Highlights
- •Personal protective equipment (PPE) is commonly used to protect healthcare workers from becoming infected with communicable diseases.
- •PPE should be donned (put on) and doffed (removed) in the correct order.
- •Various PPE protocols were tested to estimate the risk of self-contamination during doffing of PPE.
- •Most problems during PPE use were related to doffing sequences.
- •Powered air-purifying respirator-containing protocols and assisted doffing are preferred whenever possible.
Background
The aim of this study was to describe the risk of self-contamination associated with
doffing of personal protective equipment (PPE) and to compare self-contamination with
various PPE protocols.
Methods
We tested 10 different PPE donning and doffing protocols, recommended by various health
organizations for Ebola. Ten participants were recruited for this study and randomly
assigned to use 3 different PPE protocols. After donning of PPE, fluorescent lotion
and spray were applied on the external surface of the PPE to simulate contamination,
and ultraviolet light was used to count fluorescent patches on the skin.
Results
After testing 30 PPE sequences, large fluorescent patches were recorded after using
“WHO coverall and 95” and “North Carolina coverall and N95” sequences, and small patches
were recorded after using “CDC coverall and N95” and “Health Canada gown and N95”
sequences. Commonly reported problems with PPE use were breathing difficulty, suffocation,
heat stress, and fogging-up glasses. Most participants rated PPE high (18/30) or medium
(11/30) for ease of donning/doffing and comfort. PPE sequences with powered air-purifying
respirators (PAPRs) and assisted doffing were generally associated with fewer problems
and were rated the highest.
Conclusion
This study confirmed the risk of self-contamination associated with the doffing of
PPE. PAPR-containing protocols and assisted doffing should be preferred whenever possible
during the outbreak of highly infectious pathogens.
Key Words
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References
- Infection prevention and control of epidemic- and pandemic-prone acute respiratory infections in health care.2014
- Occupational safety and health standards. Hazardous materials. General description and discussion of the levels of protection and protective gear.(Standard Number 1910.120 App B; Available from:)https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDSandp_id=9767Date accessed: July 20, 2015
- Quantifying the risk of respiratory infection in healthcare workers performing high-risk procedures.Epidemiol Infect. 2014; 142: 1802-1808
- A highly precautionary doffing sequence for health care workers after caring for wet Ebola patients to further reduce occupational acquisition of Ebola.Am J Infect Control. 2016; 44: 740-744
- Variation in health care worker removal of personal protective equipment.Am J Infect Control. 2015; 43: 750-751
- Contamination of health care personnel during removal of personal protective equipment.JAMA Intern Med. 2015; 175: 1904-1910
- Are health care workers protected? An observational study of selection and removal of personal protective equipment in Canadian acute care hospitals.Am J Infect Control. 2013; 41: 240-244
Institute of Medicine (IOM) National Academy of Sciences. Reusability of Facemasks During an Influenza Pandemic: Facing the Flu. 2006.
