Isolation gowns in health care settings: Laboratory studies, regulations and standards, and potential barriers of gown selection and use

A narrative review of personal protective equipment gowns: lessons from COVID-19

This narrative review evaluates the evidence regarding the protection offered by isolation gowns, approaches to imparting antimicrobial activity to gowns, and the environmental impacts of gown use, particularly during the COVID-19 pandemic. We conducted a search of the Medline, PubMed, and Google Scholar databases for articles published between January 1, 2019 to February 20, 2024. We found that current standards pertaining to isolation gowns might be irrelevant to the protection of healthcare workers from pathogen transmission, as they focus primarily on fluid barrier resistance values that are not reflective of all transmission conditions in hospitals. Although most available isolation gowns are disposable, reusable gowns could offer greater barrier protection and are more environmentally sustainable. Several techniques have been studied for their ability to impart antimicrobial properties to isolation gowns, extending their lifespan and reducing environmental impacts. However, evidence of the effectiveness of such techniques in clinical settings is scarce. We advocate for standardised guidelines inclusive of common pathogen survival tests, comfort, and durability, which reflect the actual infection risks encountered by healthcare workers, to improve the safety and efficacy of isolation gowns in hospital settings. Further research into the clinical effectiveness of antimicrobial gowns and their long-term implications on the environment is also warranted.

UK national survey on surgical gowning for tonsillectomy

OBJECTIVE

Tonsillectomy is a common procedure performed nationally. The personal protective equipment and surgical gowning practices used during this procedure vary widely. We compiled a survey of ENT specialists to gain a national opinion about gowning in tonsillectomy with the aim of determining whether we could make it more environmentally friendly whilst maintaining the highest safety standards.

METHOD

We developed a nine-question survey that was piloted prior to final implementation. The questionnaire was sent to senior registrars and consultant otolaryngologists in the UK.

RESULTS

The survey was completed by a total of 63 ENT specialists. It was found that 82.54 per cent of clinicians would consider wearing a reusable gown that would be sterilised between each procedure.

CONCLUSION

Our survey suggests most ENT clinicians would consider using a more environmentally friendly surgical gown and some may even consider wearing no gown at all, although many are understandably concerned about the transmission of infection or blood splatter.

User experience of wearing comfort of reusable versus disposable surgical gowns and environmental perspectives: A cross-sectional survey

OBJECTIVE

To determine the user experience of wearing comfort of reusable sterile surgical gowns and compare these gowns with conventional disposable surgical gowns.

DESIGN

Cross-sectional survey.

SETTING

An academic hospital in the Netherlands.

POPULATION

Gynaecologists, surgeons, residents and operating room assistants (n=80).

METHODS

Quantitative and qualitative data were obtained via a written questionnaire. Participants provided subjective comments and scored the reusable gown on each individual topic with a score from 1 to 5 (1 = unsatisfactory, 2 = moderate, 3 = good, 4 = very good, 5 = excellent) and compared the reusable gown with the conventional disposable alternative (better, equal or worse).

MAIN OUTCOME MEASURES

Wearing comfort: ventilation and temperature regulation, fit and length, functionality, barrier function and ease of use.

RESULTS

The results of the overall scores of the reusable gown are scored as 'very good' (mean 4.3, SD ± 0.5) by its users. Regarding comparison of the gowns, more than 79% (lowest score 79%, highest score 95%) of the participants scored the reusable gown equal or higher on six of seven topics. The topic 'ease of use' was scored equal or higher by 59% of the participants. Subjective comments provided information on possible improvements.

CONCLUSIONS

The findings of this study demonstrate that there is professional acceptance regarding the utilisation of reusable surgical gowns. To facilitate broader adoption, it is imperative to foster collaboration among suppliers and healthcare institutions. The reusable surgical gown is an environmentally sustainable, safe and comfortable alternative in the operating room.

