# 2102
Health care workers are no doubt aware that they must follow a strict procedure when removing PPE's ( Personal Protective Equipment; gloves, gowns, mask, goggles) after having contact with an infectious patient.
There is, after all, the possibility of contaminating oneself taking off this gear.
That's why there are specific protocols established for PPE removal, as is shown in the CDC poster below.
Researchers at the University of North Carolina Chapel Hill, North Carolina and the Wake County Human Services, Raleigh, North Carolina have recently published a study in the CDC's Journal of Emerging Infectious Diseases that seriously calls into question the effectiveness of these protocols.
The link to the study is:
The rationale for this study (slightly reformatted for readability) is given below, followed by some discussion.
We evaluated a personal protective equipment removal protocol designed to minimize wearer contamination with pathogens. Following this protocol often resulted in virus transfer to hands and clothing. An altered protocol or other measures are needed to prevent healthcare worker contamination.
Caring for patients with communicable diseases places healthcare workers (HCWs) at risk. Infected HCWs may not only incur serious illness or death themselves but may spread infection to others. Methods to prevent HCW infections include vaccination (1), hand hygiene (2), and isolation of patients with communicable diseases (3).
A key aspect of patient isolation is proper use of personal protective equipment (PPE) to protect HCWs from pathogen exposure during patient care. PPE includes use of barriers (gowns, gloves, eye shields) and respiratory protection (masks, respirators) to protect mucous membranes, airways, skin, and clothing from contact with infectious agents (3).
The importance of PPE was underscored in the recent outbreak of severe acute respiratory syndrome (SARS). HCWs accounted for ≈20% of cases (4); failure to properly use PPE was a risk factor for HCW infection (5).
This outbreak raised concern that HCWs could contaminate their skin or clothes with pathogens during PPE removal, resulting in accidental self-inoculation and virus spread to patients, other HCWs, or fomites.
What follows in this study is a detailed explanation of how 10 volunteers properly donned PPE's, and then selected surfaces of these barriers were inoculated with a non-pathogenic virus.
Sites of contamination were as follows: front shoulder of gown, back shoulder of gown, right side of N95 respirator, upper right front of goggles, and palm of dominant hand.
Participants then performed a routine medical task (taking blood pressure) on a mannequin, then removed their PPE's using the CDC protocol.
The study participants were then tested to see if they had transferred this virus onto their hands, face, or scrubs.
The results are surprising.
(click to enlarge)
Ninety Percent of the volunteers ended up with detectable levels of the virus on their right hand, and seventy percent contaminated their left hand.
A full 100% contaminated their scrub shirts, and roughly 75% contaminated their scrub pants.
While contamination does not necessarily equate to infection, and there are always questions about viral load and how long a pathogen can remain viable on different surfaces, these findings clearly show that the current protocols need improvement.
The authors of this study conclude that the current protocol for PPE removal is inadequate to protect the wearer, and that new guidelines need to be developed (again reformatted for readability):
Developing and validating an algorithm for removing PPE that prevents contamination of the skin and clothes of HCWs are key to interrupting nosocomial transmission of infectious agents.
These experiments demonstrate that the current CDC algorithm is insufficient to protect HCWs from contamination during PPE removal.
However, options that might prevent such contamination do exist, including double gloving, use of surgical protocols for PPE removal, and PPE impregnated with an antimicrobial agent.
I confess that the levels of contamination found in this study truly surprised me. The PPE removal was done with the CDC chart in plain view, and without the stress, fear, and fatigue that would likely accompany an infectious disease outbreak.
So this study was conducted under the best conditions.
Above all, this study highlights the need for handwashing (or the use of alcohol sanitizer) immediately after removing one's gloves.
Double gloving, as suggested by the authors, would allow the wearer to remove the outer glove layer (contaminated in this study) before removing gowns, goggles, and masks.
Surgical PPE protocols call for tucking the gown sleeves underneath one's gloves. In this protocol for removal, goggles and mask are removed and then the gown and gloves are peeled off together, thus avoiding touching the outside of PPE's with ungloved hands.
During a pandemic, or any other infectious disease outbreak, PPE's will be vital equipment to protect caregivers. They aren't perfect, and neither are those who will don and remove them. But they can afford a high level of protection when used properly.
This study highlights the need for better protocols so that health care workers can be better protected while doing their jobs.
My personal kudos to the authors of this study, I suspect they may well end up saving some lives with this important work.
A Hat tip to Ironorehopper on Flutrackers for posting this study.
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