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Disinfection of personal protective equipment for management of Ebola patients

  • Vincenzo Puro
    Affiliations
    National Institute for Infectious Diseases “Lazzaro Spallanzani”, Rome, Italy
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  • Silvia Pittalis
    Correspondence
    Address correspondence to Silvia Pittalis, MD, Department of Epidemiology and Pre-Clinical Research, National Institute for Infectious Diseases “L. Spallanzani” IRCCS, Via Portuense 292, 00149 Rome, Italy.
    Affiliations
    National Institute for Infectious Diseases “Lazzaro Spallanzani”, Rome, Italy
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  • Pierangelo Chinello
    Affiliations
    National Institute for Infectious Diseases “Lazzaro Spallanzani”, Rome, Italy
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  • Emanuele Nicastri
    Affiliations
    National Institute for Infectious Diseases “Lazzaro Spallanzani”, Rome, Italy
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  • Nicola Petrosillo
    Affiliations
    National Institute for Infectious Diseases “Lazzaro Spallanzani”, Rome, Italy
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  • Mario Antonini
    Affiliations
    National Institute for Infectious Diseases “Lazzaro Spallanzani”, Rome, Italy
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  • Giuseppe Ippolito
    Affiliations
    National Institute for Infectious Diseases “Lazzaro Spallanzani”, Rome, Italy
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  • on behalf ofEbola INMI Task Force
    Author Footnotes
    † Gianni Battisti, Nazario Bevilacqua, Gianluigi Biava, Evangelo Boumis, Ilaria Caravella, Stefania Cicalini, Alessanda Coppola, Angela Corpolongo, Loredana De Marchis, Nicola De Marco, Fabio Di Gianbattista, Francesco Maria Fusco, Vincenzo Galati, Gabriele Garotto, Paolo Giacomini, Mario Guiducci, Daniela Imola, Antonio Marasco, Luisa Marchioni, Andrea Mariano, Micaela Maritti, Antonella Marzolini, Lorena Martini, Alessandro Mercuri, Paola Nieddu, Silvia Ondedei, Silvia Rosati, Fabrizio Taglietti, Maurizio Vescovo, Laura Vincenzi, Laura Vitolo, Antonio Russo, Antonella Petrecchia, Francesco Nicola Lauria
  • Author Footnotes
    † Gianni Battisti, Nazario Bevilacqua, Gianluigi Biava, Evangelo Boumis, Ilaria Caravella, Stefania Cicalini, Alessanda Coppola, Angela Corpolongo, Loredana De Marchis, Nicola De Marco, Fabio Di Gianbattista, Francesco Maria Fusco, Vincenzo Galati, Gabriele Garotto, Paolo Giacomini, Mario Guiducci, Daniela Imola, Antonio Marasco, Luisa Marchioni, Andrea Mariano, Micaela Maritti, Antonella Marzolini, Lorena Martini, Alessandro Mercuri, Paola Nieddu, Silvia Ondedei, Silvia Rosati, Fabrizio Taglietti, Maurizio Vescovo, Laura Vincenzi, Laura Vitolo, Antonio Russo, Antonella Petrecchia, Francesco Nicola Lauria
Published:September 22, 2015DOI:https://doi.org/10.1016/j.ajic.2015.07.040
      To the Editor:
      Bessesen et al highlight the potential utility of reusable elastomeric face masks to bypass the risk of N95 respirator shortages during a respiratory illness pandemic and stress the importance of efficacious disinfection to reuse facial protective equipment safely.
      • Bessesen M.T.
      • Adams J.C.
      • Radonovich L.
      • Anderson J.
      Disinfection of reusable elastomeric respirators by health care workers: a feasibility study and development of standard operating procedures.
      We would like to take the opportunity to underline the need that awareness on personal protective equipment (PPE) stocks is included in any pandemic preparedness plan. The demand for PPE must be established on the basis of the health care facility's role, defined by public health authorities to create a coordinated network approach.

      Centers for Diseases Control and Prevention. CDC tightened guidance for U.S. healthcare workers on personal protective equipment for Ebola. October 20, 2014. Available from: http://www.cdc.gov/media/releases/2014/fs1020-ebola-personal-protective-equipment.html. Accessed July 21, 2015.

      Moreover, we agree that standard operating procedures (SOPs) should be developed to be used by health care workers (HCWs) to disinfect reusable PPE. In our recent experience with 2 Ebola cases at National Institute for Infectious Diseases “Lazzaro Spallanzani” in Rome, Italy, we followed a written protocol for management of patients with Ebola virus disease (EVD), developed and updated since the beginning of the current West Africa outbreak.

      Istituto Nazionale per le Malattie Infettive “Lazzaro Spallanzani” Unità di Crisi. Procedure operative per la gestione di casi sospetti, probabili o confermati e contatti di malattia da virus Ebola (MVE). Revisione 4, 10/12/2014. Available from: http://www.inmi.it/file/ebola/ProcedureEbolaINMI10dicembre.pdf. Accessed July 21, 2015.