Clostridioides difficile spores tolerate disinfection with sodium hypochlorite disinfectant and remain viable within surgical scrubs and gown fabrics

Clostridioides difficile is the most common cause of antibiotic-associated diarrhoea globally. Its spores have been implicated in the prevalence of C. difficile infection due to their resistance and transmission ability between surfaces. Currently, disinfectants such as chlorine-releasing agents (CRAs) and hydrogen peroxide are used to decontaminate and reduce the incidence of infections in clinical environments. Our previous research demonstrated the ability of C. difficile spores to survive exposure to recommended concentrations of sodium dichloroisocyanurate in liquid form and within personal protective fabrics such as surgical gowns; however, the present study examined the spore response to clinical in-use concentrations of sodium hypochlorite. Spores were exposed to a 10 min contact time of 1000, 5000 and 10 000 p.p.m. sodium hypochlorite, and spore recovery was determined. To understand whether biocide-exposed spores transmitted across clinical surfaces in vitro , biocide-exposed spores were spiked onto surgical scrubs and patient gowns and recovery was determined by a plate transfer assay. Scanning electron microscopy was used to establish if there were any morphological changes to the outer spore coat. The results revealed that viable biocide-exposed C. difficile spores can be recovered from surgical scrubs and patient gowns, with no observable changes to spore morphology, highlighting the potential of these fabrics as vectors of spore transmission. This study demonstrates that alternative strategies should be urgently sought to disinfect C. difficile spores to break the chain of transmission in clinical environments.

Evaluation of the physical performance of disposable isolation gowns

BACKGROUND

The threat of emerging infectious diseases has highlighted the need for effective gowns to protect health care workers and patients. Although studies identified end user issues with the physical performance of gowns, the literature that evaluates the performance is scarce. This paper represents 1 of the first efforts to investigate the physical performance of a substantial set of isolation gown models in the marketplace.

METHODS

Physical performance of 20 commercial and 2 experimental disposable isolation gowns was evaluated in this study. Standard test methods were used to investigate a range of properties, including thickness, weight, tensile strength, tearing strength, and seam strength.

RESULTS

In general, due to the differences in the fibers and methods used for the construction, large variations in the tensile, tear, and seam strength results were found. When the gowns were compared to their respective Association for the Advancement of Medical Instrumentation PB70 protection levels, no clear trend was found between protection levels and tear strength or between protection levels and seam strength, while there was a linear relationship between gowns' Association for the Advancement of Medical Instrumentation PB70 levels and their tensile strength. It was found that fabric construction significantly affects the physical performance of gowns.

CONCLUSIONS

Based on this work, a new standard, American Society of Testing and Materials International F3352, was published and has been recognized by the Food and Drug Administration. American Society of Testing and Materials International F3352 is expected to help end users in selecting the appropriate protective clothing.

Isolation of Clostridioides difficile PCR Ribotype 027 from single-use hospital gown ties

Background. Clostridioides difficile is a spore-forming pathogen responsible for antibiotic-associated diarrhoea. In the USA high incidence of C. difficile infection (CDI) in clinical environments has led to interest in C. difficile spore transmission.Hypothesis. Single use hospital surgical gown ties act as a reservoir for C. difficile spores.Aim. This study sought to examine whether single-use hospital surgical gown ties used in surgery, from an acute healthcare facility, harboured C. difficile spores.Methodology. Used surgical gowns ties worn by clinicians in the healthcare facility were examined for C. difficile spore presence via spread plate and anaerobic culture. The colonies isolated from each gown tie were subcultured on C. difficile selective agar for phenotypic confirmation. Presumptive C. difficile colonies were examined using C. difficile Quik Check Complete, 16-23S PCR Ribotyping and MALDI-TOF analysis.Results. In total 17 suspected C. difficile colonies were isolated from 15 gown ties via culture. C. difficile Quik Check Complete found two isolates as possible C. difficile. MALDI-TOF and PCR Ribotyping confirmed one isolate as C. difficile PCR ribotype 027 associated with clinical outbreaks.Discussion. Our study revealed the presence of hypervirulent C. difficile ribotype 027 spores on single-use gown ties. This highlights the potential of gown ties as a vector of spore transmission across clinical environments, especially when gowns are not worn appropriately.Conclusions. Appropriate compliance to infection control procedures by healthcare workers is essential to prevent spore dissemination across clinical facilities and reduce CDI rates.

