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. 2019 Jul 1;7(7):CD011621.
doi: 10.1002/14651858.CD011621.pub3.

Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff

Jos H Verbeek  1 , Blair Rajamaki, Sharea Ijaz, Christina Tikka, Jani H Ruotsalainen, Michael B Edmond, Riitta Sauni, F Selcen Kilinc Balci
Affiliations

Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff

Jos H Verbeek et al. Cochrane Database Syst Rev. .

Update in

Abstract

Background: In epidemics of highly infectious diseases, such as Ebola Virus Disease (EVD) or Severe Acute Respiratory Syndrome (SARS), healthcare workers (HCW) are at much greater risk of infection than the general population, due to their contact with patients' contaminated body fluids. Contact precautions by means of personal protective equipment (PPE) can reduce the risk. It is unclear which type of PPE protects best, what is the best way to remove PPE, and how to make sure HCW use PPE as instructed.

Objectives: To evaluate which type of full body PPE and which method of donning or doffing PPE have the least risk of self-contamination or infection for HCW, and which training methods increase compliance with PPE protocols.

Search methods: We searched MEDLINE (PubMed up to 15 July 2018), Cochrane Central Register of Trials (CENTRAL up to 18 June 2019), Scopus (Scopus 18 June 2019), CINAHL (EBSCOhost 31 July 2018), and OSH-Update (up to 31 December 2018). We also screened reference lists of included trials and relevant reviews, and contacted NGOs and manufacturers of PPE.

Selection criteria: We included all controlled studies that compared the effects of PPE used by HCW exposed to highly infectious diseases with serious consequences, such as Ebola or SARS, on the risk of infection, contamination, or noncompliance with protocols. This included studies that used simulated contamination with fluorescent markers or a non-pathogenic virus.We also included studies that compared the effect of various ways of donning or doffing PPE, and the effects of training in PPE use on the same outcomes.

Data collection and analysis: Two authors independently selected studies, extracted data and assessed risk of bias in included trials. We planned to perform meta-analyses but did not find sufficiently similar studies to combine their results.

Main results: We included 17 studies with 1950 participants evaluating 21 interventions. Ten studies are Randomised Controlled Trials (RCTs), one is a quasi RCT and six have a non-randomised controlled design. Two studies are awaiting assessment.Ten studies compared types of PPE but only six of these reported sufficient data. Six studies compared different types of donning and doffing and three studies evaluated different types of training. Fifteen studies used simulated exposure with fluorescent markers or harmless viruses. In simulation studies, contamination rates varied from 10% to 100% of participants for all types of PPE. In one study HCW were exposed to Ebola and in another to SARS.Evidence for all outcomes is based on single studies and is very low quality.Different types of PPEPPE made of more breathable material may not lead to more contamination spots on the trunk (Mean Difference (MD) 1.60 (95% Confidence Interval (CI) -0.15 to 3.35) than more water repellent material but may have greater user satisfaction (MD -0.46; 95% CI -0.84 to -0.08, scale of 1 to 5).Gowns may protect better against contamination than aprons (MD large patches -1.36 95% CI -1.78 to -0.94).The use of a powered air-purifying respirator may protect better than a simple ensemble of PPE without such respirator (Relative Risk (RR) 0.27; 95% CI 0.17 to 0.43).Five different PPE ensembles (such as gown vs. coverall, boots with or without covers, hood vs. cap, length and number of gloves) were evaluated in one study, but there were no event data available for compared groups.Alterations to PPE design may lead to less contamination such as added tabs to grab masks (RR 0.33; 95% CI 0.14 to 0.80) or gloves (RR 0.22 95% CI 0.15 to 0.31), a sealed gown and glove combination (RR 0.27; 95% CI 0.09 to 0.78), or a better fitting gown around the neck, wrists and hands (RR 0.08; 95% CI 0.01 to 0.55) compared to standard PPE.Different methods of donning and doffing proceduresDouble gloving may lead to less contamination compared to single gloving (RR 0.36; 95% CI 0.16 to 0.78).Following CDC recommendations for doffing may lead to less contamination compared to no guidance (MD small patches -5.44; 95% CI -7.43 to -3.45).Alcohol-based hand rub used during the doffing process may not lead to less contamination than the use of a hypochlorite based solution (MD 4.00; 95% CI 0.47 to 34.24).Additional spoken instruction may lead to fewer errors in doffing (MD -0.9, 95% CI -1.4 to -0.4).Different types of trainingThe use of additional computer simulation may lead to fewer errors in doffing (MD -1.2, 95% CI -1.6 to -0.7).A video lecture on donning PPE may lead to better skills scores (MD 30.70; 95% CI 20.14,41.26) than a traditional lecture.Face to face instruction may reduce noncompliance with doffing guidance more (OR 0.45; 95% CI 0.21 to 0.98) than providing folders or videos only.There were no studies on effects of training in the long term or on resource use.The quality of the evidence is very low for all comparisons because of high risk of bias in all studies, indirectness of evidence, and small numbers of participants.

