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CliniSalus

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Summary Report
Potential Residual Pathogen Exposure Risk to Healthcare Workers During Endoscopy Procedures

This report supports governance discussion and proportionate, documented decision-making; it does not prescribe clinical or operational action.

Assessment Details

Assessor Name	Not specified
Assessor Position	Not specified
Assessor Organisation	Not specified
Report Generated	Not specified

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Potential Residual Pathogen Exposure Risk to HCWs During Endoscopy Procedures

Purpose and Scope	Page 2
Framework	Page 3
Evidence Basis	Page 4
Assessment Summary	Page 5
Risk Matrix	Page 6
Risk Interpretation	Page 7
Governance and Limitations	Page 8
Appendices	Pages 9-15

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Purpose and Scope

Purpose and Scope of this Summary Report

This Summary Report presents the output of a structured residual occupational health risk assessment tool relating to healthcare worker pathogen exposure associated with routine gastrointestinal and nasal endoscopic procedures conducted in endoscopy procedure rooms.

The report summarises the calculated risk position, the key assumptions and descriptor selections underpinning that position, and the evidence context informing those selections. It provides a framework for governance discussion and proportionate, documented decision-making regarding infection prevention and control measures in endoscopy settings, without prescribing specific clinical or operational actions.

The assessment is limited to routine gastrointestinal and nasal endoscopic procedures performed in endoscopy procedure rooms under standard procedural conditions and typical patient populations. It considers occupational exposure pathways recognised to occur during routine endoscopic workflows for healthcare workers, informed by contemporary post-pandemic evidence including quantitative aerosol measurement studies, environmental sampling, and observational research.

Areas outside the endoscopy procedure room (e.g. waiting, recovery, and reprocessing areas) are not included within the scope of this assessment. Similarly, outbreak or emergency response scenarios are not within scope of this assessment, as these circumstances are subject to separate escalation protocols under existing infection prevention and control frameworks.

This assessment does not suggest that existing infection prevention and control practices in endoscopy are inadequate or non-compliant with current guidance. Rather, it provides a structured method for evaluating whether residual occupational health risks remain under current control configurations, and whether additional or alternative control measures may be reasonably practicable when assessed against the hierarchy of controls framework.

Current infection prevention and control protocols—including those established in GENCA (2025), NHMRC (2019), and ACSQHC frameworks—have proven effective in protecting healthcare workers through comprehensive administrative controls and appropriate personal protective equipment. Recent quantitative studies have, however, characterised aerosol generation dynamics during endoscopy procedures with greater precision than previously possible, and the availability of engineering control technologies not previously available for endoscopy procedures creates opportunities to evaluate whether additional protective layers may further reduce healthcare worker exposure.

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Framework

Relationship to Regulatory and Governance Frameworks

This Summary Report aligns with Australian work health and safety legislation and national healthcare safety and quality governance frameworks, providing a structured basis for evidence-informed decision-making in endoscopy infection prevention and control.

Under the Work Health and Safety Act 2011, duty holders must eliminate risks so far as is reasonably practicable, or where elimination is not possible, minimise risks through systematic application of control measures. Safe Work Australia establishes the hierarchy of controls as the foundational framework, requiring prioritisation of higher-order controls before reliance on administrative measures or personal protective equipment (SWA, 2024).

Within healthcare, the National Safety and Quality Health Service (NSQHS) Preventing and Controlling Infections Standard operationalises this duty, requiring health service organisations to implement "an effective risk management system for infection prevention and control [that] involves the identification of hazards, and assessment and control of risks for patients, visitors and members of the workforce, so far as is reasonably practicable" (ACSQHC, 2021, p. 24).

The NSQHS Preventing and Controlling Infections Standard explicitly adopt the hierarchy of controls as the organising structure for infection risk management, requiring risks to be minimised using substitution, isolation, or engineering controls before administrative controls and PPE are considered. ACSQHC guidance emphasises that controls operating independently of sustained individual behaviour provide more consistent protection (ACSQHC, 2021, p. 25).

GENCA (Gastroenterological Nurses College of Australia) guidance translates these national principles into endoscopy-specific practice, aligning with NHMRC (2019) and ACSQHC frameworks while emphasising that infection prevention strategies must evolve as evidence emerges (GENCA & GESA, 2025). ACIPC (Australasian College for Infection Prevention and Control) similarly applies the hierarchy to airborne pathogen management, prioritising engineering controls at source (ACIPC, 2025).

