Clothes and equipment for healthcare staff to prevent Ebola and other highly infective diseases

Healthcare staff are at much greater risk of infections such as Ebola Virus Disease or SARS than people in general. One way of preventing infection is to use personal protective equipment, such as protective clothing, gloves, masks, and goggles to prevent contamination of the worker. It is unclear which type of equipment protects best and how it can best be removed after use. It is also unclear what is the best way to train workers to comply with guidance for this equipment.

Studies found

We found six studies with 295 participants in which workers' protective clothing was sprayed with a fluorescent marker or a harmless virus to simulate what happens in hospitals. Four of these compared different types of protective clothing. Two studies compared different ways of putting clothing on and taking it off. Three studies with 905 participants compared the effect of active training on the use of protective equipment to passive training. All studies had a high risk of bias.

Various types of clothing compared

In spite of protective clothing, the marker was found on the skin of 25% to 100% of workers. In one study, more breathable clothing did not lead to more contamination than non-breathable clothing, but users were more satisfied. Gowns led to less contamination than aprons in another study. Two studies did not report enough data to enable conclusions. This evidence was of very low quality.

Various types of removal of clothing compared

In one study, two pairs of gloves led to less contamination than only one pair of gloves. The outer gloves were immediately removed after the task was finished. In another study, following CDC guidance for apron or gown removal led to less contamination. This evidence was also of very low quality.

Active training

Active training, including computer simulation and spoken instructions, led to less errors with guidance on which protection to use and how to remove it among healthcare staff compared to passive training.

Quality of the evidence

We judged the quality of the evidence to be very low because of limitations in the studies, indirectness and small numbers of participants.

What do we still need to find out?

There were no studies on the effects of goggles, face shields, long-sleeved gloves or taping on the risk of contamination. We need simulation studies with several dozens of participants, preferably using exposure to a harmless virus, to find out which type and combination is most protective. The best way to remove protective clothing after use is also unclear. We need studies that use chance to assign workers to different types of training to find out which training works best. Healthcare staff exposed to highly infectious diseases should have their protective equipment registered and be followed for their risk of infection. We urge WHO and NGOs to organise more studies.

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. We also found very low quality evidence that double gloving and CDC doffing guidance appear to decrease the risk of contamination and that more active training in PPE use may reduce PPE and doffing errors more than passive training. However, the data all come from single studies with high risk of bias and we are uncertain about the estimates of effects.

We need simulation studies conducted with several dozens of participants, preferably using a non-pathogenic virus, to find out which type and combination of PPE protects best, and what is the best way to remove PPE. We also need randomised controlled studies of the effects of one type of training versus another to find out which training works best in the long term. HCWs exposed to highly infectious diseases should have their use of PPE registered and should be prospectively followed for their risk of infection.

Read the full abstract...
Background: 

In epidemics of highly infectious diseases, such as Ebola Virus Disease (EVD) or 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 HCWs use PPE as instructed.

Objectives: 

To evaluate which type or component of full-body PPE and which method of donning or removing (doffing) PPE have the least risk of self-contamination or infection for HCWs, and which training methods most increase compliance with PPE protocols.

Search strategy: 

We searched MEDLINE (PubMed up to 8 January 2016), Cochrane Central Register of Trials (CENTRAL up to 20 January 2016), EMBASE (embase.com up to 8 January 2016), CINAHL (EBSCOhost up to 20 January 2016), and OSH-Update up to 8 January 2016. We also screened reference lists of included trials and relevant reviews, and contacted NGOs and manufacturers of PPE.

Selection criteria: 

We included all eligible controlled studies that compared the effect of types or components of PPE in HCWs exposed to highly infectious diseases with serious consequences, such as EVD and SARS, on the risk of infection, contamination, or noncompliance with protocols. This included studies that simulated contamination with fluorescent markers or a non-pathogenic virus.

We also included studies that compared the effect of various ways of donning or removing PPE, and the effects of various types 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 intended to perform meta-analyses but we did not find sufficiently similar studies to combine their results.

Main results: 

We included nine studies with 1200 participants evaluating ten interventions. Of these, eight trials simulated the exposure with a fluorescent marker or virus or bacteria containing fluids. Five studies evaluated different types of PPE against each other but two did not report sufficient data. Another two studies compared different types of donning and doffing and three studies evaluated the effect of different types of training.

None of the included studies reported a standardised classification of the protective properties against viral penetration of the PPE, and only one reported the brand of PPE used. None of the studies were conducted with HCWs exposed to EVD but in one study participants were exposed to SARS.

Different types of PPE versus each other

In simulation studies, contamination rates varied from 25% to 100% of participants for all types of PPE. In one study, PPE made of more breathable material did not lead to a statistically significantly different number of spots with contamination but did have greater user satisfaction (Mean Difference (MD) -0.46 (95% Confidence Interval (CI) -0.84 to -0.08, range 1 to 5, very low quality evidence). In another study, gowns protected better than aprons. In yet another study, the use of a powered air-purifying respirator protected better than a now outdated form of PPE. There were no studies on goggles versus face shields, on long- versus short-sleeved gloves, or on the use of taping PPE parts together.

Different methods of donning and doffing procedures versus each other

Two cross-over simulation studies (one RCT, one CCT) compared different methods for donning and doffing against each other. Double gloving led to less contamination compared to single gloving (Relative Risk (RR) 0.36; 95% CI 0.16 to 0.78, very low quality evidence) in one simulation study, but not to more noncompliance with guidance (RR 1.08; 95% CI 0.70 to 1.67, very low quality evidence). Following CDC recommendations for doffing led to less contamination in another study (very low quality evidence). There were no studies on the use of disinfectants while doffing.

Different types of training versus each other

In one study, the use of additional computer simulation led to less errors in doffing (MD -1.2, 95% CI -1.6 to -0.7) and in another study additional spoken instruction led to less errors (MD -0.9, 95% CI -1.4 to -0.4). One retrospective cohort study assessed the effect of active training - defined as face-to-face instruction - versus passive training - defined as folders or videos - on noncompliance with PPE use and on noncompliance with doffing guidance. Active training did not considerably reduce noncompliance in PPE use (Odds Ratio (OR) 0.63; 95% CI 0.31 to 1.30) but reduced noncompliance with doffing procedures (OR 0.45; 95% CI 0.21 to 0.98, very low quality evidence). There were no studies on how to retain the results of training in the long term or on resource use.

The quality of the evidence was very low for all comparisons because of high risk of bias in studies, indirectness of evidence, and small numbers of participants. This means that it is likely that the true effect can be substantially different from the one reported here.

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