Personal Protective Equipment for Healthcare Workers

COVID is a highly contagious viral disease that has caused massive outbreaks throughout the world causing a pandemic. The need to curtail its spread is quite evident in the numbers itself, with over 10.5 million cases worldwide as of today. The healthcare professionals face a multitude of problems in a scenario like this and their protection is of utmost importance. This unprece-dented scenario requires them to form new habits that ensure their safety and therefore it is of great importance that information regarding personal safety be reviewed from time to time as knowledge takes time and repetition to get converted into actions and even more so to get converted to habit. A lot of misconceptions also exist regarding the equipment and practices that need to be implemented that require clari(cid:977)ication. This article reviews strategies to be used by the healthcare workers and the hospital to tackle cases effectively, provide appropriate care and at the same time ensure their own safety and safety of all other personnel at the hospital as well as patients. An important aspect covered here is personal protective. Information regarding the equipment, it’s uses, and protocols are explored with the aim of strengthening the knowledge base of the healthcare force and to reinforce precautionary measures to be taken during these tough times.


INTRODUCTION
nCoV 19 or the novel coronavirus is highly infectious agent that causes coronavirus disease or COVID. Thus, it is of utmost importance that precautions be taken to contain the disease and avoid its spread especially among health care workers who are at a very high risk of coming in contact with cases of COVID. It would be a matter of great sadness of the very person attempting to cure the diseased succumbs to it. Other than that, it is also evident that the sheer volume of patients due to the pandemic has put immense stress on the healthcare system and thus every healthcare professional that has to be isolated due to contact with cases without proper protection leads to an even more overburdened health care system. (WHO, 2020b) Highest amount of viral load is present in sputum and upper airway secretions. Coronavirus transmission occurs majorly via 2 routes; contact transmission as well as droplet transmission. If the patient's respiratory activity or certain medical procedures develop aerosols airborne transmission (>1m) may occur. The droplets are larger particles and their spread is usually limited to a 1 metre radius. Contact with the patient or fomites or surfaces may be responsible for infection. The virus is capable of being a potential source of infection for hours or even days. The viral particles enter the healthy individual via the respiratory mucosa and even the con-junctiva is a potential point of entry. (WHO, 2020a) The willingness and morale of healthcare professionals to give their best in dif icult times like this also depends on how protected they are and the quality of protocol and equipment available.
This article aims at strengthening the response to COVID by reviewing the equipment required and practices of prevention of transmission of COVID amongst healthcare workers.

METHODS
Published articles, guidelines and documents have been reviewed and their interpretations combined to create this comprehensive article.

PERSONAL PROTECTIVE EQUIPMENT
The items that constitute Personal Protective Equipment or PPE are gloves, mask, eye protection and gown with foot cover. They protect the entry of the viral particles which usually enter via the respiratory mucosa and even the conjunctiva. (WHO, 2014) Depending on the role carried out by the health care professional an appropriate level of PPE should be used, which is a combination of the above elements. (Cook, 2020)

Gloves
According to FDA, medical gloves should be used, non-sterile gloves can be used as they are being used for the protection of the healthcare workers and not for the purpose of protection of the patient from infectious agents. The length should be at least 230 mm and the thickness should be 0.5 mm. Nitrile gloves are preferred, latex may be used. (WHO, 2020b)

Mask
Various types of masks can be used which includes

FFP
This stands for iltering facepiece, the number next to it signi ies the class of protection provided by it, higher the number more the protection it provides. (Gawn, 2008) Table 1 shows the variants of FFP and their test values to qualify as either FFP 1, 2 or 3.

N95
The N95 mask uses several layers of mesh and electromagnetically charged layers to trap particulate matter and thus is effective in blocking droplets that may be carrying the viral particles. The N95 label denotes that under test conditions the mask obstructs a minimum of 95% of solid and liquid aerosol test particles (certi ied under 42 CFR 84 of National Institute for Occupational Safety and Health and the United States CDC). Masks have different ways of blocking entry of particulate matter ranging from having a small pore size to having a certain electrical charge that traps particles. This must be understood while attempting to try methods of mask sterilization otherwise it may result in reduction in the ef icacy of protection that the mask provides.

Eye Protection
This includes a visor or a face shield . A complete hood with a transparent visor is now considered best.

Gown with foot cover
The gown should cover the entire length of the arms and should cover mid-calf length of legs at least as the remaining portion will be covered by the foot covers. These are made out of speci ic materials that meet with the permeability standards set by different country wise authorities. They should have a luid repellent coat and should be disposable. It is also important to plan what kind of protection might be needed according to the anticipated proximity to patient and the type of procedure to be done. Table 2 shows the guidelines regarding the level of PPE required in some scenarios.     2. Next the gown is removed ensuring that the exterior of the gown does not come in contact with the health care personnel. This can be ensured by rolling the gown as it is being removed.

Protocol regarding wearing (Donning) and removing (Dof ing) PPE CDC guidelines for
3. Perform hand hygiene 4. Remove face shield or visor 5. Remove face mask at last 6. Perform hand hygiene again (CDC, 2020b) Figure 1 shows the (Beak Method, 2015) for glove removal. The glove in glove method (Shale and The Hand Protection Blog, 2015) of removal is shown in Figure 2 The method of gown removal should be such that the exposed part of the gown does not touch the healthcare workers clothing (CDC, 2020a) (Department of Health & Human Services, USA and Centres for Disease Control & Prevention, 2020). This is shown in Figure 3.

Important considerations
PPE is only a part of the system employed to prevent cross infection. Equal importance must be given to taking general measures to avoid infection like,

PPE misuse and overuse
PPE is expensive and limited stocks are available in India. Thus, judicious use of PPE is very essential as the battle against COVID is a long one.

Reusing of PPE
Reusing of PPE after decontamination should only be practiced in case of shortage. FFR masks are not authorized for reuse after decontamination due to factors like improper it later, reduced iltration ef iciency and so on.
Methods that can be used for decontamination include,

Appropriate allocation of resources
An inventory of PPE should be maintained, and calculated usage should be permitted. The burn rate of PPE should be calculated, and further orders should be placed accordingly.

CONCLUSIONS
The COVID pandemic has presented with unprecedented challenges regarding containment of communicable diseases making standard protocols and guidelines very essential. Proper care in handling of cases and measures taken for self-protection can halt the propagation of this disease. Proper equipment and facilities are undoubtedly importance but what is equally important is the judicious use of resources, strict adherence to protocols and enforcement of guidelines provided by reliable sources. Overuse of resources is also a form of misuse is what must be understood and therefore policy decisions must be made about when and how the protection equipment should be used.
In developing countries especially where there is a shortage of resources, decontamination and reuse of PPE may be done using standardized protocols and procedures of decontamination. This may make the inancial challenge of tackling this crisis seem less challenging. Proper communication of the guidelines and protocols is also of immense importance. Schematic diagrams, images, posters and other means of communication should be used at various points in the facility to ensure compliance.