Critically, these obligations are dynamic rather than static, requiring "ongoing careful review as the scientific body of knowledge develops" (ACSQHC, 2021, p. 25). This assessment tool supports that ongoing review process by providing a transparent, evidence-based framework for evaluating residual occupational health risks in contemporary endoscopy practice.

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Evidence Basis

Basis for Considering Occupational Exposure During Endoscopy

Endoscopy is a high-interaction clinical setting in which healthcare workers perform procedures in close proximity to patients while manipulating the aerodigestive or gastrointestinal tract. Under routine clinical conditions, published evidence demonstrates that occupational exposure pathways via aerosol, droplet/splash, and contact may occur during individual procedures and may accumulate across repeated procedures over time.

Aerosol and airborne exposure: Quantitative particle monitoring studies demonstrate that routine gastrointestinal and nasal endoscopic procedures generate measurable increases in airborne particle concentrations during common procedural phases, with staff positioned in close proximity to the patient breathing zone.

Droplet and splash exposure: Observational and microbiological studies have documented facial contamination of endoscopy personnel during routine procedures, including unrecognised splash events occurring without visible contamination.

Contact transfer: Environmental and instrument sampling studies demonstrate contamination of endoscopes and high-touch surfaces within procedure rooms consistent with routine contact-mediated exposure pathways.

The occurrence of exposure does not imply that infection or illness will necessarily result. Reasonably foreseeable health consequences may range from no infection or minor, transient effects through to clinically significant occupational illness, depending on pathogen characteristics, exposure dose and route, host susceptibility, and existing control measures. In some circumstances, illness in healthcare workers may contribute to temporary workforce unavailability or onward transmission, with associated impacts on service capability.

This evidence does not indicate failure of infection prevention and control practice. Rather, it indicates that, credible exposure pathways remain present within routine endoscopic workflows, such that reasonably foreseeable harm may vary in severity across different scenarios.

Accordingly, this evidence base informs the likelihood and consequence descriptors applied within the assessment tool and provides context for interpretation of the calculated residual risk position.

For the most current evidence review and complete reference list, readers are encouraged to review the summarised slideshow in Apendix B of this document or to access the full slideshow presentation via the Endoscopy Procedure Occupational Residual Risk Assessment Tool.

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Assessment Summary

Inputs and Calculated Risk Position

Assessment Summary

Precaution Level (GENCA aligned Precaution Levels)	Not specified
Degree of Harm / Consequence	Not specified
Likelihood	Not specified

Calculated Risk Level

Not Assessed

Consequence Score

Likelihood Score

The calculated risk level reflects the interaction of selected descriptors within this assessment framework and should be interpreted as a comparative characterisation rather than an absolute measurement of harm or probability.

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Risk Matrix

Visual Risk Characterisation

Risk Matrix Position

Calculated for procedures routinely performed under the selected precaution level

Illustrative risk position based on user-selected consequence and likelihood inputs.

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Risk Interpretation

Summary Risk Interpretation and Risk Level Actions

Risk Level Actions Table

* The above Risk Level Actions Table is a reproduction of the Risk Level Actions table published by the Australian Commission on Safety and Quality in Health Care (ACSQHC) HERE.

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Governance and Limitations

This assessment provides a structured framework for evaluating occupational health risks in endoscopy settings, but does not prescribe specific control measures. Decisions regarding control selection, implementation approaches, resource allocation, and escalation or deferral of enhanced controls remain the responsibility of the local health service, informed by organisational governance processes, clinical judgement, documented risk assessment outcomes, and statutory obligations under WHS and NSQHS frameworks.

Duty of care obligations are met through proportionate, documented decision-making processes that demonstrate: (1) systematic identification of foreseeable hazards, (2) assessment of residual risk under existing controls using the hierarchy of controls, (3) evaluation of whether additional higher-order controls are available, suitable, and reasonably practicable, and (4) transparent documentation of decisions, including the basis for adoption, deferral, or non-adoption of enhanced control measures.

This Summary Report:

is based on user-selected descriptors and assumptions;
does not account for site-specific factors such as ventilation performance, room layout, or local workflow variation;
does not evaluate outbreak or emergency scenarios; and,
should be interpreted in conjunction with broader infection prevention, work health and safety, and clinical governance processes.

This approach ensures alignment with both statutory duties and national healthcare safety standards, while recognising that control selection must be contextually appropriate and operationally feasible for each health service setting.