A simulation study to assess fluid leakage through the glove-gown interface in isolation settings

BACKGROUND

Isolation gowns are recommended to protect healthcare personnel, patients, and visitors from transfer of microorganisms and body fluids in patient isolation situations. Standards provide limited information about barrier performance of isolation gowns for possible exposure scenarios. One of the most vulnerable areas of the personal protective equipment ensemble is considered the glove-gown interface. However, current isolation gown classification standards do not consider the interface regions of the personal protective equipment system while assessing the level of protection. The purpose of this study was to quantitatively evaluate the fluid leakage through the glove-gown interface by simulating exposures and healthcare personnel arm movements in patient care for isolation settings.

METHODS

We tested fluid leakage of two examination gloves with different cuff lengths and seven isolation gown models designed with varying levels of barrier resistance and multiple cuff types.

RESULTS

Our results demonstrated that leakage through the glove-gown interface depends on multiple factors, including glove cuff length and gown cuff design. Gowns with the thumb loop design provided better protection than the elastic cuff design, and the elastic cuff design provided better protection compared to the knit cuff design for a given AAMI PB70 level. More importantly, a substantial penetration through gown fabrics was observed.

CONCLUSIONS

This research identifies a need to develop a standardized method to evaluate leakage at the glove-gown interface to improve worker protection.

Assessing personal protective equipment needs for healthcare workers

BACKGROUND

Personal protective equipment (PPE) is critical for healthcare workers (HCWs) since it acts as a barrier to infection transmission; however, current PPE is not ideally suited to their needs due to limitations in protection and comfort. Thus, the purpose of this study was to identify major issues of current PPE for body protection and assess its needs within health care.

METHODS

An online survey was conducted with a convenience sample of 200 U.S. healthcare professionals who interact with patients. The survey was designed to identify the types of PPE that HCWs currently use, assess current PPE design features for body protection, examine the effect of PPE design features for body protection, and HCWs' years of work experiences on overall PPE acceptability, and explore current PPE maintenance practices. Both quantitative and qualitative data were used for analyses.

RESULTS

This study showed the need for current PPE improvement in terms of fit, comfort, mobility, and donning and doffing for HCWs' safety and health. Donning and doffing plays an important role in HCWs' overall acceptance of PPE for body protection. This study revealed that most HCWs dispose of their PPE in a trashcan in a healthcare unit and non-disposed PPE is laundered at home, which may expose their family members to a health risk if a proper precaution is not followed.

CONCLUSION

This study provides critical insights for the needs of (a) novel PPE design research and (b) proper donning and doffing training and its strict regulatory effort to ensure HCWs' safety and health.

How COVID-19 highlighted the need for infection prevention and control measures to become central to the global conversation: experience from the conflict settings of the Middle East

Within just a few months, the coronavirus disease 2019 (COVID-19) pandemic managed to bring to the foreground the conversation that infection prevention and control (IPC) experts have been pushing for decades regarding the control of the spread of infections. Implementing the basics of IPC has been a challenge for all affected countries battling with an exponential COVID-19 curve of infection. Preventing nosocomial transmission of the disease has been difficult in highly resourced and stable contexts, but even more so in the conflict context of the Middle East. COVID-19 has added further challenges to the long list of existing ones, hindering the implementation of the optimal IPC measures that are necessary to break the chain of infection of both respiratory and non-respiratory infections in those settings. This paper outlines and gives examples of the challenges faced across the Middle East conflict setting and serves as a call for action for IPC to be prioritized, given the resources needed, and fed with contextualized evidence.

Disposable versus reusable medical gowns: A performance comparison

Background

Medical gowns are essential personal protective equipment (PPE) that prevents the spread of microorganisms and bodily fluids. During surge capacity situations, such as the COVID-19 pandemic, reusable PPE is often recommended due to shortages.

Methods

This research evaluated the performance of disposable versus reusable medical gowns by assessing their ability to provide adequate protection across their expected service lifespan. Level I, II, and III gowns were tested for water resistance and hydrostatic pressure, along with other durability assessments (breaking, tear, and seam strength, pilling resistance, dimensional stability, and air permeability, colorfastness, and fabric hand) per standard test methods. Data were collected at new for the disposable gowns and after 1, 25, 50, and 75 industrial launderings for the reusable gowns. Results were compared to the Association of the Advancement Instrumentation® (AAMI) PB70 performance specifications.

Results

Level I and II disposable gowns did not meet AAMI performance specifications for impact penetration water resistance. All 3 levels of disposable gowns also failed to meet the American Society for Testing and Materials performance requirements for breaking strength in the crosswise direction.

