Are there any best practice recommendations for PPE use during the COVID-19 pandemic?

Posted on May 10, 2020 by Gemma Percival

Summary

Consistent use of personal protective equipment (PPE), in combination with other infection control practices, can diminish the risk of infection (1).  However, there is almost no direct evidence of the efficacy of PPE on COVID-19 (2). Available indirect evidence varies in quality, and its relevance in the COVID-19 pandemic remains unclear (2). By extension, there are no universally accepted PPE guidelines and local practice variations exist. Providers should, therefore, follow their own organizational infection prevention and control policies and procedures on PPE.

I.   Current state of evidence

A recent Cochrane review concluded that the optimal type, composition, amount, and ways of using full‐body PPE remains unclear (1). There is also uncertainty regarding the best way to remove PPE after use and the best type of training long-term (1). 

Masks

  • There is no convincing evidence that medical masks are inferior to N95s for protecting against viral respiratory infections during non–aerosol‐generating procedures (3). However, there is inconsistency in recommendations for routine care and non–aerosol‐generating procedures of COVID‐19 patients (3). That said, findings from a recent systematic review align with current WHO and Public Health Agency of Canada recommendations to use medical masks for non–aerosol‐generating procedures (3).
  • For aerosol‐generating procedures, N95s are unanimously recommended by national and international guidelines (3).

Gown

  •  The WHO recommends long-sleeved non-sterile gowns and gloves for both aerosol-generating procedures and non–aerosol‐generating procedure (4). 
  • Covering more of the body improves protection but leads to difficult donning, doffing and user discomfort, which may increase contamination (1). A long gown may be the best compromise between protection and ease of doffing (1)

Eye protection

  • There is no direct evidence from randomized trials that eye protection equipment alone prevents transmission of COVID-19 (5).  Eye protection is most effective when used in combination with other PPE measures and for protection against any blood or other body fluid splashes during procedures (5).
  • Eye protection equipment should be used for primary and community care when assessing patients with possible SARS-CoV-2 infection (5).
  • Face shields provide superior protection to goggles or glasses, because they cover the face, part of the neck and all of the mask. Face shields appear to significantly reduce the amount of inhalation exposure to influenza virus (6). In a simulation study, face shields were shown to reduce immediate viral exposure by 96% when worn by a simulated health care worker within 18 inches of a cough (7). Even after 30 minutes, the protective effect exceeded 80% and face shields blocked 68% of small particle aerosols (7). 

Foot Coverings

  • WHO and Canadian guidelines do not currently recommend protective shoe coverings.
  • A recent review identified no relevant trials. In a single observational study, a single positive swab for SARS-CoV-2 was obtained from the shoe of a healthcare worker (8). General occupational health guidance recommends shoe covers when there is a risk of splashing from infected body fluids (8). Further research is needed on whether shoe covers should be added to PPE(8).

Donning and doffing

There is significant risk of self-contamination during donning and doffing (9). PPE that makes donning and doffing more difficult, increases this risk (10). Practical training, rehearsal, and buddying all appear to improve protocol adherence (6).

  • Very low‐certainty evidence that double gloves may reduce the risk of contamination during doffing and that extra disinfection of gloves with bleach or quaternary ammonium may decrease hand contamination but not alcohol‐based hand rub (1). 

II.   Doffing guidelines

Questions? Comments? Does this need to be updated? Do you have valuable points to add ? Please email ask.reakt@ubc.ca.

References

  1. Verbeek  JH, Rajamaki  B, Ijaz  S, Sauni  R, Toomey  E, Blackwood  B, Tikka  C, Ruotsalainen  JH, Kilinc Balci  FS. Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff [Internet]. Cochrane Database of Systematic Reviews. 2020 Apr 15 [cited 2020 May 10]. Available from:https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011621.pub4/full?highlightAbstract=equip%7Cprotectiv%7Cperson%7Cequipment%7Cpersonal%7Cprotective%7Cprotect
  2. The Centre for Evidence-Based Medicine. Editor’s commentary: Rapid reviews of PPE – an update [Internet]. 2020 April 14 [cited 2020 May 10]. Available from: https://www.cebm.net/covid-19/editors-commentary-rapid-reviews-of-ppe-an-update/
  3. Bartoszko, JJ, Farooqi, MAM, Alhazzani, W, Loeb, M. Medical masks vs N95 respirators for preventing COVID‐19 in healthcare workers: A systematic review and meta‐analysis of randomized trials [Internet]. Influenza Other Respi Viruses. 2020 Apr 4 [cited 2020 May 10]. Available from: https://onlinelibrary.wiley.com/doi/full/10.1111/irv.12745
  4. The Centre for Evidence-Based Medicine. What is the effectiveness of protective gowns and aprons against COVID-19 in primary care settings? [Internet]. 2020 Apr 16 [cited 2020 May 10]. Available from: https://www.cebm.net/covid-19/what-is-the-effectiveness-of-protective-gowns-and-aprons-against-covid-19-in-primary-care-settings/
  5. The Centre for Evidence Based Medicine. What is the efficacy of eye protection equipment compared to no eye protection equipment in preventing transmission of COVID-19-type respiratory illnesses in primary and community care? [Internet]. 2020 Apr 3 [cited 2020 May 10]. Available from: https://www.cebm.net/covid-19/what-is-the-efficacy-of-eye-protection-equipment-compared-to-no-eye-protection-equipment-in-preventing-transmission-of-covid-19-type-respiratory-illnesses-in-primary-and-community-care/
  6. Perencevich EN, Diekema DJ, Edmond MB. Moving Personal Protective Equipment Into the Community: Face Shields and Containment of COVID-19 [Internet]. JAMA. 2020 Apr 29 [cited 2020 May 10]. Available from: https://jamanetwork.com/journals/jama/fullarticle/2765525?resultClick=1
  7. Lindsley  WG , Noti  JD , Blachere  FM , Szalajda  JV , Beezhold  DH .  Efficacy of face shields against cough aerosol droplets from a cough simulator [Internet]. J Occup Environ Hyg. 2014 [cited 2020 May 10]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24467190
  8. The Centre for Evidence-Based Medicine. What is the evidence that COVID-19 personal protective equipment should include shoe covers? [Internet]. 2020 Apr 7 [cited 2020 May 10]. Available from: https://www.cebm.net/covid-19/what-is-the-evidence-that-covid-19-personal-protective-equipment-should-include-shoe-covers/
  9. Fischer WA, Hynes NA, Perl TM. Protecting health care workers from Ebola: Personal protective equipment is critical but is not enough. Ann Intern Med. 2014 Nov 18 [cited by Verbeek et al. 2020 April 15]. 
  10. Zamora JE, Murdoch J, Simchison B, Day AG. Contamination: A comparison of 2 personal protective systems. Canadian Medical Association Journal 2006 Aug 1 [cited by Verbeek et al. 2020 April 15]. Available from: https://www.cmaj.ca/content/175/3/249
  11. BC Children’s and BC Women’s Hospitals. Doffing (taking off) personal protective equipment: Droplet and contact and airborne precautions (includes aerosol-generating medical procedures). 2020 May 4 [cited 2020 May 10]. Available from: http://policyandorders.cw.bc.ca/resource-gallery/Documents/Infection%20Control/C-0506-12-60562%20Doffing%20(Taking%20Off)%20Personal%20Protective%20Equipment.pdf

Disclaimer

The above is intended to serve as a rapidly-created, accessible source of information curated by medical students and healthcare professionals. It is for educational purposes only and is not a complete reference resource. It is not professional medical advice, and is not a substitute for the discretion, judgment, and duties of healthcare professionals. You are solely responsible for evaluating the information above.