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Appendix A

Assessment Inputs and Selection Transparency

The following appendices A1, A2, and A3 document the selections used to generate the residual risk position, including the exact descriptor wording selected by the assessor and the alternative options available at the time of assessment. This information is provided to support transparency where the Summary Report is reviewed independently of the assessment tool.

The screenshots below shows the selection interface as it appeared when the assessment was completed, including all available options and the selection made by the assessor.

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Appendix A1

Question 1: Precaution Level Selection

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Appendix A2

Question 2: Consequence Descriptor Selection

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Appendix A3

Question 3: Likelihood Descriptor Selection

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Appendix B

Evidence Summary: Pathogens and Exposure Pathways in Endoscopy

This appendix reproduces key content from the Pathogens and Exposure Pathways in Endoscopy: Current and Emerging Evidence presentation to support independent review of the evidence basis informing this assessment.

1. Introduction

Endoscopic procedures involve close physical proximity between patients and endoscopy health care workers. Routine manipulation of the aerodigestive and gastrointestinal tracts creates repeated and cumulative opportunities for occupational exposure to biological hazards.

These hazards arise through multiple, concurrent exposure pathways, including aerosol generation, droplet and splash exposure, and contact with contaminated instruments and environmental surfaces.

2. Aerosol Generation During Endoscopy

Recent post-COVID analyses indicate that a broader range of endoscopic procedures than previously recognised meet operational definitions of aerosol generation, with reproducible increases in airborne particle concentrations measured under routine clinical conditions.

(Phillips et al., 2022; Sagami et al., 2021; Shi et al., 2025)

3. Evidence: Aerosol Generation

GI endoscopy generates significant quantities of aerosols and droplets:

Upper GI: 1.96× background particles
Transnasal: 2.00× background
Lower GI: Lower per-minute but 2.4× total due to duration
Concentrations exceed baselines by 1.3–150-fold

(Phillips et al., 2022; Pereira et al., 2022; Shi et al., 2025)

4. Splash and Droplet Exposure

Healthcare workers may be exposed to biological material through recognised pathways resulting in contamination of the face, hands, and mucous membranes. Splash exposure represents a common, and frequently under-recognised, contamination pathway.

(Johnson et al., 2019; Nylander et al., 2023)

5. Evidence: Splash Exposure

Bacterial splash contamination of the endoscopist's face: 5.3 per 100 sessions, with unrecognised splashes more frequent than recognised events. 75% of recognised splashes yielded positive bacterial cultures.

Bacterial cultures from face visors identified organisms including E. coli and Enterobacter cloacae with no visible contamination.

(Johnson et al., 2019; Nylander et al., 2023)

6. Environmental and Contact Exposure

Healthcare workers may encounter biological hazards through contact with contaminated instruments and frequently touched environmental surfaces. Contact-based exposure pathways occur across routine procedural workflows.

Contamination of high-touch surfaces within endoscopy procedure rooms is well documented.

(Johnson et al., 2019; Choi et al., 2014; Hanafiah et al., 2024)

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Appendix B (continued)

Evidence Summary: Pathogens and Exposure Pathways

7. Evidence: Surface Contamination

89.8% of endoscope external surfaces showed bacterial colonisation immediately post-procedure, indicating substantial transfer potential.

High contamination levels on surfaces: physicians' keyboards (974 CFUs), nurses' carts (918 CFUs), nurses' mice (764 CFUs).

(Johnston et al., 2019; Choi et al., 2014; Hanafiah et al., 2024)

8. Integrated Exposure Pathways

Healthcare workers are routinely exposed through multiple, overlapping pathways during standard endoscopic workflows. Aerosol generation, splash exposure, and contact transfer create a complex exposure environment intrinsic to gastrointestinal and nasal endoscopy.

(Johnston et al., 2019; Suzuki et al., 2020; Hoshi et al., 2022)

9. Bacterial and Viral Pathogens

Environmental surveillance has confirmed diverse pathogen reservoirs within endoscopy environments, providing biological context for exposure pathways and informing pathogen-specific transmission assessment.

(Phillips et al., 2022; Ye et al., 2025; Peters et al., 2011)

10. Evidence: Bacterial Transmission

Faecal aerosolisation during colonoscopy shows marked increases in respirable particles. Microbial aerosols dominated by Pseudomonas, Staphylococcus, Bacillus.

H. pylori represents recognised occupational risk with increased seroprevalence in endoscopy personnel. MDR organisms detected in bronchoscopy room air at 21–107 CFU/m³.

