INFECTIOUS DISEASES

Topic: Rational and Effective Use of PPEs

Lecturer: Dr. Iturralde

PERSONAL PROTECTIVE EQUIPMENT (PPE) List of Aerosol Generating Procedures:

 Includes any gear to protect against infection  Intubation, extubation and related procedures
 It is a specialized clothing or equipment worn by healthcare workers for  Tracheotomy/tracheostomy
protection against infectious materials  Cardiopulmonary resuscitation
 Bronchoscopy
DEFINITION OF TERMS  Dental procedures
COVID-19 SUSPECT CASE:  Surgical procedures
 Unexplained SARI (Severe Acute Respiratory Illness)  Non-invasive ventilation
o Fever, cough, occurring within 7-10 days and it requires  CPAP ventilation
hospitalization  High-frequency oscillatory ventilation
 ILI (Influenza-like Illness  almost the same with SARI but does NOT  High-flow nasal oxygen provision
require hospitalization) cases with any one of the following:  Induction of sputum
o Fever, cough, occurring within 7-10 days but it does NOT  GI endoscopy
require hospitalization, OR  Evacuation of pneumoperitoneum during laparoscopic procedures
o Unexplained AND a history of travel to or residence in an area
that reported local transmission of COVID-19 disease during Extended Use:
the 14 days prior to symptom onset, OR  Use of PPE without removing for up to 6 hours, when caring for a group
o With contact to a confirmed or probable case of COVID- 19 of COVID-19 patients
disease during the 14 days prior to the onset of symptoms
 It implies that the use of any PPE item for a longer period of time than
o Individuals with fever or cough or shortness of breath or other
normal according to standards for conventional use and manufacturer
respiratory signs or symptoms fulfilling any one of the
recommendations
following conditions:
 >/= 60 years old
Decontamination:
 With a comorbidity
 Refers to a process of decreasing antimicrobial presence in an area or
 High-risk pregnancy
on a surface
 Healthcare worker
 Removes pathogenic organisms from objects so that they are safe to
handle, use, or discard
COVID-19 PROBABLE CASE:
 Suspect case whom testing for COVID-19 is inconclusive
Disinfection:
 Suspect who underwent testing for COVID-19 not conducted in a
 Refers to the elimination of virtually all pathogenic organisms on
national or subnational reference laboratory or officially accredited
inanimate objects and surfaces thereby reducing the level of microbial
laboratory for COVID-19 confirmatory testing
contamination to acceptably safe levels
 Suspect case for whom testing could not be performed for any reason
 Elimination of all pathogenic microorganisms EXCEPT bacterial spores
o E.g. place is very far from any laboratory, problems with
on inanimate objects
transportation such those in far flung areas
 Some patients who tested negative for 2 to 3 consecutive times BUT the
Sterilization:
course of the illness is very compatible with COVID-19  you label them
 Destruction of all forms of living microorganisms from a surface or
as COVID-19 Probable Case
substance
 Process that destroys all forms of microbial life and is carried out in
COVID-19 CONFIRMED CASE:
healthcare facilities by physical or chemical methods
 Any individual, irrespective of the presence or absence of clinical signs
and symptoms, who is laboratory confirmed (using RT-PCR) for COVID-
PRACTICAL STRATEGIES TO CONSERVE PPE
19 in a test conducted at the national reference laboratory, a
 Teleconsultation/telemedicine
subnational reference laboratory, and/or officially accredited
 Use of physical barriers
laboratory testing facility
 Zoning based on risk levels of transmission
o Green: low-risk
COVID-19 Area:
o Orange/Yellow: moderate-risk
 A space or place in the hospital where probable, suspected, confirmed
o Red: high-risk
cases of COVID-19 stay for > 6 hours or where potentially aerosol
 Monitoring, audits; safety officers
generating procedures (AGP) are performed
 Earn commitment of healthcare workers
Aerosol Generating Procedures:  Extended use/reprocessing
o This is a last resort/temporary measure
 Any medical or patient care procedure that result in the production of
aerosols o This should be adopted when there is anticipated PPE shortage
that will adversely affect healthcare workers’ safety and care
 You must be familiar what these procedures are because this
delivery OR in areas where access to the global supply chain of
determines what type of PPE should be worn in the area where this is
PPE remains limited despite attempts to use exceptional
done
procurement processes

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 INFECTIOUS DISEASES
Topic: Rational and Effective Use of PPEs
Lecturer: Dr. Iturralde

