One of the key issues for healthcare systems around the world during the covid-19 pandemic has been the lack of sufficient personal protective equipment (PPE) available for healthcare workers. We recently updated a Cochrane review on PPE for healthcare workers.  The review included 22 simulation studies and two field studies comparing types of PPE used within a full-body PPE ensemble. The review found evidence that covering more parts of the body, such as the neck and the head, may lead to better protection, but at the cost of being more difficult to put on or take off. Studies showed that modifications to the design of PPE, including tabs to grab or better coverage of the glove-gown interface may lead to less contamination.  Better guidance on doffing, one-step glove and gown removal, double-gloving, verbal instructions during doffing, and using glove disinfection may all reduce contamination and increase compliance. We found only three studies that evaluated improving instruction and training for PPE use; none looked at maintaining skills in the long run.  All evidence was rated as low to very low quality. We downgraded simulation studies because they were indirectly related to the PPE issues and most comparisons were based on single studies. So, what can we learn from the Cochrane review in light of the current covid-19 pandemic?
Recently, debate and controversy have surrounded the types of masks or respirators that should be used by healthcare workers. A key point, often overlooked, is that it is not just masks or respirators that help protect their users from infection. It is the totality of the PPE elements used in combination, including gloves, gowns, masks, and face shields that offer protection within a larger hierarchy of control measures. 
Healthcare workers are at much greater risk of acquiring serious infections than the general population. This fact has been demonstrated during epidemics such as SARS, Ebola, and covid-19. In general, the risk of acquiring infection depends on the chance of encountering an infected person and on the time being exposed to this person. Compared to non-healthcare workers, many healthcare workers have a much greater risk because they are routinely exposed to contaminated body fluids such as secretions, excretions, and aerosolised droplets from patients who are infected with highly contagious diseases for prolonged periods. 
Measures to help prevent healthcare workers from becoming infected at work should be considered from the perspectives of occupational health and infection control point of view. From the occupational health perspective, it is a matter of reducing and preventing exposure to contaminated body fluids and other potentially infectious materials and contaminated surfaces. It is good practice to use a hierarchy of controls. This means that there should be a fixed order in which to consider measures to control exposure. First, one should consider measures that eliminate exposure. For example, reorganising patient flows in a hospital will greatly reduce exposure of those healthcare workers not directly involved in clinical work to patients with confirmed infectious diseases. Next, technical measures to reduce exposure should be considered, such as, when possible, choosing local or regional anaesthesia to avoid aerosol generating intubation or ensuring adequate ventilation and cleaning. Exposure can be further reduced by establishing sustainable infection prevention and control measures. PPE should be considered as the last line of defence since PPE generally reduces healthcare workers’ comfort, restricts their movement, and necessitates time and a designated place to put it on and take it off.  In addition, the protection provided by PPE depends on human factors including proper selection and use of the PPE and correctly donning and doffing it. Nevertheless, it is hard to imagine a situation in general in which healthcare workers could do without PPE. Therefore, it is important to find out if PPE works and which types work best.
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Source: The BMJ Opinion
Date: June 18, 2020