(Phillips et al., 2022; Ye et al., 2025; Yakupogullari et al., 2016)

11. Summary of Transmission Relevance

Endoscopic procedures involve occupational exposure to biologically relevant viral and bacterial agents under routine clinical conditions. Exposure arises through inhalation, splash, and contact pathways inherent to standard workflows rather than isolated events.

Pathogen-specific transmission risk should be considered with reference to identified hazards and established exposure pathways.

12. Pathogen Classes Identified

Key pathogen classes include:

Respiratory viruses (SARS-CoV-2, Influenza, RSV)
GI viruses (Norovirus, Rotavirus)
Gram-positive bacteria (S. aureus, S. pneumoniae)
Gram-negative bacteria (P. aeruginosa, E. coli)
MDR organisms (CRE, VRE, CRAB)
Mycobacteria, Blood-borne viruses

See full slideshow for evidence strength ratings

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Appendix B (continued)

Evidence Summary and References

13. References

Complete references available in full slideshow presentation. Key citations include: Phillips et al. (2022), Pereira et al. (2022), Johnston et al. (2019), Nylander et al. (2023), Choi et al. (2014), Hanafiah et al. (2024), Ye et al. (2025), Peters et al. (2011), Yakupogullari et al. (2016), Shi et al. (2025), and others.

14. Authorship and Disclaimer

Prepared by CliniSalus Pty Ltd to support evidence-informed consideration of occupational health risks. Based on published peer-reviewed literature and publicly available guidance.

Provided for general informational purposes. Not clinical, regulatory, or legal advice. Should be read in conjunction with local policies and professional judgement.

Note on Complete Evidence Presentation

This appendix provides a condensed summary of key evidence points. The complete Pathogens and Exposure Pathways in Endoscopy: Current and Emerging Evidence presentation, including full references, detailed evidence tables, and comprehensive pathogen classifications, is available through the CliniSalus Residual Risk Assessment Tool online interface.

For the most current evidence review and complete reference list, users are encouraged to review the full slideshow presentation via the Endoscopy Procedure Occupational Residual Risk Assessment Tool.

Reset to Start

Pathogens and Pathways in Endoscopy Procedures

A Brief Summary of New, Emerging, and Existing Evidence

Slide 1 of 15

Introduction

These hazards arise through multiple, concurrent exposure pathways, including aerosol generation, droplet and splash exposure, and contact with contaminated instruments and environmental surfaces containing patient secretions, blood, gastrointestinal contents, and deposited material from aerosolised particles.

Endoscopy has long been recognised as a clinical setting associated with infection transmission risk. Emerging evidence has further clarified the contribution of aerosol-generating events in addition to established droplet, splash, and contact-mediated exposure pathways.

Aerosol Generation During Endoscopy

Measurement studies conducted within endoscopy procedure rooms further demonstrate that aerosol generation occurs across multiple phases of standard endoscopic workflows, rather than being confined to infrequent or exceptional events.

(Phillips et al., 2022; Sagami et al., 2021; Shi et al., 2025)

Evidence: Aerosol Generation During Endoscopy

"GI endoscopy performed through the mouth, nose, or rectum generates significant quantities of aerosols and droplets."

Upper GI procedures produced 1.96 times the level of background particles
Transnasal produced 2.00 times
Lower GI procedures showed lower per-minute particle generation (0.63×) but significantly higher total particle counts per procedure due to longer duration, with a 2.4-fold increase compared with upper GI procedures
Airborne particle concentrations exceed environmental baselines by 1.3- to 150-fold depending on procedure type and phase

(Phillips et al., 2022)

Real-world aerosol measurements conducted in an operational endoscopy unit identified upper endoscopy, colonoscopy, bronchoscopy, and bidirectional procedures as significant aerosol sources. Mean concentrations of particles <5 μm increased by 12–141% above baseline, depending on procedure type. Sampling at head height within the healthcare worker breathing zone directly linked aerosol generation to occupational exposure potential.

(Pereira et al., 2022)

Visualisation of aerosol and droplet behaviour during upper airway and gastrointestinal endoscopy demonstrated dispersion of aerosolised material into the immediate procedural environment, particularly during insertion, withdrawal, coughing, and gag reflex events. The findings show that routine upper gastrointestinal endoscopy exhibits operational characteristics consistent with an aerosol-generating procedure, with dispersible airborne material capable of reaching healthcare worker breathing zones.
Observed reductions in aerosol spread with the use of physical barrier systems further support the identification of procedural mechanisms contributing to aerosolisation under routine clinical conditions.