ZONING High Risk Areas

Low Risk Areas
 Outpatient department, reception areas, non- COVID-19 wards
 Require Level 1 or 2 Protection PPEs
o Level 1 PPE  surgical mask, hand hygiene + alcohol
o Level 2 PPE  surgical mask, hand hygiene + alcohol, face
shields/goggles
 COVID-19 suspects/COVID-19 ward, ICCU, operating room (OR)
complex, labor room and delivery room complex, ER isolation
area/endoscopy procedure area
 High-risk activities: all aerosol-generating procedures (nebulization,
intubation, manual ventilation, non-invasive ventilation, resuscitation,
tracheostomy, and gastroenteral endoscopy), handling of other
respiratory specimen for microbiologic studies
 Require Level 4 Protection PPEs (N95 mask, face shields, surgical caps,
double globes, disposable or impermeable coveralls, scrub suit,
dedicated shoes, shoe cover)
o Although there is no benefit in doubling gloves, since we are
dealing with a relatively new disease and it is highly
transmissible, doctors wear double gloves

Moderate Risk Areas RECOMMENDED PPE IN EMERGENCY ROOM

 ER pre-triage area, ER triage area, hemodialysis unit, ICCU set-up, eye

center examination area, ENT examination area
RECOMMENDED PPE IN THE OPD
 Moderate-risk activities: non-respiratory specimen examination of
suspected patients, imaging examination of suspected patients
(including use of portable x-rays), cleaning of surgical instruments used
with suspected patients
 Require Level 3 Protection PPEs (N95 mask, face shields or googles,
surgical caps, gloves, disposable or impermeable, coveralls)

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 INFECTIOUS DISEASES
Topic: Rational and Effective Use of PPEs
Lecturer: Dr. Iturralde

RECOMMENDED PPE IN PRIVATE PATIENT ROOMS

In the Orange or Red Zone: Wear Level 3
If you are:
 Staying <4 hours
 Brief patient interaction
 Performing NPS or OPS
 Assigned as safety officer on the doffing area

In the Orange or Red Zone: Wear Level 4

If you are:
 Staying > 4 hours
RECOMMENDED PPE IN THE OPERATING ROOM  Performing close contact procedures
 Performing AGP
 In doubt!
 If you are high-risk to develop Covid-19, example you have
comorbidities like hypertension or diabetes

DESCRIPTION OF EACH PPE

PPE Description
 Specifications: disposable, non-woven, pleated, hypoallergenic, high filtration capacity, with adaptable nose bar, very low resistance
to breathing
 If you are not directly handling COVID-19 patients
Surgical Mask
 If there is no risk of splashing or spraying bodily fluids
 Extended use of up to 6 hours is FEASIBLE but it increases risk of contamination
When you use a face shield over a face mask (wherein the face shield covers
the chin and the sides of the face)  it may extend the use of face mask

 Reprocessing is NOT RECOMMENDED

 Cloth masks not considered as an alternative to surgical masks for healthcare workers
Cloth masks are allowed when used in public places (e.g. malls) but not inside the
hospitals

 Specifications: anti-fog with side shield, polycarbonate, lightweight, adjustable head strap, must cover side of face and below the chin
 If you are directly handling COVID-19 patients and/or performing AGP
 If there is a risk of splashing or spraying bodily fluids
 Extended use and limited reuse is ACCEPTED
o Discard face shields or goggles if there is damage already, it doesn’t fasten securely to the face and head, or if visibility is obscured
Eye Protection
when used
 Reprocessing is ACCEPTED
o Wash with soap/detergent and water
o Disinfect
How do you disinfect?
 0.1% sodium hypochlorite (e.g. Zonrox)
for 5 mins.
 Wipe with 70% ethyl alcohol minimum
contact time of 5 minutes
 Soak with 3% hydrogen peroxide for 30
minutes
o Rinse with water
o Airdry
o Clean and decontaminate, expose to UV radiation in a UV sterilizing cabinet for 15 mins.

