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, 2020).

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 conjunctiva is a potential point of entry (WHO, 2020).

The willingness and morale of healthcare professionals to give their best in difficult 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, 2020).

Mask

Various types of masks can be used which includes

• FFP 2

• FFP 3

• N 95

FFP

This stands for filtering facepiece, the number next to it signifies 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 (certified 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 efficacy 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 specific materials that meet with the permeability standards set by different country wise authorities. They should have a fluid 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.

Protocol regarding wearing (Donning) and removing (Doffing) PPE CDC guidelines for,

Donning

• Identify the required PPE items according to the anticipated proximity.

• Wash hands with soap and water or use a sanitizer

• Put on the gown first

• Put on the mask next and perform a seal check

Seal check is performed by blowing out after putting the mask and checking for any points of air exit or fogging of glasses etc.

• Put on the face shield or visor

• Put on gloves last.

Doffing

• Remove gloves first (ensure it does not cause contamination of hands). Gloves can be removed using the glove in glove technique or the bird beak technique.

• 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.

• Perform hand hygiene

• Remove face shield or visor

• Remove face mask at last

• Perform hand hygiene again (CDC, 2020)

Figure 1 shows the (Beak Method, 2015) for glove removal. The glove in glove method (Shale & 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, 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,

• Avoidance of unnecessary contact with visitors or relatives of patients who might have been exposed to COVID

• Proper hand washing and personal hygiene

• Maintaining proper isolation within the hospital

• Cleaning regimens for surface disinfection at least twice a day

• Proper communication of health information via posters and so on

• Appropriate waste management

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 fit later, reduced filtration efficiency and so on.

Methods that can be used for decontamination include,

• Ultraviolet Germicidal Irradiation (UVGI)

• Microwave generated steam

• Liquid Hydrogen Peroxide

• Vaporous Hydrogen Peroxide (VHP)

• Ethylene Oxide (ETO)

• Moist Heat

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.

Conclusion

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 financial 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.

Conflict of Interest

The authors declare that they have no conflict of interest for this study.

Funding Support

The authors declare that they have no funding support for this study.