admin / 28th April, 2020

Usage of Personal Protective Equipment Rationally During COVID-19 Pandemic

Regulation/Guidelines

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Summary:

The frontline healthcare workers are facing a shortage of Personal Protective Equipment (PPE), viz. face masks and shields, gloves and gowns. 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 centres, healthcare facilities like hospitals, laboratories, and primary health care / community settings.

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

There is clear evidence of human-to-human transmission of SARS-CoV-2. Primary transmission between people through respiratory droplets and contact routes.
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)
There is limited evidence to support airborne transmission of SARS-CoV-2 till date.
Healthcare workers across the world are getting infected by the SARS-CoV-2 virus, including India.
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.	Areas	Activity	Risk	PPERecommended	Remarks
1.	Health Desk	Provideinformation totravelers	Low risk	Triple layermedical maskGloves	Minimumdistance of onemeter needs tobe maintained
2.	Immigration counters,customs and airportsecurity	Provideservices to thepassengers	Low risk	Triple layermedical maskGloves	Minimumdistance of onemeter needs tobe maintained
3.	Temperature recordingstation	RecordTemperaturewith hand heldthermalrecorder	Low risk	Triple layermedical maskGloves
4.	Holding area/ Isolationfacility of APHO/ PHO	Interview &Clinicalexamination bydoctors/ nurses	ModerateRisk	N-95 masksGloves
5.	Isolation facility of APHO	Interview &Clinicalexamination bydoctors/ nurses	ModerateRisk	N-95 masksGloves
5.	Isolation facility of APHO	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.	Areas	Activity	Risk	PPERecommended	Remarks
1.	Triage area	Triaging patientsProvide triple layer mask to patient	Moderate 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)	ModerateRisk	N-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.	Areas	Activity	Risk	PPERecommended	Remarks
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.	Areas	Activity	Risk	PPERecommended	Remarks
1.	Emergency	Attending emergency cases	Moderate risk	N 95 maskGloves	When aerosol generating procedures are anticipated
1.	Emergency	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.	Areas	Activity	Risk	PPERecommended	Remarks
1.	Ambulance Transfer to various designated hospital	Transportation of patients not on any assisted ventilation	Moderate risk	N 95 maskGloves	When aerosol generating procedures are anticipated
		Management of SARI patient while transporting	High risk	Full complement of PPE
		Driving the ambulance	Low risk	Triple layer medical mask Gloves

Table 2.5: Recommended PPE for Other Supportive/ Ancillary Services
S. No.	Areas	Activity	Risk	PPERecommended	Remarks
1.	Laboratory	Sample collection and transportation	High risk	Full complement of PPE	When aerosol generating procedures are anticipated
1.	Laboratory	Sample testing	High risk	Full complement of PPE	When aerosol generating procedures are anticipated
2.	Mortuary	Dead body handling	Moderate Risk	N 95 mask Gloves	No aerosol generating procedures should be allowed. No embalming.
2.	Mortuary	While performing autopsy	High Risk	Full complement of PPE	No post-mortem unless until specified
3.	Sanitation	Cleaning frequently touched surfaces/ Floor/ cleaning linen in COVID treatment areas	Moderate risk	N-95 mask Gloves
4.	CSSD/Laun dry	Handling linen of COVID patients	Moderate risk	N-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.	Areas	Activity	Risk	PPERecommended	Remarks
1.	ASHAs/ Anganwadi and other field staff	Field Surveillance	Low Risk	Triple layer mask Gloves	Maintain 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 investigation	Field surveillance Clinical examination.	Medium risk	N 95 mask Gloves

Quarantine Facility

Table 4: Recommended PPE for Quarantine facility
S. No.	Areas	Activity	Risk	PPERecommended	Remarks
1.	Persons being quarantined		Low Risk	Triple layer mask	surveillance
2.	Healthcare staff working at quarantine facility Health	Health monitoring and temperature recording	Low Risk	Triple layer mask Gloves
2.	Healthcare staff working at quarantine facility Health	Clinical examination of symptomatic persons	Moderate Risk	N-95 masks Gloves
3.	Support staff		Low Risk	Triple layer mask Gloves

Home Quarantine

Table 5: Recommended PPE for Home Quarantine
S. No.	Areas	Activity	Risk	PPERecommended	Remarks
1.	Persons being quarantined		Low Risk	Triple layer mask
2.	Designated family member	Taking care of person being quarantined	Low Risk	Gloves	While cleaning commonly touched surfaces or handling soiled linen
3.	Other family		No Risk	No PPE required	Maintain 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

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.
Always keep a distance of at least 1 meter from contacts/suspect/confirmed COVID-19 cases.
Follow the protocol for disposing off PPEs in infection prevention and control guidelines available on the website of MoHFW.