NOTE: The reuse, reprocessing of goggles or face shields without decontamination or sterilization is strongly discouraged because it is
one of the principal sources of transmission to healthcare workers

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 INFECTIOUS DISEASES
Topic: Rational and Effective Use of PPEs
Lecturer: Dr. Iturralde

PPE Description
 Specifications: at least 95% filtration efficiency, fluid resistance, with nose clip, 2-strap design with welded strap attachment, with nose
foam; FIT TESTING
Fit Testing is a critical component to a respiratory protection program whenever workers use tight fitting respirators. Use a test
agent either qualitatively detected by the wearer’s sense of taste, smell or involuntary cough of irritant smoke OR quantitative
measure by an instrument to verify the respirator’s fit

 If you are directly handling COVID-19 patients and/or performing AGP

 If there is risk of splashing or spraying bodily fluids
 Can be used for up to 8 hours
 Extended use is SAFE and ACCEPTED provided that the respirator must maintain its fit and function
Respirators (N95, N99,  Conditions that prevent extended use: soiled with blood/bodily fluids, discarded after AGP, close contact with suspect/confirmed cases,
N100) damaged, hard to breathe through
 Extended use is favored over reuse
 Reuse after extended use is NOT ACCEPTED
Reuse is permitted provided that you do or observe the following steps:
 Reduce contact transmission
 You can rotate 5-7 pieces of N95 respirators for each healthcare workers (this is very expensive to do!)  you use 1 N95 in a
particular day, take off and store it by hanging in a storage area or use a breathable container such as paper bag in between
uses
 Avoid respirators touching each other in storage areas to minimize potential cross-contamination
 Minimize cross-contamination by labeling the respirator of each healthcare worker
 Use a face shield over an N95 respirator

A limited reuse for not more than 5 times per device to ensure adequate safety margin

Contact transmission caused by touching a contaminated mask is identified as a primary hazard for use and reuse of respirator

 Reprocessing:
o Vapor of hydrogen peroxide for 55 minutes  allow reuse for up to 3 times
o UV radiation lamp for 15 minutes  allow reuse for up to 3 times
o Moist heat incubation at 70oC for 30 minutes  allow reuse for up to 2 times

 Decontamination methods are NOT RECOMMENDED by current evidences such as:

o Use of ethylene oxide, ionizing radiation, microwave, high temperature (autoclaving)
 Expired N95 masks can still be used as long as there is no signs of damage (e.g. no discoloration, residue, no loss of elasticity of the ear
loops)  better get in touch with the manufacturer prior to use
 Damage to the shape of the respirators due to reprocessing may affect fit and protection properties

 Components: headgear or hood, face shield, head harness, nose cup assembly, spectacles, visor covers, inhalation and exhalation
valves, port adapter, cartridge filter, PAPR system, belt, air hose, battery chargers, etc.
 PAPR is a battery powered blower that forces air through filter cartridges or canister into the breathing zone of the wearer. An airflow
is created inside, either a tight-fitting face piece or loose-fitting hood/helmet providing a higher assigned protection factor (APF)
 It uses High Efficiency Particulate Air or HEPA filter which implies that they have a greater level of respiratory protection than N95
masks
Personal Air-Purifying  Loose-fitting PAPR is better than Tight-fitting non-powered purifying respirator
Respirators (PAPR)
Advantages:
 No fit testing
 It can be worn with a limited amount of facial hair
 Significant splash protection for the face and the eyes
 Full face of HCW can be seen because there is no need to wear a mask
 Better interpersonal communication
 Can be cleaned, disinfected, reused, shared
 Less taxing (easier to breath)

Disadvantages:
 Limited downward vertical view
 Batteries need to be recharged and replaced
 Required storage space
 Limited ability to use stethoscope
 Reduced ability to hear
 Access may be even more limited due to cost and need for routine maintenance

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 INFECTIOUS DISEASES
Topic: Rational and Effective Use of PPEs
Lecturer: Dr. Iturralde

PPE Description
 Material non-woven polypropylene (disposable single use), or non-woven cloth, polyester-cotton (washable, reusable)
 Long-sleeved, tie back, covers down to mid-calf, lightweight, durable, breathable, water, and blood-resistant
 Worn over scrub suit
In conventional capacity situations, use of surgical or isolation gowns are recommended
In contingency capacity strategies, you shift gown toward the use of cloth gowns  just like in this pandemic because
it can be REUSED

 Cotton-made gown over polypropylene made gown

Use a clean isolation gown when entering suspected or confirmed COVID-19 patients
Gowns
If having close contact with COVID-19 patients  use 2 layers of gowns (cotton-made + polypropylene made gown)
 Inner layer – polypropylene
 Outer layer – cotton

Dispose the cotton gown once stained or soiled  replace immediately if necessary

 In the operating room, you don a sterile gown as 1st layer then proceed at the operating cubicle for another layer of sterile gowning
process
 Remove or dispose the gown if it is wet, soiled or damaged, exposed to chemicals or infectious substances/ fluids from the body, or
used it in providing care outside designated COVID-19 areas