(Passi, 2022; Heymer et al., 2022)

Real-time particle monitoring showed significant increases in airborne particles during gastroscopy (4.58%) and bronchoscopy (4.43%) relative to background levels.

(Shi et al., 2025)

Direct Contact, Splash and Droplet Exposure During Endoscopy

During gastrointestinal endoscopy, healthcare workers may be exposed to biological material, including bacterial pathogens, through recognised exposure pathways resulting in contamination of the face, hands, and mucous membranes.

Splash exposure to the face represents a common, and frequently under-recognised, contamination pathway.

(Johnson et al., 2019; Nylander et al., 2023)

Evidence: Direct Contact, Splash and Droplet Exposure During Endoscopy

Bacterial splash contamination of the endoscopist's face was observed at a rate of 5.3 per 100 endoscopy sessions, with unrecognised splashes occurring more frequently than recognised events.
Microbiological analysis showed that 75% of recognised splash incidents yielded positive bacterial cultures, indicating that actual exposure rates are likely higher than those identified through visible contamination alone.

(Johnson et al., 2019)

In a prospective pilot study, bacterial cultures from face visors worn by endoscopists and assistants following individual gastrointestinal endoscopy procedures identified skin, oronasal, and enteric organisms, including Escherichia coli and Enterobacter cloacae.
No visors showed visible contamination, indicating that facial exposure may occur without overt splash events. These findings support the presence of unrecognised droplet or splash contamination pathways during routine endoscopic practice.

(Nylander et al., 2023)

Environmental and Surface-Mediated Contact Exposure During Endoscopy

In addition to aerosol, splash and droplet exposure, healthcare workers may encounter biological hazards through contact with contaminated instruments and frequently touched environmental surfaces during and between endoscopic procedures.

These contact-based exposure pathways occur across routine procedural workflows and are not confined to discrete events.

Contamination of high-touch surfaces within endoscopy procedure rooms is well documented, and evidence from broader healthcare settings further demonstrates the persistence of surface-mediated contamination mechanisms relevant to endoscopy environments.

(Johnson et al., 2019; Choi et al., 2014; Hanafiah et al., 2024)

Evidence: Environmental and Surface-Mediated Contact Exposure During Endoscopy

Bacterial colonisation was identified on 89.8% of endoscope external surfaces immediately following withdrawal from colonoscopy, indicating substantial potential for transfer during intra-procedural repositioning and post-procedural handling.

(Johnston et al., 2019, pp. 819–820)

High levels of bacterial contamination were measured on surfaces routinely contacted by endoscopy personnel, including physicians' computer keyboards (974 CFUs), nurses' carts (918 CFUs), and nurses' computer mice (764 CFUs).

(Choi et al., 2014)

Biofilm formation pathways were identified in surface-isolated bacteria, including poly-β-1,6-N-acetyl-D-glucosamine synthesis genes (PgaC, PgaB, PgaD), providing a mechanistic basis for bacterial persistence despite routine disinfection. Surface-associated organisms were also shown to exhibit antimicrobial resistance, enabling survival on hospital surfaces and facilitating transmission through routine healthcare worker contact.

(Hanafiah et al., 2024)

Integrated Exposure Pathways and Environmental Contamination

Available evidence indicates that healthcare workers in endoscopy procedure rooms are routinely exposed to biological hazards through multiple, overlapping exposure pathways during standard endoscopic workflows.

Aerosol generation during routine procedural phases, together with splash exposure and contact transfer from contaminated instruments and high-touch environmental surfaces, creates a complex exposure environment intrinsic to gastrointestinal and nasal endoscopy rather than attributable to isolated events or atypical practice, as demonstrated by measured increases in airborne particle concentrations, unrecognised facial contamination, and persistent surface contamination under routine clinical conditions.

The relative contribution of exposure pathways varies by procedure type, reflecting differences in anatomical site, instrumentation, and patient physiological responses, with upper gastrointestinal and transnasal procedures primarily generating aerosols associated with respiratory and oropharyngeal secretions and lower gastrointestinal procedures generating aerosols from intestinal contents.

