Regulation/Guidelines

Usage of Personal Protective Equipment Rationally During COVID-19 Pandemic

  • 28th April, 2020
Guidelines for usage of personal protective equipment during COVID-19

The World Health Organization (WHO) has declared the recent infections of COVID-19 as pandemic.  As COVID-19 cases are rising in India, frontline healthcare workers are facing a shortage of Personal Protective Equipment (PPE), viz. face masks and shields, gloves and gowns, which has led to a situation of panic. The Ministry of Health and Family Welfare (MOHFW) released guidelines on the rational use of PPEs for health care professionals to be followed all over the country. This is applicable for points of entries (POEs), quarantine centers, healthcare facilities like hospitals, laboratories, and primary health care / community settings.

COVID-19: An Introduction

Coronavirus disease 2019 (COVID-19) is a viral infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The outbreak of COVID-19 was initially identified from a seafood market in Wuhan city in Hubei Province of China in mid-December, 2019. Presently it has spread to more than 185 countries/territories worldwide. 

Transmission of COVID-19 virus

  1. There is clear evidence of human-to-human transmission of SARS-CoV-2. Primary transmission between people through respiratory droplets and contact routes.
  2. Direct contact with infected people can transmit SARS-CoV-2. Even indirect contact with surfaces in the immediate environment or with objects used on the infected person (e.g., stethoscope or thermometer)
  3. There is limited evidence to support airborne transmission of SARS-CoV-2 till date.
  4. Healthcare workers across the world are getting infected by the SARS-CoV-2 virus, including India.
  5. The people most at risk of COVID-19 infection are those who are in close contact with a suspect/confirmed COVID-19 patient or who care for such patients.

Personal protective equipment (PPE)

PPE refers to protective gears designed to protect the wearer from injury or contracting infection or illness by minimizing the exposure to a biological agent.

Components of PPE and Rationale use

  • Face shield and goggles

    The protection of the mucous membranes of the eyes/nose/mouth by using face shields/ goggles is an important part of standard and contact precautions. The flexible frame of goggles must provide a good seal with the skin of the face, covering the eyes and the nearby areas and also provide space for prescription glasses.

  • Masks

    Protecting the airway from the particulate matter generated by droplets / aerosols prevents human infection related to respiratory viruses like COVID-19. The virus enters the host through mucous membranes of the mouth and nose by infective droplets or through a contaminated hand. Hence the droplet precautions/airborne precautions using masks are crucial while dealing with a suspected or confirmed case of COVID-19/performing aerosol-generating procedures. Masks are of different types. The type of mask to be used is related to the particular risk profile of the category of personnel and his/her work. There are two types of masks which are recommended for various categories of personnel working in hospital or community settings, depending upon the work environment.

    a) Triple-layer medical mask

    A triple layer medical mask is a disposable mask, fluid-resistant, provides protection to the wearer from droplets of infectious material emitted during coughing/sneezing/talking.

    b) N-95 Respirator mask

    An N-95 respirator mask is a respiratory protective device with high filtration efficiency to airborne particles. To provide the requisite air seal to the wearer, such masks are designed to achieve a very close facial fit.

    Such masks should have high fluid resistance, good breathability (preferably with an expiratory valve), clearly identifiable internal and external faces, duckbill/cup-shaped structured design that does not collapse against the mouth.

    If worn correctly, the filtration capacity of these masks exceeds those of triple-layer medical masks. Since these provide a much tighter air seal than triple-layer medical masks, they are designed to protect the wearer from inhaling airborne particles.

  • Gloves

    If a person touches an object/surface contaminated by COVID-19 infected person, and then touches his own eyes, nose, or mouth, he may get infected with the virus. Care should be exercised while handling objects/surfaces potentially contaminated by suspect/confirmed cases of COVID-19.