Conclusions

The adoption of reusable gowns may result in increased protection and significant cost savings due to their superior durability and sustainability when compared to disposable gowns.

Barrier resistance of double layer isolation gowns

Background

Isolation gowns are one of the crucial pieces of personal protective equipment (PPE) to prevent the migration of microorganisms and body fluids from patients to health care personnel and vice versa. Underperforming isolation gowns in terms of fluid resistance, could potentially put lives in danger. Wearing multiple layers of isolation gowns could theoretically increase the fluid penetration resistance. This study investigates if 2-layer lower barrier level isolation gowns meet the barrier effectiveness requirements of a single higher barrier level isolation gown.

Methods

Three commonly used ANSI/AAMI Level 2 isolation gown models were selected and tested in single layer and double layer configurations in accordance with ANSI/AAMI PB70 requirements.

Results

Total of 240 experiments were conducted to analyze the effects of gown model, fabric region, and the number of gown layers on AATCC 127 and AATCC 42 test results. In regard to AATCC 42, there was a significant difference among the different gown models, and the number of gown layers. Similar to AATCC 42 results, there was a significant difference among the different gown models, and the number of gown layers for AATCC 127; additionally, the gown regions was also significantly different.

Conclusion

Test results demonstrated that the double layer isolation gown configurations do not always provide equal fluid penetration resistance as required for a single Level 3 isolation gown using the standard test methods specified in ANSI/AAMI PB70.

Engineering laminated paper for SARS-CoV-2 medical gowns

The COVID-19 pandemic has highlighted the need for diversity in the market and alternative materials for personal protective equipment (PPE). Paper has high coatability for tunable barrier performance, and an agile production process, making it a potential substitute for polyolefin-derived PPE materials. Bleached and newsprint papers were laminated with polyethylene (PE) coatings of different thicknesses, and characterised for their potential use as medical gowns for healthcare workers and COVID-19 patients. Thicker PE lamination improved coating homogeneity and water vapour resistance. 49 GSM bleached paper with 16 GSM PE coating showed high tensile and seam strength, and low water vapour transmission rate (WVTR). Phi-X174 bacteriophage testing revealed that paper laminated with 15 GSM coating hinders virus penetration. This research demonstrates that PE laminated paper is a promising material for low cost viral protective gowns.

Strategic Role and Challenges of Community Pharmacists in SARS-CoV-2 Outbreak

This study highlights the importance of community pharmacists' strategic role in hindering the progression of the SARS-CoV-2 virus in the community setting and innovative measures to protect themselves. This article focuses on the features, control, and prevention of COVID-19 and social awareness measures of the pandemic. The means employed by the community pharmacist to safeguard his health while providing pharmaceutical services during COVID-19 is compiled and presented to benefit health-care professionals around the world. As per the US Center for Disease Control and Prevention, community pharmacists play a crucial role in providing essential drugs to patients without knowing their current COVID-19 status. They also work in conditions that make them susceptible to COVID-19 exposure. Despite the availability of guidelines, community pharmacists need to be trained in personal protective equipment for efficient protection and prevention of spread. Community pharmacists are essential frontline warriors against transmission of the SARS-CoV-2 virus in the community and act as frontline workers to educate the public on COVID-19. They are at high risk and need to observe necessary precautions to mitigate the spread of the virus.

COVID-19 Solutions Are Climate Solutions: Lessons From Reusable Gowns

The COVID-19 pandemic has laid bare the inadequacy of the U.S. healthcare system to deliver timely and resilient care. According to the American Hospital Association, the pandemic has created a $202 billion loss across the healthcare industry, forcing health care systems to lay off workers and making hospitals scramble to minimize supply chain costs. However, as the demand for personal protective equipment (PPE) grows, hospitals have sacrificed sustainable solutions for disposable options that, although convenient, will exacerbate supply strains, financial burden, and waste. We advocate for reusable gowns as a means to lower health care costs, address climate change, and improve resilience while preserving the safety of health care workers. Reusable gowns' polyester material provides comparable capacity to reduce microbial cross-transmission and liquid penetration. In addition, previous hospitals have reported a 50% cost reduction in gown expenditures after adopting reusable gowns; given the current 2000% price increase in isolation gowns during COVID-19, reusable gown use will build both healthcare resilience and security from price fluctuations. Finally, with the United States' medical waste stream worsening, reusable isolation gowns show promising reductions in energy and water use, solid waste, and carbon footprint. The gowns are shown to withstand laundering 75–100 times in contrast to the single-use disposable gown. The circumstances of the pandemic forewarn the need to shift our single-use PPE practices to standardized reusable applications. Ultimately, sustainable forms of protective equipment can help us prepare for future crises that challenge the resilience of the healthcare system.

