Authors: Giulio Antonelli, John Gásdal Karstensen, Purnima Bhat, Uchenna Ijoma, Chukwuemeka Osuagwu, Hailemichael Desalegn, Hanna Abera, Claire Guy, Peter Vilmann, Mario Dinis-Ribeiro, Thierry Ponchon, Luis Carlos Sabbagh, Nonthalee Pausawasdi, Govind Makharia, Cesare Hassan, Andrew Veitch, Lars Aabakken, Alanna Ebigbo, for the Endoscopy and COVID-19 Cascade Working Group, European Society of Gastrointestinal Endoscopy, World Endoscopy Organization and World Gastroenterology Organization
The ongoing COVID-19 pandemic has forced endoscopy units to stop or markedly reduce all elective endoscopic procedure sand has consequently contracted endoscopic capacity through-out the world, with growing concern for a mid- and long-term increase in the burden of gastrointestinal diseases [1–4]. The reopening of endoscopic services is crucial to resume elective procedures but must be balanced with the need to protect healthcare personnel who are already over-represented in terms of COVID 19 morbidity and mortality [5–7].
Resumption of partial or full endoscopy capacity depends on implementation of several interventions, such as availability of Personal Protective Equipment (PPE), COVID-19 testing, distancing and separation according to the level of infection, use of tele-medicine, availability of vaccines and others. At least some of these interventions are resource-consuming, representing a limitation in developing countries .
The European Society of Gastrointestinal Endoscopy (ESGE), the American Society of Gastrointestinal Endoscopy (ASGE) and the British Society of Gastroenterology (BSG) have all issued position statements providing guidance and recommendations for the resumption of endoscopic activity following peaks/waves of COVID-19 [5,6,9,10]. The majority of recommendations in the position papers are based on expert opinions and early survey-based or observational evidence. Many recommendations are resource-sensitive and may be unavailable in low-resource settings due to issues such as extensive costs, personnel unavailability, lack of sufficient healthcare professional training and logistical limitations [8,11].
At the time this paper was drafted, nearly 3 million cases and 70 000 coronavirus-related deaths had been reported in the African Continent, with the majority of states still reporting a high rate of community transmission . Furthermore, the availability and the access to COVID-19 vaccination in African countries may be limited 
The European Society of Gastrointestinal Endoscopy (ESGE) and the World Gastroenterology Organization (WGO) have been publishing Cascade guidelines aiming to apply existing data and adapt existing guidelines for use in resource-limited settings [14–19]. This Cascade guideline is the result of a joint effort of ESGE, WEO and WGO, aiming to standardize guidance for resumption of gastrointestinal endoscopy in the different phases of the COVID-19 pandemic also in resource limited settings.