Authors' conclusions: We found very low quality evidence that more breathable types of PPE may not lead to more contamination, but may have greater user satisfaction. Alterations to PPE, such as tabs to grab may decrease contamination. Double gloving, following CDC doffing guidance, and spoken instructions during doffing may reduce contamination and increase compliance. Face-to-face training in PPE use may reduce errors more than video or folder based training. Because data come from single small studies with high risk of bias, we are uncertain about the estimates of effects.We still need randomised controlled trials to find out which training works best in the long term. We need better simulation studies conducted with several dozen participants to find out which PPE protects best, and what is the safest way to remove PPE. Consensus on the best way to conduct simulation of exposure and assessment of outcome is urgently needed. HCW exposed to highly infectious diseases should have their use of PPE registered and should be prospectively followed for their risk of infection in the field.

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Conflict of interest statement

Jos Verbeek: None known.

Blair Rajamaki: None known.

Sharea Ijaz: None known.

Christina Mischke: None known.

Jani Ruotsalainen: None known.

F Selcen Kilinc Balci: None known.

Erja Mäkelä: None known.

Kaisa Neuvonen: None known.

Michael Edmond: I have given several lectures to non‐profit professional associations (e.g. APIC) on topics related to infection control that in some instances provide an honorarium. None of these lectures were for industry.

Riitta Sauni: None known.

Raluca C Mihalache: None known.

