Use of personal protective equipment to care for patients with COVID-19: scoping review

Garcia, Gracielle Pereira Aires; Fracarolli, Isabela Fernanda Larios; Santos, Heloisa Ehmke Cardoso dos; Souza, Virgínia Ramos dos Santos; Cenzi, Camila Maria; Marziale, Maria Helena Palucci

doi:10.1590/1983-1447.2021.20200150

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Scoping Review • Rev. Gaúcha Enferm. 42 (spe) • 2021 • https://doi.org/10.1590/1983-1447.2021.20200150 copy

Use of personal protective equipment to care for patients with COVID-19: scoping review

Uso de equipo de protección personal para el cuidado de pacientes con COVID-19: revisión del alcance

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective

To summarize the knowledge about recommendations for the use of personal protective equipment necessary for the provision of care by health professionals to patients suspected or infected by the new coronavirus.

Method

Scoping review with search for primary studies, reviews and preprints articles in English, Portuguese and Spanish, in the last 20 years on the bases WOS/ISI, SCOPUS, MEDLINE/PuBMed, CINAHL, LILACS and SciELO. Unpublished studies in journals were surveyed on bioRxiv and SciELO preprints.

Results

23 studies were eligible. Experiences with coronavirus prior to SARS-CoV-2 revealed that the equipment was an essential barrier in preventing transmission and followed the recommendations for standard precautions, contact, droplet and aerosol. In 13 (57%) studies, this equipment complied international recommendations and in 10 (45%) local recommendations.

Conclusion

The personal protective equipment used does not follow global standardization according to type, quality and adequate provision, exposing these professionals to the risk of contamination.

