COVID-19: Guidelines on rational use of Personal Protective Equipment

Novel Coronavirus Disease 2019 (COVID-19): Guidelines on rational use of Personal Protective Equipment

Personal Protective Equipment (PPE): Components of PPE are goggles, face-shield, mask, gloves, coverall/gowns (with or without aprons), head cover and shoe cover.

Face shield and goggles: Contamination of mucous membranes of the eyes, nose and mouth is likely in a scenario of droplets generated by cough, sneeze of an infected person or during aerosol generating procedures carried out in a clinical setting. Inadvertently touching the eyes/nose/mouth with a contaminated hand is another likely scenario.

Masks: Masks are of different types. The type of mask to be used is related to 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:

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

2. N-95 Respirator mask:  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.

Gloves:  Nitrile gloves are preferred over latex gloves because they resist chemicals, including certain disinfectants such as chlorine

Coverall/Gowns: Coveralls and gowns are deemed equally acceptable as there is a lack of comparative evidence to show whether one is more effective than the other in reducing transmission to health workers. Gowns are considerably easier to put on and for removal.

Shoe covers: Shoe covers should be made up of impermeable fabric to be used over shoes to facilitate personal protection and decontamination.

Head covers: Coveralls usually cover the head. Those using gowns, should use a head cover that covers the head and neck while providing clinical care for patients. Hair and hair extensions should fit inside the head cover.

1. Rational use of PPE

The PPEs are to be used based on the risk profile of the health care worker. The document describes the PPEs to be used in different settings.

Point of Entry

S. No.	Setting	Activity	Risk	Recommended PPE	Remarks
1	Health Desk	Provide information to travelers	Low risk	Triple layer medical mask Gloves	Minimum distance of one meter needs to be maintained.
2	Immigration counters, customs and airport security	Provide services to the passengers	Low risk	Triple layer medical mask Gloves	Minimum distance of one meter needs to be maintained.
3	Temperature recording station	Record Temperature with hand held thermal recorder.	Low risk	Triple layer medical mask Gloves
4	Holding area/ Isolation facility of APHO/ PHO	Interview & Clinical examination by doctors/ nurses	Moderate Risk	N-95 masks Gloves
5	Isolation facility of APHO	Clinical management (doctors, nurses)	Moderate Risk	N-95 masks Gloves
		Attending to severely ill passenger	High risk	Full complement of PPE	When aerosol generating procedures are anticipated
5	Sanitary staff	Cleaning frequently touched surfaces/ Floor/ cleaning linen	Moderate risk	N-95 mask Gloves
6	Administrative staff	Providing administrative support	No risk	No PPE	No contact with patients of COVID- 19. They should not venture into areas where suspect COVID-19 cases are being managed.

Hospital Setting

S. No	Setting	Activity	Risk	Recommended PPE	Remarks
1	Triage area	Triaging patients Provide triple layer mask to patient.	Moderate risk	N 95 mask Gloves	Patients get masked.
2	Screening area help desk/ Registration counter	Provide information to patients	Moderate risk	N-95 mask Gloves
3	Temperature recording station	Record temperature with hand held thermal recorder	Moderate Risk	N 95 mask Gloves
4	Holding area/ waiting area	Nurses / paramedic interacting with patients	Moderate Risk	N 95 mask Gloves	Minimum distance of one meter needs to be maintained.
5	Doctors chamber	Clinical management (doctors, nurses)	Moderate Risk	N 95 mask Gloves	No aerosol generating procedures should be allowed.
6	Sanitary staff	Cleaning frequently touched surfaces/ Floor/ cleaning linen	Moderate risk	N-95 mask Gloves
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

# All hospitals should identify a separate triage and holding area for patients with Influenza like illness. If there is no triage area / holding area for patients due to resource constraints, such hospitals will follow the above guidance for general OPD.

In-patient Services

S. No.	Setting	Activity	Risk	Recommended PPE	Remarks
1	Individual isolation rooms/ cohorted isolation rooms	Clinical management	Moderate risk	N 95 mask Gloves	Patient masked. Patients stable. No aerosol generating activity.
2	ICU/ Critical care	Critical care management	High risk	Full complement of PPE	Aerosol generating activities performed.
3	ICU /critical care	Dead body packing	High risk	Full complement of PPE
4	ICU/ Critical care	Dead body transport to mortuary	Low Risk	Triple Layer medical mask Gloves
5	Sanitation	Cleaning frequently touched surfaces/ floor/ changing linen	Moderate risk	N-95 mask Gloves
6	Other Non- COVID treatment areas of hospital	Attending to infectious and non-infectious patients	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

Emergency Department

S.No	Setting	Activity	Risk	Recommended PPE	Remarks
1	Emergency	Attending emergency cases	Moderate risk	N 95 mask Gloves	When aerosol generating procedures are anticipated
2		Attending to severely ill patients of SARI	High risk	Full complement of PPE	Aerosol generating activities performed.