Figures

1
1
International symbol indicating biohazards
2
2
PRISMA study flow diagram for search up to Jan 2016
3
3
PRISMA study flow diagram for search between 2016 and 2018
4
4
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
5
5
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
1.1
1.1. Analysis
Comparison 1 PAPR versus E‐RCP Attire, Outcome 1 Any contamination.
1.2
1.2. Analysis
Comparison 1 PAPR versus E‐RCP Attire, Outcome 2 Contamination > 1 cm.
1.3
1.3. Analysis
Comparison 1 PAPR versus E‐RCP Attire, Outcome 3 Contamination area.
1.4
1.4. Analysis
Comparison 1 PAPR versus E‐RCP Attire, Outcome 4 Donning noncompliance.
1.5
1.5. Analysis
Comparison 1 PAPR versus E‐RCP Attire, Outcome 5 Doffing noncompliance.
1.6
1.6. Analysis
Comparison 1 PAPR versus E‐RCP Attire, Outcome 6 Donning time.
1.7
1.7. Analysis
Comparison 1 PAPR versus E‐RCP Attire, Outcome 7 Doffing time.
2.1
2.1. Analysis
Comparison 2 Four types of PPE attire compared, Outcome 1 A vs B Contamination, mean number of spots.
2.2
2.2. Analysis
Comparison 2 Four types of PPE attire compared, Outcome 2 A vs B Usability score (1‐5).
2.3
2.3. Analysis
Comparison 2 Four types of PPE attire compared, Outcome 3 A vs B Donning time.
2.4
2.4. Analysis
Comparison 2 Four types of PPE attire compared, Outcome 4 A vs B Doffing time.
2.5
2.5. Analysis
Comparison 2 Four types of PPE attire compared, Outcome 5 A vs D Contamination, mean number of spots.
2.6
2.6. Analysis
Comparison 2 Four types of PPE attire compared, Outcome 6 A vs D Usability score (1‐5).
2.7
2.7. Analysis
Comparison 2 Four types of PPE attire compared, Outcome 7 A vs D Donning time.
2.8
2.8. Analysis
Comparison 2 Four types of PPE attire compared, Outcome 8 A vs D Doffing time.
3.1
3.1. Analysis
Comparison 3 Formal versus local available attire, Outcome 1 Contamination.
4.1
4.1. Analysis
Comparison 4 Gown versus apron, Outcome 1 Contamination with marker; individual doffing.
4.2
4.2. Analysis
Comparison 4 Gown versus apron, Outcome 2 Contamination with marker; CDC doffing.
5.1
5.1. Analysis
Comparison 5 Sealed suit versus traditional suit, Outcome 1 Contamination fluorescent lotion.
5.2
5.2. Analysis
Comparison 5 Sealed suit versus traditional suit, Outcome 2 Contamination MS2.
6.1
6.1. Analysis
Comparison 6 Gown easy to doff versus standard gown, Outcome 1 Contamination with fluorescent marker.
6.2
6.2. Analysis
Comparison 6 Gown easy to doff versus standard gown, Outcome 2 Contamination with bacteriophage.
7.1
7.1. Analysis
Comparison 7 Gloves with tab versus standard gloves, Outcome 1 Any contamination of hands.
8.1
8.1. Analysis
Comparison 8 Mask with tabs versus no mask tabs, Outcome 1 Contamination of head from hands.
8.2
8.2. Analysis
Comparison 8 Mask with tabs versus no mask tabs, Outcome 2 Contamination of hands from mask.
9.1
9.1. Analysis
Comparison 9 CDC versus individual doffing, Outcome 1 Gown; Contamination with fluor marker.
9.2
9.2. Analysis
Comparison 9 CDC versus individual doffing, Outcome 2 Apron; Contamination with fluor marker.
10.1
10.1. Analysis
Comparison 10 Doffing with double gloves versus doffing with single gloves, Outcome 1 Contamination: virus detected.
10.2
10.2. Analysis
Comparison 10 Doffing with double gloves versus doffing with single gloves, Outcome 2 Contamination: virus quantity.
10.3
10.3. Analysis
Comparison 10 Doffing with double gloves versus doffing with single gloves, Outcome 3 Non‐compliance: any error.
11.1
11.1. Analysis
Comparison 11 Doffing with hypochlorite versus doffing with alcohol‐based glove sanitiser, Outcome 1 Contamination MS2.
11.2
11.2. Analysis
Comparison 11 Doffing with hypochlorite versus doffing with alcohol‐based glove sanitiser, Outcome 2 Contamination Ph6.
12.1
12.1. Analysis
Comparison 12 Donning and doffing with instructions versus without instructions, Outcome 1 Persons with one or more errors.
12.2
12.2. Analysis
Comparison 12 Donning and doffing with instructions versus without instructions, Outcome 2 Mean errors.
13.1
13.1. Analysis
Comparison 13 Active training in PPE use versus passive training, Outcome 1 Noncompliance with PPE.
14.1
14.1. Analysis
Comparison 14 Active training in PPE doffing versus passive training, Outcome 1 Noncompliance doffing protocol.
15.1
15.1. Analysis
Comparison 15 Computer simulation versus no simulation, Outcome 1 Number of errors while donning.
15.2
15.2. Analysis
Comparison 15 Computer simulation versus no simulation, Outcome 2 Number of errors while doffing.
16.1
16.1. Analysis
Comparison 16 Video‐based learning versus traditional lecture, Outcome 1 Skills in PPE donning.
See this image and copyright information in PMC

Update of

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Marklund 2002 {published data only}
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McLaws 2016 {published data only}
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Mehtar 2015 {published data only}
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Minnich 2003 {published data only}
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Muyembe‐Tamfum 1999 {published data only}
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References to studies awaiting assessment

Chugtai 2018 {published data only}
    1. Chughtai AA, Chen X, Macintyre CR. Risk of self‐contamination during doffing of personal protective equipment. Am J Infect Control 2018;46(12):1329‐1334. [DOI: 10.1016/j.ajic.2018.06.003; PUBMED: PMID: 30029796] - DOI - PubMed
Suen 2018 {published data only}
    1. Suen LKP, Guo YP, Tong DWK, Leung PHM, Lung D, Ng MSP, Lai TKH, Lo KYK, Au‐Yeung CH, Yu W. Self‐contamination during doffing of personal protective equipment by healthcare workers to prevent Ebola transmission. Antimicrob Resist Infect Control 2018;7:1. - PMC - PubMed

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