Keywords
Coronavirus infections; Personal protective equipment; Health personnel

Recommendations regarding the use of PPE
Authors/year	WHO	CDC	Others
Shapiro SE, McCauley LA2121. Shapiro SE, McCauley LA. SARS update: Winter, 2003 to 2004. AAOHN J. 2004 [cited 2020 Apr 28];5 (5) 199-203. doi: doi: https://doi.org/10.1177/216507990405200506 https://doi.org/10.1177/2165079904052005... 2004	Standard precautions, of contact and respiratory when treating suspected SARS customers. N95 adjusted and not reused. Use of surgical masks to limit transmission. Eye protection and hand hygiene before and after contact with the patient.
Thorne CD, Khozin S2222. Thorne CD, Khozin S, McDiarmid MA. Using the hierarchy of control technologies to improve healthcare facility infection control: lessons from severe acute respiratory syndrome. J Occup Environ Med. 2004;46(7):613-22. doi: https://doi.org/10.1097/01.jom.0000134191.92225.f2 https://doi.org/10.1097/01.jom.000013419... 2004	Hand hygiene, wearing a cloak, gloves, adjusted N95 and eye protection. PPE standardization requires training. In case of aerosol generation, it requires a higher level of respiratory protection, such as hoods or fitted face pieces.
Chia SE, et al.2323. Chia S, Koh D, Fones C, Qian F, Ng V, Tan BH, et al. Appropriate use of personal protective equipment among healthcare workers in public sector hospitals and primary healthcare polyclinics during the SARS outbreak in Singapore. Occup Environ Med. 2005;62(7):473-7. doi: https://doi.org/10.1136/oem.2004.01502 https://doi.org/10.1136/oem.2004.01502... 2005			The Singapore Ministry of Health manual recommends hand hygiene and the use of PPE. The recommended PPE are: N95, glasses/face shields, cloak (long sleeve) and disposable gloves.
Yen MY, et al.2424. Yen MY, Lin YE, Su IJ, Huang FY, Huang FY, Ho MS, et al. Using an integrated infection control strategy during outbreak control to minimize nosocomial infection of severe acute respiratory syndrome among healthcare workers. J Hosp Infect. 2006;62(2):195-9. doi: https://doi.org/10.1016/j.jhin.2005.02.011 https://doi.org/10.1016/j.jhin.2005.02.0... 2006	N95, eye protection, cloak, and latex gloves.		Taiwan's Department of Health also advises a second layer of outer gloves, apron, head, and foot cover.
Suwantarat N, Apisarnthanarak, A2525. Suwantarat N, Apisarnthanarak A. Risks to healthcare workers with emerging diseases: lessons from MERS-CoV, ebola, SARS, and avian flu. Curr Opin Infect Dis. 2015;28(4):349-61. doi: https://doi.org/10.1097/QCO.0000000000000183 https://doi.org/10.1097/QCO.000000000000... 2015	Reinforce the use of N95. Training is a key component of using PPE.
Weber DJ, et al.2626. Weber DJ, Rutala WA, Fischer WA, Kanamori H, Sickbert-Bennett, EE. Emerging infectious diseases: focus on infection control issues for novel coronaviruses (Severe Acute Respiratory Syndrome-Cov and Middle East Respiratory Syndrome-Cov), hemorrhagic fever viruses (Lassa and Ebola), and highly pathogenic avian influenza viruses, A(H5N1) and A(H7N9). Am J Infect Control. 2016];44(5 Suppl):e91-e100. doi:https://doi.org/10.1016/j.ajic.2015.11.018 https://doi.org/10.1016/j.ajic.2015.11.0... 2016	Basic individual training on equipping and unequipping PPE, with an explicit written list of all stages of equipping and unequipping.