Reopening of dental clinics during SARS-CoV-2 pandemic: an evidence-based review of literature for clinical interventions

Background

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes serious acute respiratory diseases including pneumonia and bronchitis with approximately 2.3% fatality occurrence.

Main body

This study argues the main concepts that need to be considered for the gradual reopening of dental offices include treatment planning approaches, fundamental elements needed to prevent transmission of SARS-CoV-2 virus in dental healthcare settings, personal protection equipment (PPE) for dental health care providers, environmental measures, adjunctive measures, and rapid point of care tests in dental offices.

Conclusion

This article seeks to provide an overview of existing scientific evidence to suggest a guideline for reopening dental offices.

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

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) coveralls were more difficult to doff than isolation gowns (very 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). According to three studies that tested more recently introduced full-body PPE ensembles, there may be no difference in contamination. 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. 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.

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

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.

Increased adhesion of methicillin-resistant Staphylococcus aureus to the surface of personal protective clothing damaged by friction during nursing action

BACKGROUND

Health care workers wear protective clothing when caring for patients with infectious diseases. However, during the action of patient care, the generated contact pressure may damage the surface of the protective clothing.

METHODS

Fabrics of protective clothing were damaged by a machine using a force similar to the contact pressure that occurs during nursing care. A total of 50 μL of blood containing methicillin-resistant Staphylococcus aureus (MRSA) (5 × 10⁶ colony-forming units/mL) was dropped onto the pressed or rubbed fabrics. After removing the blood, the residual bacterial count on the surface of the clothing was measured.

RESULTS

In the undamaged fabrics, the number of adherent MRSA was significantly higher on class 6 protective clothing than on the other tested clothing. The number of adherent MRSA significantly increased on the rubbed surgical gown and rubbed class 3 protective clothing than on the undamaged clothing.

CONCLUSIONS

Because the damaged fabrics of protective clothing may cause bacterial carryover, health care workers should pay attention to preventing self-contamination when doffing the protective clothing.

A systematic risk-based strategy to select personal protective equipment for infectious diseases

•

Selection of personal protective equipment (PPE) can be systematic and risk-based.

•

Potential exposures are compared with sites susceptible to infection.

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Facilitates transparent decision-making about personal protective equipment.

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PPE evaluation includes: donning/doffing/changing, usability, and fit for purpose.

Background

Personal protective equipment (PPE) is a primary strategy to protect health care personnel (HCP) from infectious diseases. When transmission-based PPE ensembles are not appropriate, HCP must recognize the transmission pathway of the disease and anticipate the exposures to select PPE. Because guidance for this process is extremely limited, we proposed a systematic, risk-based approach to the selection and evaluation of PPE ensembles to protect HCP against infectious diseases.

Methods

The approach used in this study included the following 4 steps: (1) job hazard analysis, (2) infectious disease hazard analysis, (3) selection of PPE, and (4) evaluation of selected PPE. Selected PPE should protect HCP from exposure, be usable by HCP, and fit for purpose.

Results

The approach was demonstrated for the activity of intubation of a patient with methicillin-resistant Staphylococcus aureus or Severe Acute Respiratory Syndrome coronavirus. As expected, the approach led to the selection of different ensembles of PPE for these 2 pathogens.

Discussion

A systematic risk-based approach to the selection of PPE will help health care facilities and HCP select PPE when transmission-based precautions are not appropriate. Owing to the complexity of PPE ensemble selection and evaluation, a team with expertise in infectious diseases, occupational health, the health care activity, and related disciplines, such as human factors, should be engaged.

Conclusions

Participation, documentation, and transparency are necessary to ensure the decisions can be communicated, critiqued, and understood by HCP.

