Rational use of PPE for (COVID-19)

This document summarizes WHO’s recommendations for the rational use of personal protective equipment (PPE) in healthcare and community settings, as well as during the handling of cargo; in this context, PPE includes gloves, medical masks, goggles or a face shield, and gowns, as well as for specific procedures, respirators (i.e., N95 or FFP2 standard or equivalent) and aprons. This document is intended for those who are involved in distributing and managing PPE, as well as public health authorities and individuals in healthcare and community settings, and it aims to provide information about when PPE use is most appropriate.

Preventive measures for COVID-19 disease:

Based on the available evidence, the COVID-19 virus is transmitted between people through close contact and droplets, not by airborne transmission. The people most at risk of infection are those who are in close contact with a COVID-19 patient or who care for COVID-19 patients.

Preventive and mitigation measures are key in both healthcare and community settings. The most effective preventive measures in the community include:

  • performing hand hygiene frequently with an alcohol-based hand rub if your hands are not visibly dirty or with soap and water if hands are dirty;
  • avoiding touching your eyes, nose and mouth;
  • practicing respiratory hygiene by coughing or sneezing into a bent elbow or tissue and then immediately disposing of the tissue;
  • wearing a medical mask if you have respiratory symptoms and performing hand hygiene after disposing of the mask;
  • maintaining social distance (a minimum of 1 m) from individuals with respiratory symptoms.

Additional precautions are required by healthcare workers to protect themselves and prevent transmission in the healthcare setting. Precautions to be implemented by healthcare workers  caring for patients with COVID-19 disease include using PPE appropriately; this involves selecting the proper PPE and being trained in how to put on, remove and dispose of it. PPE is only one effective measure within a package that comprises  administrative and environmental and engineering controls, as described in WHO’s Infection prevention and control of  epidemic- and pandemic-prone acute respiratory infections in health care. These controls are summarized here.

  • Administrative controls include ensuring the availability of resources for infection prevention and control measures, such as appropriate infrastructure, the development of clear infection prevention and control policies, facilitated access to laboratory testing, appropriate triage and placement of patients, adequate staff-to-patient ratios and training of staff.
  • Environmental and engineering controls aim at reducing the spread of pathogens and reducing the contamination of surfaces and inanimate objects. They include providing adequate space to allow social distance of at least 1 m to be maintained between patients and between patients and  healthcare workers and ensuring the availability of well- ventilated isolation rooms for patients with suspected or  confirmed COVID-19 disease.

COVID-19 is a respiratory disease that is different from Ebola  virus disease, which is transmitted through infected bodily fluids. Due to these differences in transmission, the PPE requirements for COVID-19 are different from those required for Ebola virus disease. Specifically, coveralls (sometimes called Ebola PPE) are not required when managing COVID-19 patients.

Disruptions in the global supply chain of PPE:

The current global stockpile of PPE is insufficient, particularly for medical masks and respirators; the supply of gowns and goggles is soon expected to be insufficient also. Surging global demand − driven not only by the number of COVID-19 cases but also by misinformation, panic buying and stockpiling − will result in further shortages of PPE globally. The capacity to expand PPE production is limited, and the current demand for respirators and masks cannot be met, especially if the widespread, inappropriate use of PPE continues.

Recommendations for optimizing the availability of PPE:

In view of the global PPE shortage, the following strategies can facilitate optimal PPE availability:

Minimize the need for PPE:

The following interventions can minimize the need for PPE while protecting healthcare workers and other individuals from exposure to the COVID-19 virus in healthcare settings.

Consider using tele-medicine to evaluate suspected cases of  COVID-19 disease, thus minimizing the need for these  individuals to go to healthcare facilities for evaluation.

  • Use physical barriers to reduce exposure to the COVID-19 virus, such as glass or plastic windows. This approach can be implemented in areas of the healthcare setting where patients will first present, such as triage areas, the  registration desk at the emergency department or at the  pharmacy window where medication is collected.
  • Restrict healthcare workers from entering the rooms of COVID-19 patients if they are not involved in direct care. Consider bundling activities to minimize the number of times a room is entered (e.g., check vital signs during medication administration or have food delivered by healthcare workers while they are performing other care) and plan which activities will be performed at the bedside.