Butt TS, et al.2727. Butt TS, Koutlakis-Barron I, AlJumaah S, AlThawadi S, AlMofada S. Infection control and prevention practices implemented to reduce transmission risk of middle east respiratory syndrome-coronavirus in a tertiary care institution in Saudi Arabia. Am J Infect Control. 2016;44(5):605-11. doi: https://doi.org/10.1016/j.ajic.2016.01.004 https://doi.org/10.1016/j.ajic.2016.01.0... 2016	Hand hygiene, environment, and equipment cleaning, use of PPE, such as respirators with high-efficiency particulate (for example, N95).
Kim CJ, et al.2828. Kim CJ, Choi WS, Jung Y, Kiem S, Seol HY, Woo HJ, et al. Surveillance of the middle east respiratory syndrome (MERS) Coronavirus (CoV) infection in healthcare workers after contact with confirmed MERS patients: incidence and risk factors of MERS-CoV seropositivity. Clin Microbiol Infect. 2016;22(10):880-6. doi:https://doi.org/10.1016/j.cmi.2016.07.017 https://doi.org/10.1016/j.cmi.2016.07.01... 2016		N95 or powered air-purifying respirator (PAPR), isolation suit (coveralls), goggles or face shield and gloves.
Alraddadi BM, et al.2929. Alraddadi BM, Al-Salmi HS, Jakobs-Slifka K, Slayton RB, Estivariz CF, Geller AI, et al. Risk factors for middle east respiratory syndrome coronavirus infection among healthcare personnel. Emerg Infect Dis. 2016;22(11):1915-20. Available from: https://doi.org/10.3201/eid2211.160920 https://doi.org/10.3201/eid2211.160920... 2016			Use of N95 by professionals in close contact with infected patient.
Maestre NMA, et al.3030. Maestre Naranjo MA, Dietl Sagüés M, Olivares Román S, García Arcones R, Gómez Crego R, Rodríguez de la Pinta ML. Actuación de un servicio de prevención de riesgos laborales para la atención a casos sospechosos de enfermedad respiratoria por coronavirus (MERS-CoV): A propósito de un caso. Med Segur Trab]. 2017 [cited 2020 Apr 28];63(247):93-102. Available from:Available from:http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S0465-546X2017000200093&lng=es&nrm=iso&tlng=es http://scielo.isciii.es/scielo.php?scrip... 2017			Action measures before a patient's admission. Workers are registered, monitored and trained on the agent's risks, use of appropriate PPE and the protocol implementation for different situations in which the use of PPE is necessary.
Al-Tawfiq JA, et al.3131. Al-Tawfiq JA, Rothwell S, Mcgregor HA, Khouri ZA. A multi-faceted approach of a nursing led education in response to MERS-Cov infection. J Infect Public Health. 2018 [cited 2020 Apr 28];11(2):260-4. doi: doi:https://doi.org/10.1016/j.jiph.2017.08.006 https://doi.org/10.1016/j.jiph.2017.08.0... 2018		Cloak, gloves, head cover (hood) and N95, hand hygiene, PPE equipping and unequipping.
Saud HA, et al.3232. Aman SH, Aljaber MI, Alwehaibi AI, Aman FH, Algaeed HA, Almasoud SM, et al. Awareness of MERS-CoV among staff members of Prince Sultan Military Medical City in Riyadh, Saudi Arabia. BioRxiv [Preprint]. 2018 [cited 2020 Apr 28] : [30 p.]. Available from: https://www.biorxiv.org/content/10.1101/474205v1 doi: https://doi.org/10.1101/474205 https://www.biorxiv.org/content/10.1101/... 2018	Preventive measures with protection of the nose, eyes, and any other places from which the medical team can contract the disease.

