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Meta-Analysis
. 2020 Apr 15;4(4):CD011621.
doi: 10.1002/14651858.CD011621.pub4.

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

Jos H Verbeek  1 , Blair Rajamaki  2 , Sharea Ijaz  3 , Riitta Sauni  4 , Elaine Toomey  5 , Bronagh Blackwood  6 , Christina Tikka  7 , Jani H Ruotsalainen  8 , F Selcen Kilinc Balci  9
Affiliations
Meta-Analysis

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, severe acute respiratory syndrome (SARS), or coronavirus (COVID-19), healthcare workers (HCW) are at much greater risk of infection than the general population, due to their contact with patients' contaminated body fluids. Personal protective equipment (PPE) can reduce the risk by covering exposed body parts. It is unclear which type of PPE protects best, what is the best way to put PPE on (i.e. donning) or to remove PPE (i.e. doffing), and how to train HCWs to 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 contamination or infection for HCW, and which training methods increase compliance with PPE protocols.

Search methods: We searched CENTRAL, MEDLINE, Embase and CINAHL to 20 March 2020.

Selection criteria: We included all controlled studies that evaluated the effect of full-body PPE used by HCW exposed to highly infectious diseases, on the risk of infection, contamination, or noncompliance with protocols. We also included studies that compared the effect of various ways of donning or doffing PPE, and the effects of training on the same outcomes.

Data collection and analysis: Two review authors independently selected studies, extracted data and assessed the risk of bias in included trials. We conducted random-effects meta-analyses were appropriate.

Main results: Earlier versions of this review were published in 2016 and 2019. In this update, we included 24 studies with 2278 participants, of which 14 were randomised controlled trials (RCT), one was a quasi-RCT and nine had a non-randomised design. Eight studies compared types of PPE. Six studies evaluated adapted PPE. Eight studies compared donning and doffing processes and three studies evaluated types of training. Eighteen studies used simulated exposure with fluorescent markers or harmless microbes. In simulation studies, median contamination rates were 25% for the intervention and 67% for the control groups. Evidence for all outcomes is of very low certainty unless otherwise stated because it is based on one or two studies, the indirectness of the evidence in simulation studies and because of risk of bias. Types of PPE The use of a powered, air-purifying respirator with coverall may protect against the risk of contamination better than a N95 mask and gown (risk ratio (RR) 0.27, 95% confidence interval (CI) 0.17 to 0.43) but was more difficult to don (non-compliance: RR 7.5, 95% CI 1.81 to 31.1). In one RCT (59 participants), people with a long gown had less contamination than those with a coverall, and coveralls were more difficult to doff (low-certainty evidence). Gowns may protect better against contamination than aprons (small patches: mean difference (MD) -10.28, 95% CI -14.77 to -5.79). PPE made of more breathable material may lead to a similar number of spots on the trunk (MD 1.60, 95% CI -0.15 to 3.35) compared to 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). Modified PPE versus standard PPE The following modifications to PPE design may lead to less contamination compared to standard PPE: sealed gown and glove combination (RR 0.27, 95% CI 0.09 to 0.78), a better fitting gown around the neck, wrists and hands (RR 0.08, 95% CI 0.01 to 0.55), a better cover of the gown-wrist interface (RR 0.45, 95% CI 0.26 to 0.78, low-certainty evidence), added tabs to grab to facilitate doffing of masks (RR 0.33, 95% CI 0.14 to 0.80) or gloves (RR 0.22, 95% CI 0.15 to 0.31). Donning and doffing Using Centers for Disease Control and Prevention (CDC) recommendations for doffing may lead to less contamination compared to no guidance (small patches: MD -5.44, 95% CI -7.43 to -3.45). One-step removal of gloves and gown may lead to less bacterial contamination (RR 0.20, 95% CI 0.05 to 0.77) but not to less fluorescent contamination (RR 0.98, 95% CI 0.75 to 1.28) than separate removal. Double-gloving may lead to less viral or bacterial contamination compared to single gloving (RR 0.34, 95% CI 0.17 to 0.66) but not to less fluorescent contamination (RR 0.98, 95% CI 0.75 to 1.28). Additional spoken instruction may lead to fewer errors in doffing (MD -0.9, 95% CI -1.4 to -0.4) and to fewer contamination spots (MD -5, 95% CI -8.08 to -1.92). Extra sanitation of gloves before doffing with quaternary ammonium or bleach may decrease contamination, but not alcohol-based hand rub. Training The 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 to 41.26) than a traditional lecture. Face-to-face instruction may reduce noncompliance with doffing guidance more (odds ratio 0.45, 95% CI 0.21 to 0.98) than providing folders or videos only.

Authors' conclusions: We found low- to very low-certainty evidence that covering more parts of the body leads to better protection but usually comes at the cost of more difficult donning or doffing and less user comfort, and may therefore even lead to more contamination. More breathable types of PPE may lead to similar contamination but may have greater user satisfaction. Modifications to PPE design, such as tabs to grab, may decrease the risk of contamination. For donning and doffing procedures, following CDC doffing guidance, a one-step glove and gown removal, double-gloving, spoken instructions during doffing, and using glove disinfection may reduce contamination and increase compliance. Face-to-face training in PPE use may reduce errors more than folder-based training. We still need RCTs of training with long-term follow-up. We need simulation studies with more participants to find out which combinations of PPE and which doffing procedure protects best. Consensus on simulation of exposure and assessment of outcome is urgently needed. We also need more real-life evidence. Therefore, the use of PPE of HCW exposed to highly infectious diseases should be registered and the HCW should be prospectively followed for their risk of infection.