(Johnston et al., 2019; Suzuki et al., 2020; Hoshi et al., 2022;
Nylander et al., 2023; Shi et al., 2025)

Bacterial and Viral Pathogens and Multidrug-Resistant Organisms

Environmental surveillance using air sampling, surface culture, and molecular detection has confirmed the presence of diverse pathogen reservoirs within endoscopy environments, providing biological context for the exposure pathways described above and informing pathogen-specific transmission assessment.

(Phillips et al., 2022; Ye et al., 2025; Peters et al., 2011; Perdelli et al., 2008;
Thamboo et al., 2020; Yakupogullari et al., 2016; Yang et al., 2025)

Evidence: Bacterial and Viral Pathogens and Multidrug-Resistant Organisms

Bacterial transmission risk during endoscopy arises through aerosolisation, droplet deposition, and contact transfer from contaminated instruments and environmental surfaces.

Faecal aerosolisation represents a distinct lower gastrointestinal exposure pathway, with marked increases in respirable airborne particles documented during colonoscopy, including rectal intubation, extubation, and application of abdominal pressure.

(Phillips et al., 2022)

Routine endoscopy has also been shown to generate microbial aerosols dominated by opportunistic bacterial genera, including Pseudomonas, Staphylococcus, and Bacillus species, rather than classical enteric pathogens.

(Ye et al., 2025)

Helicobacter pylori is routinely encountered in gastrointestinal endoscopy populations and represents a recognised occupational risk, with increased seroprevalence reported among endoscopy personnel compared with non-medical controls.

(Peters et al., 2011)

Viral material has similarly been detected in blood-containing aerosols, with epidemiological evidence indicating rare but recognised endoscopy-associated transmission linked primarily to biopsy and polypectomy rather than diagnostic procedures alone.

(Perdelli et al., 2008; Thamboo et al., 2020)

Multidrug-resistant organisms further extend this risk profile, with carbapenem-resistant Klebsiella pneumoniae detected in bronchoscopy room air at concentrations of 21–107 CFU/m³ and genomic analyses demonstrating high homology between airborne and patient isolates, indicating patient-derived environmental dissemination. Airborne carbapenem-resistant Acinetobacter baumannii has also been identified in healthcare environments, with documented persistence for up to 27 days and clonal continuity between environmental and clinical isolates, supporting the presence of sustained environmental reservoirs relevant to healthcare worker exposure.

(Yakupogullari et al., 2016; Yang et al., 2025)

Summary of Transmission Relevance

Collectively, the available pathogen-specific evidence indicates that gastrointestinal and nasal endoscopic procedures are recognised to involve occupational exposure of healthcare workers to biologically relevant viral and bacterial agents under routine clinical conditions.

Such exposure may arise through inhalation, splash, and contact pathways inherent to standard procedural workflows rather than isolated or atypical events, and is supported by measured aerosol generation, documented contamination, and pathogen detection in clinical and environmental samples relevant to endoscopy settings.

Accordingly, pathogen-specific transmission risk in endoscopy environments should be considered with reference to identified hazards and established exposure pathways, rather than assumptions that exposure can be fully mitigated through individual behaviours or downstream protective measures alone.

Pathogen Classes Identified

Table 1.1. Representative pathogen classes and primary exposure procedures.

Pathogen Class	Representative Pathogens	Primary Procedure Exposure	Evidence Strength*
Respiratory Viruses	SARS‑CoV‑2; Influenza B; RSV; Rhinovirus; non‑SARS coronaviruses	Upper GI; Bronchoscopy; Transnasal	⭐⭐⭐
Gastrointestinal Viruses	Norovirus (GII); Rotavirus†; Astrovirus†	Upper GI (vomiting); Lower GI (faecal shedding)	⭐⭐⭐
Gram-Positive Bacteria	Staphylococcus aureus; Streptococcus pneumoniae; Enterococcus spp.	Upper GI; Bronchoscopy; Transnasal	⭐⭐⭐
Gram-Negative Bacteria	Pseudomonas aeruginosa; Escherichia coli; Salmonella spp.; H. pylori†	All endoscopy procedures	⭐⭐ / ⭐⭐
Multidrug-Resistant Organisms	CRE (incl. CRKP); VRE; CRAB; MDR Pseudomonas	Lower GI; Bronchoscopy	⭐⭐ / ⭐⭐
Mycobacteria	Mycobacterium tuberculosis; NTM	Bronchoscopy	⭐⭐⭐
Spore-Forming Bacteria	Clostridioides difficile†	Lower GI (colonoscopy)	⭐⭐
Blood-Borne Viruses	HBV; HCV; HIV†	Upper GI (biopsy); Lower GI (polypectomy)	⭐⭐

* Evidence strength ratings reflect the quality and quantity of available data on aerosol, droplet, contact, and splash exposure pathways in endoscopy and related clinical settings.