    While using gloves, Nitrile gloves are preferred over latex gloves in the highly infectious pandemic. Moreover, they resist chemicals, including certain disinfectants such as chlorine. There is a high rate of allergies to latex and contact allergic dermatitis among health workers. However, if nitrile gloves are not available, latex gloves can be used. Nonpowdered gloves are preferred to powdered gloves

  • Coverall/Gowns

    Coverall/gowns are generally designed to protect the torso of healthcare providers from exposure to the virus. Typically coveralls provide overall protection as they are made to cover the whole body, including back and lower legs and sometimes head and feet as well, the design of medical/isolation gowns do not provide continuous whole-body protection (e.g., possible openings in the back, coverage to the mid-calf only). It is possible to eliminate or reduce contact and droplet exposure of COVID-19 by protecting healthcare workers working very close (within 1 meter) of suspect/confirmed COVID-19 cases or their secretions by wearing appropriate clothing

    There is no comparative evidence between coveralls and gowns in reducing the transmission of biological agents and are equally acceptable. Coveralls/gowns have specific and stringent standards that prevent exposure to biologically contaminated solid particles and also protecting from chemical hazards.

  • Shoe covers

    Shoe covers are used over shoes and are made up of impermeable fabric for personal protection and decontamination.

Head covers

Coveralls generally cover the head. Head covers are for those using gowns, while providing treatment for patients. Hair and hair extensions must fit inside the head cover.

Rationale of Use of PPE

According to the guidelines, the PPEs are recommended based on the risk profile of the health
care worker.

Table 1: Recommended PPE for Point of Entry
S. No.AreasActivityRiskPPERecommendedRemarks
1.Health DeskProvideinformation totravelersLow riskTriple layermedical maskGlovesMinimumdistance of onemeter needs tobe maintained
2.Immigration counters,customs and airportsecurityProvideservices to thepassengersLow riskTriple layermedical maskGlovesMinimumdistance of onemeter needs tobe maintained
3.Temperature recordingstationRecordTemperaturewith hand heldthermalrecorderLow riskTriple layermedical maskGloves 
4.Holding area/ Isolationfacility of APHO/ PHOInterview &Clinicalexamination bydoctors/ nursesModerateRiskN-95 masksGloves 
5.Isolation facility of APHOInterview &Clinicalexamination bydoctors/ nursesModerateRiskN-95 masksGloves 
Attending to severely ill passenger   High risk Full complement of PPE   When aerosol generating  procedures are anticipated
 6.  Sanitary staff   Cleaning frequently touched surfaces/ Floor/ cleaning linen No risk N-95 maskGloves  
 7. Administrative staff   Providing administrative support No risk No PPE No contact with patients of COVID19. They should not venture into areas where suspect COVID-19 cases are being managed.

Hospitals

Out Patient Department (Respiratory Clinic / Separate screening area)

Hospitals all over the country should create a separate triage and holding area for patients with symptoms of influenza. If there is no space for triage area / holding area for patients, such hospitals need to follow the guidance for general OPD.

