 1E). This is the first study to assess the impact of the COVID-19 pandemic on endoscopy practices around the world. We surveyed endoscopy units representing 55 countries across 6 continents. The most important finding of the present study was the massive cutback of endoscopy procedures by 83% (compared with baseline procedures) across the world during the pandemic period. This type of approach both by the health/ hospital authorities and the endoscopists has several undoubtable reasons: to save resources for COVID-19 patients (medical and nurse staff, hospital beds, intensive care units, economical resources, PPE) and to reduce the risk of infection (staff and patients). An interesting finding was the relatively higher volume of upper and lower endoscopies performed in Oceania during the COVID period, possibly a reflection of the impact of COVID 19 in these countries (only 1500 cases by May 25, 2020). In addition, our survey showed that only 34 of the participating centers (13.5%) reported SARS-CoV-2–positive cases among their endoscopy staff, suggesting that the risk of transmission of this infection among endoscopy personnel while using appropriate PPE may be low. This finding is in agreement with data from an Italian study showing a low risk of infection7Repici A. et al.Gut. 2020; Google Scholar as well. Although several gastrointestinal societies have suggested that all endoscopic procedures should be considered aerosol-generating procedures, our survey showed that the use of N95 masks was significantly higher during upper compared with lower endoscopy procedures. This could be due to the perception of an increased risk of transmission via aerosolized droplets perceived to be higher during upper endoscopy. This is the first study to evaluate the impact of COVID-19 pandemic on 252 endoscopy units worldwide across 6 continents encompassing 55 countries. A substantial reduction (>80%) in endoscopy procedures has been noted globally. Future research can evaluate potential clinical impacts of this reduction. In general, the proportion of endoscopy units reporting infected personnel has been low.