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

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Verbeek, Jos H, Ijaz, Sharea, Mischke, Christina, Ruotsalainen, Jani H, Mäkelä, Erja, Neuvonen, Kaisa, Edmond, Michael B, Sauni, Riitta +2 more·2016·Cochrane Database of Systematic Reviews
DOI 10.1002/14651858.cd011621.pub2PMC PMC10068873
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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 METHODS: 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 otherIn 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 otherTwo 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 otherIn 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,

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  • A recent Cochrane Database Systematic Review has shown that the role and level of protection of personal protective equipment is still unclear.

    “A recent Cochrane Database Systematic Review has shown that the role and level of protection of personal protective equipment is still unclear [38].”

    From Joint EFLM-COLABIOCLI Recommendation for venous blood sampling (2018) · cites this paper as [38]

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Cited by

Sorted by citations

Authors
Verbeek, J. H., Ijaz, S., Mischke, C., Ruotsalainen, J. H., Mäkelä, E., Neuvonen, K., Edmond, M. B., Sauni, R., Kilinc Balci, F. S., & Mihalache, R. C.
Affiliations
  • Finnish Institute of Occupational Health (FI)
  • Finnish Institute of Occupational Health; Cochrane Work Review Group; PO Box 310 Kuopio Finland 70101
  • University of Iowa Hospitals and Clinics (US)
  • Centers for Disease Control and Prevention (CDC); National Personal Protective Technology Laboratory (NPPTL), National Institute for Occupational Safety and Health (NIOSH); 626 Cochrans Mill Road Pittsburgh PA USA 15236
ORCID
Venue
Cochrane Database of Systematic Reviews
Publisher
Wiley
Published
2016-04-19
Volume
4
Pages
CD011621-CD011621
ISSN
  • 1361-6137 (ISSN-L)
  • 1465-1858
DOI
10.1002/14651858.cd011621.pub2
PMC
PMC10068873
OpenAlex
W3046701250
Cited by
113
References
6
Citations by year
2026: 1 · 2025: 3 · 2024: 7 · 2023: 6 · 2022: 8 · 2021: 22 · 2020: 31 · 2019: 16 · 2018: 8 · 2017: 10 · 2016: 1
FWCI
1.79
Type
journal article
Language
en
Update notices
new_version (2019-07-01)
Open access
Locations
  • Cochrane Database of Systematic Reviews (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
National Institutes of Health (CC999999)
Topics
  • Health Sciences › Medicine › Infectious Diseases › Infection Control in Healthcare
  • Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Infection Control and Ventilation
  • Health Sciences › Medicine › Infectious Diseases › Viral Infections and Outbreaks Research
Keywords
personal protective equipment, healthcare workers, occupational infection prevention, Ebola virus disease, SARS, body fluid exposure, contact precautions, PPE donning and doffing, PPE training, PPE compliance, self-contamination, nosocomial infections, occupational health and safety, infection prevention and control training
MeSH terms
Personal Protective Equipment, Body Fluids, Health Personnel, Humans, Respiratory Protective Devices, Gloves, Protective, Infectious Disease Transmission, Patient-to-Professional, Hemorrhagic Fever, Ebola, Severe Acute Respiratory Syndrome, Surgical Attire

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