- Survival of influenza viruses on environmental surfaces.J Infect Dis. 1982; 146: 47-51
- The survival of filoviruses in liquids, on solid substrates and in a dynamic aerosol.J Appl Microbiol. 2010; 109: 1531-1539
- Environment and body contamination: a comparison of two different removal methods in three types of personal protective clothing.Am J Infect Control. 2014; 42: e39-e45
- A pilot study to assess use of fluorescent lotion in patient care simulations to illustrate pathogen dissemination and train personnel in correct use of personal protective equipment.Antimicrob Resist Infect Control. 2016; 5: 40
- Respiratory protection for healthcare workers treating Ebola virus disease (EVD): are facemasks sufficient to meet occupational health and safety obligations?.Int J Nurs Stud. 2014; 51: 1421-1426
- Uncertainty, risk analysis and change for Ebola personal protective equipment guidelines.Int J Nurs Stud. 2014; 52: 899-903
- Response to Martin-Moreno et al. (2014) Surgical mask or no mask for health workers not a defensible position for Ebola.Int J Nurs Stud. 2014; 51: 1694-1695
- Ebola: doctors and nurses at the front line need thanks and protection, not punishment and blame.(Available from:)https://sphcm.med.unsw.edu.au/infectious-diseases-blog/ebola-doctors-and-nurses-front-line-need-thanks-and-protection-notDate: 2014Date accessed: October 31, 2014
- Ebola virus disease and the need for new personal protective equipment.JAMA. 2014; 312: 2495-2496
- Contamination: a comparison of 2 personal protective systems.CMAJ. 2006; 175: 249-254
- Personal protective equipment in the context of filovirus disease outbreak response—rapid advice guideline.(Available from:)http://www.who.int/csr/resources/publications/ebola/ppe-guideline/en/Date: 2014Date accessed: November 4, 2014
- Ebola: Personal Protective Equipment (PPE) Donning and Doffing Procedures—Powered Air-Purifying Respirator (PAPR) and Coveralls.(Available from:)https://www.cdc.gov/vhf/ebola/hcp/ppe-training/PAPRRespirator_Coveralls/donning_01.htmlDate accessed: October 13, 2017
- Ebola: Personal Protective Equipment (PPE) Donning and Doffing Procedures—N95 and coverall.(Available from:)https://www.cdc.gov/vhf/ebola/hcp/ppe-training/n95Respirator_Coveralls/donning_01.htmlDate accessed: October 15, 2017
- Safe use of personal protective equipment in the treatment of infectious diseases of high consequence. Stockholm: ECDC.2014
- Personal Protective Equipment—Higher Risk Exposure—With described video.(Available from:)http://www.hc-sc.gc.ca/ahc-asc/media/video/ppe-high-risk-epi-risque-eleve-eng.php?audio=yesDate accessed: November 12, 2017
- North Carolina Preferred Guidance Donning and Doffing of Personal Protective Equipment (PPE) in Hospital Ebola Isolation Units.(Available from:)
- Personal protective equipment.
- Personal Protective Equipment (PPE) Guidelines and Information.https://challenges.openideo.com/content/personal-protective-equipment-ppe-guidelines-information(Available from:)Date accessed: April 12, 2017
- Guidance on personal protective equipment (PPE) to be used by healthcare workers during management of patients with confirmed ebola or persons under investigation (PUIs) for Ebola who are clinically unstable or have bleeding, vomiting, or diarrhea in U.S. hospitals, including procedures for donning and doffing PPE.(Available from:)https://www.cdc.gov/vhf/ebola/healthcare-us/ppe/guidance.htmlDate accessed: May 30, 2018
- Glitterbug kits.(Available from:)https://glitterbug.net.au/products/Date accessed: January 2, 2018
- Effective personal protective clothing for health care workers attending patients with severe acute respiratory syndrome.Am J Infect Control. 2004; 32: 90-96
- Use of personal protective equipment among health care personnel: results of clinical observations and simulations.Am J Infect Control. 2017; 45: 17-23
- Assessment of healthcare worker protocol deviations and self-contamination during personal protective equipment donning and doffing.Infect Control Hosp Epidemiol. 2017; 38: 1077-1083
- A cluster randomized clinical trial comparing fit-tested and non-fit-tested N95 respirators to medical masks to prevent respiratory virus infection in health care workers.Influenza Other Respir Viruses. 2011; 5: 170-179
- A randomized clinical trial of three options for N95 respirators and medical masks in health workers.Am J Respir Crit Care Med. 2013; 187: 960-966
- A method for evaluating health care workers' personal protective equipment technique.Am J Infect Control. 2011; 39: 415-420
Article info
Publication history
Published online: July 17, 2018
Footnotes
Funding/support: This study was supported by a seed grant from the School of Public Health and Community Medicine, University of New South Wales.
Conflicts of interest: All authors completed the Unified Competing Interest form (available on request from the corresponding author) and declare that:
- •3M Australia provided support to AAC for facemask testing as part of his PhD thesis.
- •Professor C. Raina MacIntyre has held an Australian Research Council Linkage Grant with 3M as the industry partner, for investigator-driven research. 3M contributed supplies of masks and respirators for investigator-driven clinical trials. She received research grants and laboratory testing as in-kind support from Pfizer, GSK, and Bio-CSL for investigator-driven research.
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Copyright
© 2018 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