Biocide Resistance and Transmission of Clostridium difficile Spores Spiked onto Clinical Surfaces from an American Health Care Facility

Clostridium difficile is the primary cause of antibiotic-associated diarrhea globally. In unfavorable environments, the organism produces highly resistant spores which can survive microbicidal insult. Our previous research determined the ability of C. difficile spores to adhere to clinical surfaces, finding that spores had markedly different hydrophobic properties and adherence abilities. Investigation into the effect of the microbicide sodium dichloroisocyanurate on C. difficile spore transmission revealed that sublethal concentrations increased spore adherence without reducing viability. The present study examined the ability of spores to transmit across clinical surfaces and their response to an in-use disinfection concentration of 1,000 ppm of chlorine-releasing agent sodium dichloroisocyanurate. In an effort to understand if these surfaces contribute to nosocomial spore transmission, surgical isolation gowns, hospital-grade stainless steel, and floor vinyl were spiked with 1 × 10⁶ spores/ml of two types of C. difficile spore preparations: crude spores and purified spores. The hydrophobicity of each spore type versus clinical surface was examined via plate transfer assay and scanning electron microscopy. The experiment was repeated, and spiked clinical surfaces were exposed to 1,000 ppm sodium dichloroisocyanurate at the recommended 10-min contact time. Results revealed that the hydrophobicity and structure of clinical surfaces can influence spore transmission and that outer spore surface structures may play a part in spore adhesion. Spores remained viable on clinical surfaces after microbicide exposure at the recommended disinfection concentration, demonstrating ineffectual sporicidal action. This study showed that C. difficile spores can transmit and survive between various clinical surfaces despite appropriate use of microbicides.IMPORTANCE Clostridium difficile is a health care-acquired organism and the causative agent of antibiotic-associated diarrhea. Its spores are implicated in fecal to oral transmission from contaminated surfaces in the health care environment due to their adherent nature. Contaminated surfaces are cleaned using high-strength chemicals to remove and kill the spores; however, despite appropriate infection control measures, there is still high incidence of C. difficile infection in patients in the United States. Our research examined the effect of a high-strength biocide on spores of C. difficile which had been spiked onto a range of clinically relevant surfaces, including isolation gowns, stainless steel, and floor vinyl. This study found that C. difficile spores were able to survive exposure to appropriate concentrations of biocide, highlighting the need to examine the effectiveness of infection control measures to prevent spore transmission and to consider the prevalence of biocide resistance when decontaminating health care surfaces.

Experience of Chicagoland acute care hospitals in preparing for Ebola virus disease, 2014-2015

During the 2014-2015 Ebola Virus Disease (EVD) outbreak, hospitals in the United States selected personal protective equipment (PPE) and trained healthcare personnel (HCP) in anticipation of receiving EVD patients. To improve future preparations for high-consequence infectious diseases, it was important to understand factors that affected PPE selection and training in the context of the EVD outbreak. Semistructured interviews were conducted with HCP involved with decision-making during EVD preparations at acute care hospitals in the Chicago, IL area to gather information about the PPE selection and training process. HCP who received training were surveyed about elements of training and their perceived impact and overall experience by email invitation. A total of 28 HCP from 15 hospitals were interviewed, and 55 HCP completed the survey. Factors affecting PPE selection included: changing guidance, vendor supply, performance evaluations, and perceived risk and comfort for HCP. Cost did not affect selection. PPE acquisition challenges were mitigated by: sharing within hospital networks, reusing PPE during training, and improvising with existing PPE stock. Selected PPE ensembles were similar across sites. Training included hands-on activities with trained observers, instructional videos, and simulations/drills, which were felt to increase HCP confidence. Many felt refresher training would be helpful. Hands-on training was perceived to be effective, but there is a need to establish the appropriate frequency of refresher training frequency to maintain competence. Lacking confidence in the CDC guidance, interviewed trainers described turning to other sources of information and developing independent PPE evaluation and selection. Response to emerging and/or high consequence infectious diseases would be enhanced by transparent, risk-based guidance for PPE selection and training that addresses protection level, ease of use, ensembles, and availability.

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

BACKGROUND

In epidemics of highly infectious diseases, such as Ebola Virus Disease (EVD) or Severe Acute Respiratory Syndrome (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 HCW 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 self-contamination or infection for HCW, and which training methods increase compliance with PPE protocols.

