Healthcare Hygiene magazine May 2020 | Page 21

disease (EVD) epidemics, the use of gloves, gowns and masks each help to reduce the infection rate in healthcare personnel. As Verbeck, et al. (2020) note, “More consistent use of gloves, gowns, masks and goggles was each related to fewer infections among healthcare workers. Also, theoretically, protecting the skin and the mucous membranes of the mouth nose and eyes will prevent transmission. We have therefore little doubt that in a technical sense PPE will help and that the minimum amount of PPE needed is gloves, gown, and mouth, nose and eye protection, as recommended by WHO and CDC. The guidance does not, however, indicate which type or quality‐level of PPE is most protective.” In their review, the researchers sought to identify which PPE protects best by only including studies that compared one type of PPE against an alternative type of PPE, such as gowns against coveralls or goggles against face shields only when used as part of full PPE. They explain, “There is still uncertainty about the optimal type, composition, amount and ways of using full‐body PPE to prevent skin and mucous membrane contamination of healthcare workers while treating patients infected with highly infectious diseases. Since full‐body protection has mainly evolved as a direct result of experiences gained from the recent outbreaks of deadly viruses, there are still many types of PPE available with varying types of components. The comparative effectiveness of one type against another is still unknown. Regarding the equipment, there is uncertainty whether face shields protect as well as goggles, especially when goggles are combined with a hood. There is uncertainty whether and when double or triple gloves would be more protective than single gloves. Regarding suits, it is unclear if gowns are as protective as coveralls, and how breathable and impermeable for liquids or viruses they should be. Some argue that using more breathable material would decrease the risk of contamination.” When it comes to donning and doffing procedures for pathogens such as EVD, the authors say “there is uncertainty about the effect of integrity checks of gloves and other equipment, and whether gloves should be changed when highly contaminated. With doffing especially, it is unclear if this should be done in pairs with a helper buddy removing part of the PPE, or if this can be done alone. Another element of the doffing procedure that is uncertain is if spraying with a disinfectant such as chlorine spray is more protective than not using spray. It is not clear which disinfectant is the best antiviral: chlorine solution or alcohol gel, and at which concentration. Also, for COVID‐19, different procedures for donning and doffing PPE are recommended.  Giwa (2020) proposes a specific procedure of doffing PPE, but the procedure is not consistent with the procedures proposed by CDC in 2020. Others, including the CDC, have proposed that gown and gloves should be doffed in a one‐step procedure (Osei‐Bonsu 2019), to minimize self‐contamination. It is also unclear what are the best ways to train healthcare workers and how to best maintain the skills needed for proper use of PPE.” The challenge is that despite using proper articles of PPE, the likely biggest risk of infection is associated with self‐con- tamination by healthcare personnel inappropriately removing the PPE, studies have found. Verbeck, et al. (2020) outline an intervention that could help boost proper compliance: www.healthcarehygienemagazine.com • may 2020 Despite problematic PPE use, we know from studies conducted during the SARS and Ebola virus disease (EVD) epidemics, the use of gloves, gowns and masks each help to reduce the infection rate in healthcare personnel. “First, healthcare workers, their supervisors, or occupational health professionals should choose the proper type of PPE, as indicated in the guidance described above. Then, the healthcare worker needs to know how to don and doff PPE according to the guidelines provided. Next, the healthcare worker needs to comply with established procedures for correctly using, donning and doffing PPE. Education and training are used to increase compliance. The emphasis in teaching the correct use of PPE is on doing everything slowly and carefully to minimize the risk of making a mistake. Often an assistant or buddy, sometimes coupled with a mirror, is used while donning PPE, while a hygienist supervises doffing. Compliance can be increased by personal supervision and instruction, checklists, audits of performance, by providing feedback, and by allowing sufficient time for donning and doffing. Education and training on uptake and compliance with PPE should have an effect in both the short term and the long term… Compliance with PPE can also be improved by providing sufficient, comfortable, well‐fitting, and more user‐ and patient‐friendly PPE.” References: Carrillo I, Floyd A, Valverde C, Tingle T and Zabaneh F. Immediate Use Steam Sterilization (IUSS) Sterilizes N95 Masks Without Mask Damage. Infect Control Hosp Epidemiol. DOI: 10.1017/ice.2020.145 CDC. Decontamination and Reuse of Filtering Facepiece Respirators. Accessible at: Fischer R, et al. Assessment of N95 respirator decontamination and re-use for SARS-CoV-2. Heimbuch BK and Harnish D. Research to Mitigate a Shortage of Respiratory Protection Devices During Public Health Emergencies. 2019; Available from: https://www.ara.com/news/ara-research-mitigate-shortage- respiratory-protection-devices-during-public-health-emergenciesexternal icon Kenney P, et al. Hydrogen Peroxide Vapor sterilization of N95 respirators for reuse. medRxiv (2020). Mills D, et al. Ultraviolet germicidal irradiation of influenza-contaminated N95 filtering facepiece respirators. Am J Infect Control. 2018. 46(7): p. e49-e55. National Institutes of Health. NIH COVID-19 Treatment Guidelines. Care of Critically Ill Patients with COVID-19. April 2020. OSHA. Temporary Enforcement Guidance - Healthcare Respiratory Protection Annual Fit-Testing for N95 Filtering Facepieces During the COVID-19 Outbreak. March 14, 2020. van Doremalen N, et al. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. J New Eng J Med. 2020. Verbeck JH, et al. Cochrane Systematic Review: Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff. April 15, 2020. https://doi. org/10.1002/14651858.CD011621.pub4 Viscusi DJ, et al., Evaluation of five decontamination methods for filtering facepiece respirators. Ann Occ Hygiene, 2009. 53(8): p. 815-827. 21