Ideally, visitors will not be allowed but if this is not possible, restrict the number of visitors to areas where COVID-19 patients are being isolated; restrict the amount of time visitors are allowed to spend in the area; and provide clear instructions about how to put on and remove PPE and perform hand hygiene to ensure visitors avoid self-contamination.

Ensure PPE use is rationalized and appropriate:

PPE should be used based on the risk of exposure (e.g., type of activity) and the transmission dynamics of the pathogen (e.g., contact, droplet or aerosol). The overuse of PPE will have a further impact on supply shortages. Observing the following recommendations will ensure that the use of PPE rationalized.

  • The type of PPE used when caring for COVID-19 patients will vary according to the setting and type of personnel and activity (Table 1).  Healthcare workers involved in the direct care of patients should use the following PPE: gowns, gloves, medical mask and eye protection (goggles or face shield).
  • Specifically, for aerosol-generating procedures (e.g., tracheal intubation, non-invasive ventilation, tracheostomy, cardiopulmonary resuscitation, manual ventilation before intubation, bronchoscopy) healthcare workers should use respirators, eye protection, gloves and gowns; aprons should also be used if gowns are not fluid resistant.
  • Respirators (e.g., N95, FFP2 or equivalent standard) have been used for an extended time during previous public health emergencies involving acute respiratory illness when PPE was in short supply. This refers to wearing the same respirator while caring for multiple patients who have the same diagnosis without removing it, and evidence indicates that respirators maintain their protection when used for extended periods. However, using one respirator for longer than 4 hours can lead to discomfort and should be avoided
  • Among the general public, persons with respiratory symptoms or those caring for COVID-19 patients at home should receive medical masks. For additional information, see Home care for patients with suspected novel  coronavirus (COVID-19) infection presenting with mild symptoms, and management of their contacts.
  • For asymptomatic individuals, wearing a mask of any type is not recommended. Wearing medical masks when they are not indicated may cause unnecessary cost and a procurement burden and create a false sense of security that can lead to the neglect of other essential preventive measures. For additional information, see Advice on the use of masks in the community, during home care and in  healthcare settings in the context of the novel coronavirus (2019-nCoV) outbreak.

Coordinate PPE supply chain management mechanisms:

The management of PPE should be coordinated through essential national and international supply chain management mechanisms that include but are not restricted to:

using PPE forecasts that are based on rational

quantification models to ensure the rationalization of

requested supplies;

  • monitoring and controlling PPE requests from countries and large responders;
  • promoting the use of a centralized request management approach to avoid duplication of stock and ensuring strict adherence to essential stock management rules to limit wastage, overstock and stock ruptures;
  • monitoring the end-to-end distribution of PPE;
  • monitoring and controlling the distribution of PPE from medical facilities stores.

Handling cargo from affected countries:

The rationalized use and distribution of PPE when handling cargo from and to countries affected by the COVID-19 outbreak includes following these recommendations:

  • Wearing a mask of any type is not recommended when handling cargo from an affected country.
  • Gloves are not required unless they are used for protection against mechanical hazards, such as may occur when manipulating rough surfaces.
  • Importantly, the use of gloves does not replace the need for appropriate hand hygiene, which should be performed frequently, as described above.
  • When disinfecting supplies or pallets, no additional PPE is required beyond what is routinely recommended. To date, there is no epidemiological information to suggest that contact with goods or products shipped from countries affected by the COVID-19 outbreak have been the source of COVID-19 disease in humans. WHO will continue to closely monitor the evolution of the COVID-19 outbreak and will update recommendations as needed.
  1. In addition to using the appropriate PPE, frequent hand hygiene and respiratory hygiene should always be performed. PPE should be discarded in an appropriate waste container after use, and hand hygiene should be performed before putting on and after taking off PPE.
  2. The number of visitors should be restricted. If visitors must enter a COVID-19 patient’s room, they should be provided with clear instructions about how to put on and remove PPE and about performing hand hygiene before putting on and after removing PPE; this should be supervised by a healthcare worker.
  3. This category includes the use of no-touch thermometers, thermal imaging cameras, and limited observation and questioning, all while maintaining a spatial distance of at least 1 m.  
  4. All rapid response team members must be trained in performing hand hygiene and how to put on and remove PPE to avoid self-contamination.

Ref. Article: WHO Interim Guidance, 27-02-2020

WHO reference number: WHO/2019-nCov/IPC PPE_use/2020.1

 

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