SEARCH METHODS

We searched MEDLINE (PubMed up to 15 July 2018), Cochrane Central Register of Trials (CENTRAL up to 18 June 2019), Scopus (Scopus 18 June 2019), CINAHL (EBSCOhost 31 July 2018), and OSH-Update (up to 31 December 2018). We also screened reference lists of included trials and relevant reviews, and contacted NGOs and manufacturers of PPE.

SELECTION CRITERIA

We included all controlled studies that compared the effects of PPE used by HCW exposed to highly infectious diseases with serious consequences, such as Ebola or SARS, on the risk of infection, contamination, or noncompliance with protocols. This included studies that used simulated contamination with fluorescent markers or a non-pathogenic virus.We also included studies that compared the effect of various ways of donning or doffing PPE, and the effects 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 planned to perform meta-analyses but did not find sufficiently similar studies to combine their results.

MAIN RESULTS

We included 17 studies with 1950 participants evaluating 21 interventions. Ten studies are Randomised Controlled Trials (RCTs), one is a quasi RCT and six have a non-randomised controlled design. Two studies are awaiting assessment.Ten studies compared types of PPE but only six of these reported sufficient data. Six studies compared different types of donning and doffing and three studies evaluated different types of training. Fifteen studies used simulated exposure with fluorescent markers or harmless viruses. In simulation studies, contamination rates varied from 10% to 100% of participants for all types of PPE. In one study HCW were exposed to Ebola and in another to SARS.Evidence for all outcomes is based on single studies and is very low quality.Different types of PPEPPE made of more breathable material may not lead to more contamination spots on the trunk (Mean Difference (MD) 1.60 (95% Confidence Interval (CI) -0.15 to 3.35) than 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).Gowns may protect better against contamination than aprons (MD large patches -1.36 95% CI -1.78 to -0.94).The use of a powered air-purifying respirator may protect better than a simple ensemble of PPE without such respirator (Relative Risk (RR) 0.27; 95% CI 0.17 to 0.43).Five different PPE ensembles (such as gown vs. coverall, boots with or without covers, hood vs. cap, length and number of gloves) were evaluated in one study, but there were no event data available for compared groups.Alterations to PPE design may lead to less contamination such as added tabs to grab masks (RR 0.33; 95% CI 0.14 to 0.80) or gloves (RR 0.22 95% CI 0.15 to 0.31), a sealed gown and glove combination (RR 0.27; 95% CI 0.09 to 0.78), or a better fitting gown around the neck, wrists and hands (RR 0.08; 95% CI 0.01 to 0.55) compared to standard PPE.Different methods of donning and doffing proceduresDouble gloving may lead to less contamination compared to single gloving (RR 0.36; 95% CI 0.16 to 0.78).Following CDC recommendations for doffing may lead to less contamination compared to no guidance (MD small patches -5.44; 95% CI -7.43 to -3.45).Alcohol-based hand rub used during the doffing process may not lead to less contamination than the use of a hypochlorite based solution (MD 4.00; 95% CI 0.47 to 34.24).Additional spoken instruction may lead to fewer errors in doffing (MD -0.9, 95% CI -1.4 to -0.4).Different types of trainingThe 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 20.14,41.26) than a traditional lecture.Face to face instruction may reduce noncompliance with doffing guidance more (OR 0.45; 95% CI 0.21 to 0.98) than providing folders or videos only.There were no studies on effects of training in the long term or on resource use.The quality of the evidence is very low for all comparisons because of high risk of bias in all studies, indirectness of evidence, and small numbers of participants.

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. Alterations to PPE, such as tabs to grab may decrease contamination. Double gloving, following CDC doffing guidance, and spoken instructions during doffing may reduce contamination and increase compliance. Face-to-face training in PPE use may reduce errors more than video or folder based training. Because data come from single small studies with high risk of bias, we are uncertain about the estimates of effects.We still need randomised controlled trials to find out which training works best in the long term. We need better simulation studies conducted with several dozen participants to find out which PPE protects best, and what is the safest way to remove PPE. Consensus on the best way to conduct simulation of exposure and assessment of outcome is urgently needed. HCW exposed to highly infectious diseases should have their use of PPE registered and should be prospectively followed for their risk of infection in the field.