      A voluntary clinical task force of infectious diseases specialists, intensivists, and nurses underwent rigorous training to became practiced and competent with the protocol and PPE donning-doffing discipline. PPE to be used was carefully selected according to international updated technical recommendations and lessons learned from previous experiences in endemic areas and western countries. The following 3 PPE options were selected: goggles-based option (goggles, splash-proof fit-tested FFP3-N95 respirator, disposable hood [covering head, neck, and shoulders] with integrated surgical type IIR face mask (high filtration efficiency and spash resistance), double or triple layer of gloves, rubber boots, full body head-to-foot impermeable biohazard suit, plastic apron); face mask–based option (elastomeric face mask with disposable filters rather than goggles-N95 respirator-hood); and powered air-purifying respirator (PAPR)–based option (with a PAPR [composed of hood, motor unit, waist belt, and breathing tube to be put on the suit] rather than goggles-disposable hood). PAPR use was recommended in performing an aerosol-generating procedure and had always been used by intensivists providing critical care. Otherwise, the PAPR was used by HCWs expecting to spend long periods of time while caring for patients, according to a personal choice on safety and comfort. All of the PPE was disposable, except for the goggles, face masks, and PAPR components. We developed written SOPs for PPE disinfection whenever performed by a HCW under supervision of another member of the task force, who virtually was the next user. Similar to Bessesen at al, we used a 0.5% chlorine solution as the disinfectant, according to the World Health Organization's guidance for care of patients with EVD.

      World Health Organization. Interim infection prevention and control guidance for care of patients with suspected or confirmed filovirus haemorrhagic fever in health-care settings, with focus on Ebola. December 2014. Available from: http://www.who.int/csr/resources/publications/ebola/filovirus_infection_control/en/. Accessed September 11, 2015

      Before exiting the isolation area, the HCWs in the removal area were sprayed with 0.5% chlorine solution by another HCW in full PPE, from the clean area, at a 1.5 m safe distance. Outer surfaces of goggles, elastomeric face masks (after removing and discarding filters), and PAPR hood and motor unit were disinfected with wipes dampened with 0.5% chlorine. Once doffed, goggles, face masks, and PAPR hood; breathing tube; and waist belt were immersed fully in 0.5% chlorine for a minimum of 30 minutes and were then thoroughly rinsed with water to remove irritating hypochlorite residues before reuse. No breaches in the disinfection SOPs were notified, and no transmission of Ebola virus occurred among HCWs caring for the 2 patients with EVD.
      However, we noted some critical points in PAPR components disinfection. A large PPE removal area for drying of components is needed; during the PPE doffing, the detachment of each component takes time and needs good practice; throughout chlorine spraying, care should be taken to prevent liquid from entering the air outlet; and finally, the motor unit cannot be immersed in 0.5% chlorine solution.
      We believe the safety concerns on PPE disinfection warrant further investigation, and public health officials, scientists, and clinicians fighting emerging infectious diseases should keep close collaboration with manufacturers to improve the response to present and future epidemics.

      References

        • Bessesen M.T.
        • Adams J.C.
        • Radonovich L.
        • Anderson J.
        Disinfection of reusable elastomeric respirators by health care workers: a feasibility study and development of standard operating procedures.
        Am J Infect Control. 2015; 43: 629-634
      1. Centers for Diseases Control and Prevention. CDC tightened guidance for U.S. healthcare workers on personal protective equipment for Ebola. October 20, 2014. Available from: http://www.cdc.gov/media/releases/2014/fs1020-ebola-personal-protective-equipment.html. Accessed July 21, 2015.

      2. Istituto Nazionale per le Malattie Infettive “Lazzaro Spallanzani” Unità di Crisi. Procedure operative per la gestione di casi sospetti, probabili o confermati e contatti di malattia da virus Ebola (MVE). Revisione 4, 10/12/2014. Available from: http://www.inmi.it/file/ebola/ProcedureEbolaINMI10dicembre.pdf. Accessed July 21, 2015.

      3. World Health Organization. Interim infection prevention and control guidance for care of patients with suspected or confirmed filovirus haemorrhagic fever in health-care settings, with focus on Ebola. December 2014. Available from: http://www.who.int/csr/resources/publications/ebola/filovirus_infection_control/en/. Accessed September 11, 2015

      Linked Article

      • Disinfection of reusable elastomeric respirators by health care workers: A feasibility study and development of standard operating procedure
        American Journal of Infection ControlVol. 43Issue 12
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          We thank the authors for their comments about disinfection of medical equipment with chlorine. In contrast with our work, they engaged a small number of staff in extensive training to prepare for safe handling of a small number of highly contagious patients with Ebola virus disease. They do not present their standard operating procedure, but they state that they used bleach solutions with a chlorine concentration of 5,000 ppm, as recommended by the World Health Organization. In contrast with their program, which relied on extensive training of personnel, our work was aimed at developing a standard operating procedure to be used in the event of a pandemic of respiratory illness, especially influenza.
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