Pre-hospital (Ambulance) Services

S. No.	Setting	Activity	Risk	Recommended PPE	Remarks
1	Ambulance Transfer to designated hospital	Transporting patients not on any assisted ventilation	Moderate risk	N-95 mask Gloves
		Management of SARI patient while transporting	High risk	Full complement of PPE	When aerosol generating procedures are anticipated
		Driving the ambulance	Low risk	Triple layer medical mask Gloves	Driver helps in shifting patients to the emergency

Other Supportive/ Ancillary Services

S. No.	Setting	Activity	Risk	Recommended PPE	Remarks
1.	Laboratory	Sample collection and transportation	High risk	Full complement of PPE
		Sample testing	High risk	Full complement of PPE
2	Mortuary	Dead body handling	Moderate Risk	N 95 mask Gloves	No aerosol generating procedures should be allowed. No embalming.
		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/Laundry	Handling linen of COVID patients	Moderate risk	N-95 mask Gloves
5	Other supportive services	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.

Health Workers in Community Setting

S. No.	Setting	Activity	Risk	Recommended PPE	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

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

Home Quarantine

S. No.	Setting	Activity	Risk	Recommended PPE	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.

Personal Protection Equipment (PPE) -Specifications(for Contact& Airborne precautions)

 1. PPE Kit

• Gloves
  • Nitrile
  • Non-sterile
  • Powder free
  • Outer gloves preferably reach mid-forearm (minimum 280 mm total length)
  • Different sizes (6.5 & 7)
  • Quality compliant with the below standards, or equivalent:

2. EU standard directive 93/42/EEC Class I, EN 455

3. EU standard directive 89/686/EEC Category Ill, EN 374

4. ANSI/SEA 105-2011

5. ASTM D6319-10

• Coverall (medium and large)*
  • Impermeable to blood and body fluids
  • Single use
  • Avoid culturally unacceptable colors g. black
  • Light colors are preferable to better detect possible contamination
  • Thumb/finger loops to anchor sleeves in place
  • Quality compliant with following standard

6. Meets or exceeds ISO 16603 class 3 exposure pressure, or equivalent

• Goggles
  • With transparent glasses, zero power, well fitting, covered from all sides with elastic band/or adjustable
  • Good seal with the skin of the face
  • Flexible frame to easily fit all face contours without too much pressure
  • Covers the eyes and the surrounding areas and accommodates for prescription glasses
  • Fog and scratch resistant
  • Adjustable band to secure firmly so as not to become loose during clinical activity
  • Indirect venting to reduce fogging
  • May be re-usable (provided appropriate arrangements for decontamination are in place) or disposable
  • Quality compliant with the below standards, or equivalent:

7. EU standard directive 86/686/EEC, EN 166/2002

8. ANSI/SEA 1-2010

• N-95 Masks
  • Shape that will not collapse easily
  • High filtration efficiency
  • Good breathability, with expiratory valve
  • Quality compliant with standards for medical N95 respirator:

9. NIOSH N95, EN 149 FFP2, or equivalent

• Fluid resistance: minimum 80 mmHg pressure based on ASTM F1862, ISO 22609, or equivalent
• Quality compliant with standards for particulate respirator that can be worn with full• face shield
• Shoe Covers
  • Made up of the same fabric as of coverall
  • Should cover the entire shoe and reach above ankles
• Face Shield
  • Made of clear plastic and provides good visibility to both the wearer and the patient
  • Adjustable band to attach firmly around the head and fit snuggly against the forehead
  • Fog resistant (preferable)
  • Completely covers the sides and length of the face
  • May be re-usable (made of material which can be cleaned and disinfected) or disposable
  • Quality compliant with the below standards, or equivalent:

10. EU standard directive 86/686/EEC, EN 166/2002

11. ANSI/SEA 1-2010

12. Triple Layer Medical Mask

• Three layered medical mask of non-woven material with nose piece, having filter efficiency of 99% for 3 micron particle

13. ISI specifications orequivalent

14. Gloves

• • Nitrile
  • Non-sterile
  • Powderfree
  • Outer gloves preferably reach mid-forearm (minimum 280mm total length)
  • Different sizes (6.5 & 7)
  • Quality compliant with the below standards, or equivalent:
• EU standard directive 93/42/EEC Class I, EN 455
• EU standard directive 89/686/EEC Category Ill, EN 374
• ANSI/SEA 105-2011
• ASTM D6319-10

5. BodyBags- Specifications

 Impermeable

• Leak proof
• Air sealed
• Double sealed
• Disposable
• Opaque
• White
• U shape with Zip
• 4/6 grips
• Size: 2.2 x 1.2 Mts
• Standards:

a) ISO 16602:2007

b) ISO 16603:2004

c) IS016604:2004

d) ISO/DIS 22611:2003

All items to be supplied need to be accompanied with certificate of analysis from national/ international organizations/labs indicating conformity to standards

All items: Expiry 5 years

* Due to scarcity of coveralls, and risk versus benefit, that as an emergency temporary measure in larger public interest, in present given circumstances, the fabric that cleared/passed  ‘Synthetic  Blood Penetration Resistance Test’ (ISO 16603) and the garment that passed ‘Resistance to penetration by biologically contaminated solid particles (ISO 22612:2005) may be considered as the benchmark specification to manufacture Coveralls.” The Coveralls should be taped at the seams to prevent fluid/droplets/aerosol entry.

The test for these two standards (ISO 16603 and ISO 22612:2005), which can be performed in Indian laboratories are as per WHO Disease Commodity Package (Version 4.0)

By: Ministry of Health and Family Welfare Directorate General of Health Services