PubMed Disclaimer

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

Riitta Sauni: none known

Bronagh Blackwood: none known

Elaine Toomley: none known

Figures

1
1
International symbol indicating biohazards
2
2
PRISMA study flow diagram for search up to January 2016
3
3
PRISMA study flow diagram for search between 2016 and 2018
4
4
Study flow diagram for 2020 April update
5
5
'Risk of bias' summary: review authors' judgements about each 'Risk of bias' item for each included study
6
6
'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: Three types of PPE compared, Outcome 1: Time for donning
5.2
5.2. Analysis
Comparison 5: Three types of PPE compared, Outcome 2: Time for doffing
6.1
6.1. Analysis
Comparison 6: Gown sealed gloves versus standard gown, Outcome 1: Contamination fluorescent lotion
6.2
6.2. Analysis
Comparison 6: Gown sealed gloves versus standard gown, Outcome 2: Contamination MS2
7.1
7.1. Analysis
Comparison 7: Gown easy to doff versus standard gown, Outcome 1: Contamination with fluorescent marker
7.2
7.2. Analysis
Comparison 7: Gown easy to doff versus standard gown, Outcome 2: Contamination with bacteriophage
8.1
8.1. Analysis
Comparison 8: Gown with gown‐glove improvement vs standard gown‐gloves, Outcome 1: People with contamination
9.1
9.1. Analysis
Comparison 9: Gown with marked inside versus standard gown, Outcome 1: Noncompliance donning: people with errors
9.2
9.2. Analysis
Comparison 9: Gown with marked inside versus standard gown, Outcome 2: Noncompliance: errors during performance
9.3
9.3. Analysis
Comparison 9: Gown with marked inside versus standard gown, Outcome 3: Noncompliance doffing: people with errors
10.1
10.1. Analysis
Comparison 10: Gloves with tab versus standard gloves, Outcome 1: Any contamination of hands
11.1
11.1. Analysis
Comparison 11: Mask with tabs versus no mask tabs, Outcome 1: Contamination of head from hands
11.2
11.2. Analysis
Comparison 11: Mask with tabs versus no mask tabs, Outcome 2: Contamination of hands from mask
12.1
12.1. Analysis
Comparison 12: Doffing with double gloves versus doffing with single gloves, Outcome 1: Contamination: virus detected
12.2
12.2. Analysis
Comparison 12: Doffing with double gloves versus doffing with single gloves, Outcome 2: Contamination: virus quantity
12.3
12.3. Analysis
Comparison 12: Doffing with double gloves versus doffing with single gloves, Outcome 3: Non‐compliance: any error
12.4
12.4. Analysis
Comparison 12: Doffing with double gloves versus doffing with single gloves, Outcome 4: Contamination with fluorescent
13.1
13.1. Analysis
Comparison 13: CDC versus individual doffing, Outcome 1: Gown: contamination with fluor marker
13.2
13.2. Analysis
Comparison 13: CDC versus individual doffing, Outcome 2: Apron: contamination with fluor marker
14.1
14.1. Analysis
Comparison 14: Single‐step doffing vs CDC standard, Outcome 1: Fluorescent contamination
14.2
14.2. Analysis
Comparison 14: Single‐step doffing vs CDC standard, Outcome 2: Bacterial contamination
15.1
15.1. Analysis
Comparison 15: Doffing with extra sanitation of gloves versus standard no sanitation, Outcome 1: Bacterial contamination
16.1
16.1. Analysis
Comparison 16: Donning and doffing with instructions versus without instructions, Outcome 1: People with one or more errors
16.2
16.2. Analysis
Comparison 16: Donning and doffing with instructions versus without instructions, Outcome 2: Non‐compliance: mean errors
16.3
16.3. Analysis
Comparison 16: Donning and doffing with instructions versus without instructions, Outcome 3: Fluorescence contamination
17.1
17.1. Analysis
Comparison 17: Active training in PPE use versus passive training, Outcome 1: Noncompliance with PPE
18.1
18.1. Analysis
Comparison 18: Doffing with hypochlorite versus doffing with alcohol‐based glove sanitiser, Outcome 1: Contamination MS2
18.2
18.2. Analysis
Comparison 18: Doffing with hypochlorite versus doffing with alcohol‐based glove sanitiser, Outcome 2: Contamination Ph6
19.1
19.1. Analysis
Comparison 19: Active training in PPE doffing versus passive training, Outcome 1: Noncompliance doffing protocol
20.1
20.1. Analysis
Comparison 20: Computer simulation versus no simulation, Outcome 1: Number of errors while donning
20.2
20.2. Analysis
Comparison 20: Computer simulation versus no simulation, Outcome 2: Number of errors while doffing
21.1
21.1. Analysis
Comparison 21: Video‐based learning versus traditional lecture, Outcome 1: Skills in PPE donning
See this image and copyright information in PMC

Update of

Comment in

References

References to studies included in this review

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