Evidence Strength Indicators (for Table 1.1)

⭐⭐⭐	Confirmed via direct detection in aerosol samples (air sampling with culture or molecular methods) OR confirmed gastrointestinal infection with documented aerosol generation mechanism.
⭐⭐	Confirmed gastrointestinal/respiratory colonisation with plausible aerosol generation mechanism (vomiting, toilet flushing, coughing) OR occupational seroprevalence data demonstrating transmission risk.
⭐	Plausible based on patient colonisation and known aerosol generation pathways; direct aerosol detection pending.
†	Documented transmission mechanism present (vomiting, faecal disturbance, blood exposure) with limited direct aerosol sampling data. Representative citations: (Habibi et al., 2021; Guo et al., 2021; Shi et al., 2025; Tan et al., 2024; Rupprom et al., 2024; Johnston et al., 2019; Yang et al., 2025; Yakupogullari et al., 2016; Perdelli et al., 2008; Thamboo et al., 2020.)

References

Choi, E. S., Choi, J. H., Lee, J. M., Lee, S. M., Lee, Y. J., Kang, Y. J., Kim, E. S., Cho, K. B., Park, K. S., Jang, B. K., Hwang, J. S., Chung, W. J., Ryoo, N. H., Jeon, S. W., & Jung, M. K. (2014). Is the Environment of the Endoscopy Unit a Reservoir of Pathogens? Intestinal Research, 12(4), 306. https://doi.org/10.5217/ir.2014.12.4.306	Yakupogullari, Y., Otlu, B., Ersoy, Y., Kuzucu, C., Bayindir, Y., Kayabas, U., Togal, T., & Kizilkaya, C. (2016). Is airborne transmission of Acinetobacter baumannii possible: A prospective molecular epidemiologic study in a tertiary care hospital. American Journal of Infection Control, 44(12), 1595–1599. https://doi.org/10.1016/j.ajic.2016.05.022	Peters, C., Schablon, A., Bollongino, K., Seidler, A., & Nienhaus, A. (2011). The occupational risk of Helicobacter pylori infection among gastroenterologists and their assistants. BMC Infectious Diseases, 11, 154. https://doi.org/10.1186/1471-2334-11-154
Hanafiah, A., Sukri, A., Yusoff, H., Chan, C. S., Hazrin-Chong, N. H., Salleh, S. A., & Neoh, H. (2024). Insights into the Microbiome and Antibiotic Resistance Genes from Hospital Environmental Surfaces: A Prime Source of Antimicrobial Resistance. Antibiotics, 13(2), 127. https://doi.org/10.3390/antibiotics13020127	Suzuki, T., Hayakawa, K., Ainai, A., Iwata-Yoshikawa, N., Sano, K., Nagata, N., Saito, S., Ogiso, S., Yagami, K., Takahashi, H., Hasegawa, H., & Ohmagari, N. (2020). Facial protection for prevention of droplet transmission. Journal of Infection and Chemotherapy, 26(10), 1070–1073. https://doi.org/10.1111/jgh.15219	Kitwadee Rupprom, Yuwanda Thongpanich, Woravat Sukkham, Fuangfa Utrarachkij, & Leera Kittigul. (2024). Recovery and Quantification of Norovirus in Air Samples from Experimentally Produced Aerosols. Food and Environmental Virology. https://doi.org/10.1007/s12560-024-09590-7
Gastroenterological Nurses College of Australia and Gastroenterological Society of Australia. (2025). Infection prevention and control in endoscopy: 2025 update. https://www.acipc.org.au/wp-content/uploads/2025/05/2025-Infection-Prevention-and-Control-in-Endoscopy.pdf	Thamboo, A., Lea, J., Sommer, D. D., Sowerby, L. J., Abdalkhani, A., Diamond, C., & Rourke, R. (2020). Clinical evidence-based review and recommendations of aerosol-generating medical procedures in otolaryngology–head and neck surgery. Journal of Otolaryngology – Head & Neck Surgery, 49, 28. https://doi.org/10.1186/s40463-020-00458-1	Sagami, R., Nishikiori, H., Sato, T., & Murakami, K. (2021). Aerosols produced by upper gastrointestinal endoscopy: A quantitative evaluation. American Journal of Gastroenterology, 116(1), 202–205. https://doi.org/10.14309/ajg.0000000000000983
Habibi, N., Uddin, S., Al‐Salameen, F., Al‐Amad, S., Kumar, V., Al‐Otaibi, M., Razzack, N. A., Shajan, A., & Shirshikar, F. (2021). SARS‐CoV‐2, other respiratory viruses and bacteria in aerosols: Report from Kuwait's hospitals. Indoor Air, 31(6), 1815–1825. https://doi.org/10.1111/ina.12871	Nylander, D., Leeds, J., Perry, J., Narayanan, M., Dipper, C., Gunn, M., Nayar, M., Speight, A., & Oppong, K. W. (2023). Bacterial contamination of endoscopist and assistant face visors during gastrointestinal endoscopy: a pilot study. Frontline Gastroenterology, 14(6), 505–511. https://doi.org/10.1136/flgastro-2023-102427	Shi, J., Lv, Y., Wu, W., Liu, D., Guo, D., Duan, X., Liu, Z., & Guo, X. (2025). Characterization of particle emissions and microbial exposure risks in endoscopy room. Building and Environment, 284, 113492. https://doi.org/10.1016/j.buildenv.2025.113492
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Authorship Statement