Recommendations regarding the use of PPE
Authors/Year	WHO	CDC	Others
Jones RM, et al.3333. Jones RM, Bleasdale SC, Maita D, Brosseau LM. A systematic risk-based strategy to select personal protective equipment for infectious diseases. Am J Infect Control. 2020;48(1):46-51. doi: https://doi.org/10.1016/j.ajic.2019.06.023 https://doi.org/10.1016/j.ajic.2019.06.0... 2020	Eye and face protection, head, and hair protection. Equipment includes: headbands, caps, surgical head covers and surgical helmets or hoods. Gloves are the main hand protection devices.
Huh S3434. Huh S. How to train the health personnel for protecting themselves from novel coronavirus (COVID-19) infection during their patient or suspected case care. J Educ Eval Health Prof. 2020;17:10. doi: https://doi.org/10.3352/jeehp.2020.17.10 https://doi.org/10.3352/jeehp.2020.17.10... 2020			Double gloves and protective clothing for the whole body, including shoes, KF94 equivalent mask and gloves (add safety glasses or face shield if necessary).
Wang H, Wang S, Yu K 3535. Wang H, Wang S, Yu K. COVID-19 infection epidemic: the medical management strategies in Heilongjiang Province, China. Crit Care. 2020;24:107. doi: https://doi.org/10.1186/s13054-020-2832-8 https://doi.org/10.1186/s13054-020-2832-... 2020			Training protocols on the use of masks, goggles, waterproof clothing and face shields.
Houghton C, et al.3636. Houghton C, Meskell P, Delaney H, Smalle M, Glenton C, Booth A, et al. Barriers and facilitators to healthcare workers' adherence with infection prevention and control (IPC) guidelines for respiratory infectious diseases: a rapid qualitative evidence synthesis. Cochrane Database Syst Rev. 2020;4(4):CD013582. doi: https://doi.org/10.1002/14651858.CD013582 https://doi.org/10.1002/14651858.CD01358... 2020	PPE (cloaks, gloves, masks, goggles) and hand hygiene.
Verbeek JH, et al.3737. Verbeek JH, Rajamaki B, Ijaz S, Sauni R, Toomey E, Blackwood B, et al. Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff. Cochrane Database Syst Rev. 2020;4(4):CD011621. doi:https://doi.org/10.1002/14651858.CD011621.pub4 https://doi.org/10.1002/14651858.CD01162... 2020		Gloves, masks, goggles or face shields, long-sleeve cloaks and N95.
Ferioli M, et al.3838. Ferioli M, Cisterino C, Leo V, Pisani L, Palange P, Nava S. Protecting healthcare workers from SARS-CoV-2 infection: practical indications. Eur Respir Rev. 2020;29(155):200068. doi: https://doi.org/10.1183/16000617.0068-2020 l https://doi.org/10.1183/16000617.0068-20... 2020	N95, glasses or face shield, long-sleeve water-resistant cloak and gloves. The use of N95 for a longer period is indicated in order to rationalize its use.	Respirator to be used (FFP2 European standard), when in contact with suspected and confirmed patients and in procedures with aerosol generation.	Use of the FFP2 respirator and bath after removing the PPE, disinfecting the ears and mouth.
Kowalski LPMD, et al.3939. Kowalski LP, Sanabria A, Ridge JA, Ng WT, Bree R, Rinaldo A, et al. COVID-19 pandemic: effects and evidence-based recommendations for otolaryngology and head and neck surgery practice. Head Neck. 2020;42(6):1259-67. doi: https://doi.org/10.1002/hed.26164 https://doi.org/10.1002/hed.26164... 2020			Guides on operating room with a negative pressure environment, ventilation system with a high efficiency particulate air filter. Use the coveralls with apron and goggles with face shield.
Zelaya S, et al.4040. Zelaya S, Gutiérrez M, Castellanos E, Dominguez R. Medidas de protección en personal de salud para prevención de COVID-19. San Salvador: Instituto Nacional de Salud; 2020 [citado 2020 abr 28]. 10 p. Disponible en: Disponible en: http://docs.bvsalud.org/biblioref/2020/08/1087768/medidas-de-proteccion-de-bioseguridad-p-de-salud-17ago20.pdf http://docs.bvsalud.org/biblioref/2020/0... 2020			N95 or similar, PAPR, glove, cloak with long, disposable sleeves, in some cases recommends the use of protective clothing including sneakers, safety glasses or face shield.
Brazil4141. Ministério da Saúde (BR). Secretaria de Atenção Primária à Saúde. Procedimento operacional padronizado: Equipamento de proteção individual e segurança no trabalho para profissionais de saúde da APS no atendimento às pessoas com suspeita ou infecção pelo novo coronavírus (Covid-19). Versão 2. Brasília, DF: Ministério da Saúde; 2020 [cited 2020 Apr 28]. Available from:Available from:https://www.unasus.gov.br/especial/covid19/pdf/67 https://www.unasus.gov.br/especial/covid... 2020			Mask, apron, glasses and gloves; wear a surgical mask to assist the user with respiratory symptom. N95/FFP2 is indicated in procedures that can generate aerosols.
Paraguay4242. Ministerio de Salud Publica y Bienestar Social (PY). Dirección de Vigilancia de Enfermedades Transmisibles. Dirección General de Vigilancia de la Salud. Guía técnica de prevención y control de infecciones durante la atención sanitaria de casos sospechosos o confirmados de covid-19. Asunción: Ministerio de Salud Publica y Bienestar Social; 2020 [cited 2020 Apr 28]. 30 p. Available from: https://www.mspbs.gov.py/dependencias/portal/adjunto/2cf2cb-Prevencinycontroldeinfecciones23.03.pdf https://www.mspbs.gov.py/dependencias/po... 2020			Use of surgical mask, waterproof cloaks. The coveralls should be used according to the exposure risk category. The use of glasses and face shields when there is a risk of contact with secretions, in addition to N95 or similar. Reuse is not recommended, except in extreme needs.
Gallasch CH, et al.4343. Gallasch CH, Cunha ML, Pereira LAS, Silva-Junior JS. Prevention related to the occupational exposure of health professionals workers in the COVID-19 scenario. Rev Enferm UERJ. 2020;28:e49596. Available from: https://doi.org/10.12957/reuerj.2020.49596 https://doi.org/10.12957/reuerj.2020.495... 2020			Recommends hand hygiene, use of goggles or face shield, surgical mask, waterproof apron and procedure gloves. The use of a cap and N95 or FFP2 are indicated during the performance of aerosol-generating procedures.

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[1] Corresponding author:
Gracielle Pereira Aires Garcia Email: gracielleaires@gmail.com