 Extended use is ACCEPTABLE

 Reuse/reprocessing of cloth gown ACCEPTED
 Reprocessing of cotton gowns:
o Machine wash  with warm water + laundry detergent
o Manual wash  soak and stir with hot water and then soak in .05% chlorine for 30 mins. then rinse with water and dry fully

Alternatives:
 Disposable lab coats  less durable
 Disposable impermeable plastic aprons  cannot protect arms and back of torso
 Reusable patient gowns/lab coats  design and thickness are not comparable

Combinations of the ff. may be considered for activities that may involve body fluids and there are NO GOWNS AVAILABLE:
 Long sleeve apron + Long sleeve patient gowns/Laboratory coat
 Open back gowns + Long sleeve patient gowns/Laboratory coat
 Sleeve covers + Aprons/Long sleeve patient gowns/Laboratory coats

 Made of high-density polyethylene formed into non-woven fabric; other materials are polypropylene fiber with polyethylene coating,
breathable, lightweight, water-based liquids and aerosol repellant, low linting, tunneled elastic bands for the wrists, ankles and face,
and thumb loops
 Ideal color is white or light blue, ideally single-use, biohazard protective cover all clothing
 If you are directly handling COVID-19 patients (whether suspected, confirmed or probable) and/or performing AGP (aerosol generating
procedures)
Coverall (HAZMAT Suit)  If there is risk of splashing or spraying bodily fluids
 Provide 360o protection (including back, lower legs, head and feet)
 Reuse/reprocessing is ACCEPTABLE in times of severe shortage
o Ideally they are for single use only BUT reuse/reprocessing is ACCEPTABLE especially if supply is an issue  just clean, disinfect,
or sanitize it
 Disinfection:
o Wash with soap/detergent and water
o Disinfection (Soak with .1% sodium hypochlorite, 3% hydrogen peroxide for 30 minutes)
o Rinse with water
o Air and sun drying

Alternatives to Commercially available Coveralls:

 Non-woven polypropylene  same material used to make reusable shopping bags
 Thermoplastic polymers  it is recyclable and reusable

 Coveralls can be washed if they are used in low-risk areas (green areas)
 Infectious Disease experts do not recommend non-woven polypropylene coveralls as these are not meant for healthcare workers who
come into direct contact with infected patients
 Advise on locally-manufactured coveralls:
o License to operate (national standards, technical requirements, safety testing)

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 INFECTIOUS DISEASES
Topic: Rational and Effective Use of PPEs
Lecturer: Dr. Iturralde

PPE Description

Surgical Cap

 Specifications: disposable, non-woven surgical bouffant cap, shower-type

 Worn if you are part of the Level 3 or 4 PPE

Shoe Cover

 Specifications: disposable, non-woven

 Fabric does not tear/break easily
 Non-skid, does not slip on wet floor
 No recommendation for use of shoe covers vs. no shoe covers for healthcare personnel caring for patients with COVID-19
 It is used for extra protection

 Specifications: hypoallergenic, nitrile, powder-free, latex-free (some are too thin), standard thickness, beaded cuff, smooth with
micro-textured finish, safe grip easy downing and comfort, excellent hand fitting
 Superb tensile strength
 With left and right hand marking on gloves
Gloves  Extended use is NOT RECOMMENDED
 Double gloving is not recommended, EXCEPT in surgical procedures where there is increased risk of glove perforation
o But in settings where there is limited healthcare workers  double gloving is done
o There is no study or RCT or meta-analysis showing its benefit
o Why is double gloving utilized even if it is not recommended?
 Using a single pair of gloves put one at a theoretical risk that the organism may be transferred from the
contaminated PPE to the hands after removal of the contaminated gloves/clothing which may contribute to
infections
 Recommendations:
o When providing direct care for a COVID-19 patient and then removed followed by hand hygiene
o When doing PE
o Do not use the same pair for multiple patients  this is also the reason for double gloving in the COVID-19 areas
 The inner gloves remains while the outer gloves is used only ONCE for each patient
o Change gloves between dirty and clean tasks in the delivery of care to the patient (accompanied by hand hygiene)

KEYPOINTS
 Most personal protective equipment are designed for single use; the following PPEs may be reprocessed then reused:
o N95 mask
o Goggles
o Face shields
o Scrubs
o Coveralls
o Covered shoes
o Cotton gowns
 Reprocessing should follow the principles of cleaning and decontamination before disinfection and sterilization
 Disinfection and reuse of disposable PPE may be possible, but always be aware that the processes used may compromise the integrity of the product and impact
its effectiveness
 PPE not only protects you from acquiring infection, it is also a way for you to protect other people

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