This document has been prepared by CliniSalus Pty Ltd to support evidence-informed consideration of occupational health risks associated with gastrointestinal and nasal endoscopic procedures in Australian healthcare settings. The content is based on published peer-reviewed literature and publicly available guidance current at the time of preparation.

Disclaimer

This material is provided for general informational purposes. It is not intended to provide clinical, regulatory, or legal advice and should be read in conjunction with local infection prevention and control policies, workplace health and safety requirements, and professional judgement.

The information presented reflects the evidence and guidance available at the time of preparation. Its relevance and application may vary depending on local context, organisational arrangements, and regulatory obligations.

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Select the applicable precaution level for the procedure being assessed.
Assess the likely degree of harm should exposure occur.
Estimate the likelihood of exposure via aerosol, droplet, contact, and splash pathways.
Identify the combined residual risk position and consider whether additional controls warrant evaluation.

Use the calculator output to support multidisciplinary discussion, documentation, and ongoing review of occupational exposure risks in endoscopy services.

When ready, select "Return to Risk Assessment" below to begin or continue your assessment.

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Summary ReportPotential Residual Pathogen Exposure Risk to Healthcare Workers During Endoscopy Procedures

Assessment Details

Table of Contents

Purpose and Scope

Framework

Evidence Basis

Assessment Summary

Assessment Summary

Calculated Risk Level

Risk Matrix

Risk Matrix Position

Risk Interpretation

Risk Level Actions Table

Governance and Limitations

Appendix A

Appendix A1

Appendix A2

Appendix A3

Appendix B

1. Introduction

2. Aerosol Generation During Endoscopy

3. Evidence: Aerosol Generation

4. Splash and Droplet Exposure

5. Evidence: Splash Exposure

6. Environmental and Contact Exposure

Appendix B (continued)

7. Evidence: Surface Contamination

8. Integrated Exposure Pathways

9. Bacterial and Viral Pathogens

10. Evidence: Bacterial Transmission

11. Summary of Transmission Relevance

12. Pathogen Classes Identified

Appendix B (continued)

13. References

14. Authorship and Disclaimer

Note on Complete Evidence Presentation

Pathogens and Pathways in Endoscopy Procedures

Introduction

Aerosol Generation During Endoscopy

Evidence: Aerosol Generation During Endoscopy

Direct Contact, Splash and Droplet Exposure During Endoscopy

Evidence: Direct Contact, Splash and Droplet Exposure During Endoscopy

Environmental and Surface-Mediated Contact Exposure During Endoscopy

Evidence: Environmental and Surface-Mediated Contact Exposure During Endoscopy

Integrated Exposure Pathways and Environmental Contamination

Bacterial and Viral Pathogens and Multidrug-Resistant Organisms

Evidence: Bacterial and Viral Pathogens and Multidrug-Resistant Organisms

Summary of Transmission Relevance

Pathogen Classes Identified

References

Authorship Statement

Disclaimer

Next Steps: Applying the Residual Risk Calculator

Residual Risk Calculator
Endoscopy Procedures

Summary Report
Potential Residual Pathogen Exposure Risk to Healthcare Workers During Endoscopy Procedures