Table 2.1: Recommended PPE for Out Patient Department (Respiratory Clinic / Separate screening area
S. No.AreasActivityRiskPPERecommendedRemarks
1. Triage area Triaging patientsProvide triple layer mask to patientModerate risk N 95 maskGloves Patients get masked
2. Screening area help desk/ Registration counter Provide information to patients Moderate  risk N-95 maskGloves
3. Temperature recording station Record temperature with hand held thermal recorder Low risk Triple layermedical maskGloves 
4. Holding area/ waiting area Nurses / paramedic interacting with patients Moderate Risk N 95 maskGloves  Minimum distance of one meter needs to be maintained.
5. Doctors chamber Clinical management (doctors, nurses) ModerateRiskN-95 masksGloves  No aerosol generating procedures should be allowed
 6.  Sanitary staf f Cleaning frequently touched surfaces/ Floor/ cleaning linen   Moderate risk N-95 maskGloves  
 7. Visitors accompanying young children and elderlies   Support in navigating various service areas Low risk Triple layer medical mask    No other visitors should be allowed to accompany patients in OPD settings. The visitors thus allowed should practice hand hygiene
Table 2.2: Recommended PPE for In-patient Services
S. No.AreasActivityRiskPPERecommendedRemarks
1. Individual isolation rooms/ cohorted isolation rooms Clinical management Moderate risk N 95 maskGloves Patients masked. Patients stable. No aerosol generating activity
2. ICU/ Critical Critical care High risk Full complement of PPE Aerosol generating
3. ICU/ Critical Critical care Dead body packing High risk Full complement of PPE  
4. ICU/ Critical Critical care Dead body transport to mortuary Low risk Triple Layer medical mask
5. Sanitation Cleaning frequently touched surfaces/ floor/ changing linen ModerateRisk N-95 mask  Gloves
 6.  Other NonCOVID treatment areas of hospital Attending to infectious and non-infectious patients No possibility of exposure to COVID patients. They should not venture into COVID-19 treatment areas. Risk as per assessed profile of patients PPE as per hospital infection prevention control practices. No possibility of exposure to COVID patients. They should not venture into COVID-19 treatment areas.  
 7. Caretaker accompanying the admitted patient   Taking care of the admitted patient Low risk Triple layer medical mask   The caretaker thus allowed should practice hand hygiene, maintain a distance of 1 meter
Table 2.3: Recommended PPE for Emergency Department
S. No.AreasActivityRiskPPERecommendedRemarks
1. Emergency Attending emergency cases Moderate risk N 95 maskGlovesWhen aerosol generating procedures are anticipated
Attending to severely ill patients of SARI High risk Full complement of PPE Aerosol generating proceduresperformed.
Table 2.4: Recommended PPE for Pre-hospital (Ambulance) Services
S. No.AreasActivityRiskPPERecommendedRemarks
1. Ambulance Transfer to various designated hospital Transportation of patients not on any assisted ventilation Moderate risk N 95 maskGlovesWhen aerosol generating procedures are anticipated
Management of SARI patient while transporting High risk Full complement of PPE
Driving the ambulanceLow risk Triple layer medical mask Gloves
Table 2.5: Recommended PPE for Other Supportive/ Ancillary Services
S. No.AreasActivityRiskPPERecommendedRemarks
1. Laboratory Sample collection and transportationHigh risk Full complement of PPEWhen aerosol generating procedures are anticipated
Sample testing High risk Full complement of PPE
2. MortuaryDead body handlingModerate RiskN 95 mask Gloves No aerosol generating procedures should be allowed. No embalming.
While performing autopsyHigh Risk Full complement of PPE No post-mortem unless until specified
3. SanitationCleaning frequently touched surfaces/ Floor/ cleaning linen in COVID treatment areasModerate risk N-95 mask Gloves
4. CSSD/Laun dry Handling linen of COVID patients Moderate riskN-95 mask Gloves
5. Other supportive services Administrative Administrative, Financial Engineering Security, etc.No risk No PPE No possibility of exposure to COVID patients. They should not venture into COVID-19 treatment areas.

Healthcare Workers in Community Setting

Table 3: Recommended PPE for Health Workers in Community Setting
S. No.AreasActivityRiskPPERecommendedRemarks
1. ASHAs/ Anganwadi and other field staff Field SurveillanceLow Risk Triple layer mask GlovesMaintain distance of one meter. Surveillance team to carry adequate triple layer masks to distribute to suspect cases detected on field surveillance
2. Doctors at supervisory level conducting field investigationField surveillance Clinical examination.Medium riskN 95 mask Gloves

Quarantine Facility

Table 4: Recommended PPE for Quarantine facility
S. No.AreasActivityRiskPPERecommendedRemarks
1. Persons being quarantined Low Risk Triple layer masksurveillance
2. Healthcare staff working at quarantine facility HealthHealth monitoring and temperature recordingLow RiskTriple layer mask Gloves
Clinical examination of symptomatic personsModerate RiskN-95 masks Gloves
3. Support staffLow RiskTriple layer mask Gloves

Home Quarantine

Table 5: Recommended PPE for Home Quarantine
S. No.AreasActivityRiskPPERecommendedRemarks
1. Persons being quarantined Low Risk Triple layer mask
2. Designated family memberTaking care of person being quarantinedLow RiskGlovesWhile cleaning commonly touched surfaces or handling soiled linen
3. Other familyNo RiskNo PPE requiredMaintain a distance of at least 1 meter from person under home quarantine. Senior citizens in the household should stay away from such persons under home quarantine.

Key Points to keep in mind while using PPE

  1. The most important thing is PPEs are not an alternative to basic preventive public health measures such as hand hygiene, respiratory hygiene, and behavior, which need to be followed at all times.
  2. Always keep a distance of at least 1 meter from contacts/suspect/confirmed COVID-19 cases.
  3. Follow the protocol for disposing off PPEs in infection prevention and control guidelines available on the website of MoHFW.

Reference:

  1. Guidelines on rational use of Personal Protective Equipment.pdf. Available at: https://www.mohfw.gov.in/pdf/GuidelinesonrationaluseofPersonalProtectiveEquipment.pdf. A ccessed on April 06, 2020.