Ebola Virus Disease: Clinical Challenges, Recognition, and Management

The 2014 to 2016 Ebola outbreak response resulted in many lessons learned about biocontainment patient care, leading to enhanced domestic capabilities for highly infectious and hazardous communicable diseases. However, additional opportunities for improvement remain. The article identifies and describes key considerations and challenges for laboratory analysis, clinical management, transportation, and personnel management during the care of patients infected with Ebola or other special pathogens. Dedication to maintaining preparedness enables biocontainment patient care teams to perform at the highest levels of safety and confidence.

Potential Risk of Virus Carryover by Fabrics of Personal Protective Gowns

Personal protective gowns and coveralls are classified based on barrier efficiency that validates protection from fluid penetration under certain pressures. Materials standardized in this system have been found suitable for emergency medical practices confronting highly contagious diseases. Nevertheless, adhesion of blood, and body fluids from virus-infected patients to the surface of protective clothing still imposes a risk of pathogen transmission in the process of doffing, or undressing. We performed a small-scale experiment to test the possibility of infectious virus carryover on the surface of different fabrics used in commercially available protective gowns. Application of a lentivirus vector that expresses green fluorescent protein allowed easy monitoring of infectious viral loads on fabrics. Results indicate that fabrics of level-3 surgical gowns serve better to reduce virus transmission compared to fabrics of chemical protective clothing with the same or higher barrier efficiency. Analysis of sliding angles provided indexes of fluid repellency, which were inversely related to virus carryover potentials. Droplets of infectious body fluids may easily roll off fabrics with water-repellent finishing. Thus, virus carryover is a measurable risk factor to be considered for better choice of personal protective clothing.

Novel Test Method for the Evaluation of Fluid Leakage at the Glove-Gown Interface and Investigation of Test Parameters

BACKGROUND

Exposure to patients' blood/body fluids could be life-affecting, when providing care to patients with infectious diseases. Although the glove-gown interface is considered one of the weakest points of the protective ensemble system, there is a lack of research, and existing standards do not provide much guidance on strategies to minimize gaps between the gowns and gloves. Currently, there is no known standard test method to evaluate fluid leakage or assess performance improvements with new gowns/gloves.

STUDY DESIGN

A novel test method with a robotic arm, which has the capability to simulate health care personnel's arm movements during fluid exposure, was developed to determine the leakage at the glove-gown interface. This article explains the test method and investigates the effect of movement, exposure type, exposure duration, procedure duration, and existence of pressure on the amount of leaked fluid at the glove-gown interface.

RESULTS

Test results suggest that, with the exception of procedure duration, all parameters significantly affected the amount of fluid leaked at the glove-gown interface. Leakage was higher for soaking when compared to spraying, increased as the exposure duration increased, and was greater with the application of pressure.

CONCLUSIONS

The novel method developed in this study could be used by manufacturers of personal protective equipment to evaluate their products. Standard development organizations could adapt this test method in their specifications, testing standards, and guidelines.

Environmental considerations in the selection of isolation gowns: A life cycle assessment of reusable and disposable alternatives

BACKGROUND

Isolation gowns serve a critical role in infection control by protecting healthcare workers, visitors, and patients from the transfer of microorganisms and body fluids. The decision of whether to use a reusable or disposable garment system is a selection process based on factors including sustainability, barrier effectiveness, cost, and comfort. Environmental sustainability is increasingly being used in the decision-making process. Life cycle assessment is the most comprehensive and widely used tool used to evaluate environmental performance.

METHODS

The environmental impacts of market-representative reusable and disposable isolation gown systems were compared using standard life cycle assessment procedures. The basis of comparison was 1,000 isolation gown uses in a healthcare setting. The scope included the manufacture, use, and end-of-life stages of the gown systems.

RESULTS

At the healthcare facility, compared to the disposable gown system, the reusable gown system showed a 28% reduction in energy consumption, a 30% reduction in greenhouse gas emissions, a 41% reduction in blue water consumption, and a 93% reduction in solid waste generation.

CONCLUSIONS

Selecting reusable garment systems may result in significant environmental benefits compared to selecting disposable garment systems. By selecting reusable isolation gowns, healthcare facilities can add these quantitative benefits directly to their sustainability scorecards.