WHO Guidance on PPE for Ebola Stresses Individual Choice

November 03, 2014

Are face shields better protection than goggles for clinicians caring for patients with Ebola?

And which works best — a disposable gown and apron, or a disposable coverall and apron?

Clinicians looking for certainty will not always find it in updated guidance issued on Oct. 31 by the World Health Organization (WHO) on personal protective equipment (PPE) for clinicians treating patients infected with a filovirus such as Ebola. In many of its recommendations, an expert WHO panel noted a dearth of good evidence.

This caveat extends to the pros and cons of heavy-duty PPE that includes full face protection, a head cover, and a particulate respirator compared with "less robust" PPE, which has come to mean a face mask, goggles, a gown, and double gloves. The panel's "systematic review yielded no comparative evidence for the different types of PPE," WHO stated.

However, the panel cited "high quality evidence" for its number-one recommendation — the need for PPE that protects the mucous membranes of the eyes, mouth, and nose from contaminated droplets and fluids of a patient with Ebola. Other essentials to prevent transmission of the virus, the panel said, are face cover, head cover, protective foot wear, gown or coveralls, and double gloves.

How to protect the eyes is a toss-up between a face shield and goggles. Here the panel noted the "very low quality evidence" for their comparative effectiveness. It pointed out some advantages of wearing a face shield, such as less fogging, a wider range of view, and more exposure of the face, "facilitating communication and interaction between patient and healthcare worker." Nevertheless, the panel said face shields and goggles were equally effective in protecting against Ebola, and choosing one or the other boiled down to user preference and local availability.

In its PPE recommendations, the Centers for Disease Control and Prevention (CDC) has come down on the side of face shields partly because they fog up less than goggles.

Giving clinicians a choice between different items of PPE is prudent as they seek a balance between protecting against infection and providing "the best possible care to patients with maximum ease, dexterity, comfort and minimal heat-related stress," WHO stated in a news release. According to the United Nations agency, the heat-related stress possible with impermeable PPE can increase the risk for accidental exposure to the virus as well as limit the time a clinician can remain in this gear.

"In most cases, there was no evidence to show that any one of the options recommended is superior to other options available for healthcare worker safety," WHO stated.

No WHO Consensus on Covering All Skin Surfaces

Two other pieces of WHO guidance accompanied by low quality evidence on comparative effectiveness involved body wear and head protection.

In the case of body wear, WHO guidelines call for either a disposable gown and apron or a disposable coverall and apron. Both items should be made with a fabric tested for resisting the penetration of blood, blood-borne pathogens, and body fluids, according to the panel's weaker "conditional" recommendation.

Likewise, the jury is out on shoulder-draping hoods that are integrated into coveralls versus stand-alone head coverings that also protect the neck. In another conditional recommendation, the WHO panel suggested a separate head covering because it can be removed separately from a gown or coverall.

The WHO guidance on PPE for Ebola care touches on the matter of complete skin coverage. This subject came to the forefront in the United States after two Texas nurses — Nina Pham and Amber Vinson — contracted the virus from Liberian patient Thomas Eric Duncan. During the first several days of Duncan's hospitalization, before his Ebola diagnosis was confirmed and healthcare workers switched to hazmat-style suits, the nurses were exposed to the patient's body fluids while wearing PPE that left some of their skin bare (Pham and Vinson recovered from their illnesses).

Soon after the nurses contracted the virus, the CDC revised its PPE guidelines to recommend "no-skin-showing" PPE whenever a hospital patient has a known Ebola infection. The CDC also recommends full coverage when an infection is suspected, but unconfirmed in an emergency room patient who is vomiting, bleeding, or having diarrhea.

The WHO panel, however, failed to reach a consensus on skin exposure. "Nine experts were of the opinion that all skin surfaces should be covered, three disagreed, and one was absent during voting," WHO said.

Don't Attach Gloves With Tape

Two WHO recommendations involved gloves, and here the panel worked with evidence of "moderate quality."

The first recommendation favors double-gloving over single-gloving. Studies show that the tactile impairment associated with double-gloving "is overcome within a few days, even when performing delicate surgery," WHO stated.

WHO advised that clinicians should wear the inner glove under the cuff of their gown or coverall, and the outer glove over the cuff. They should avoid taping gloves to their garments because that may interfere with safely removing their PPE.

In a second recommendation, the panel said that, whenever possible, clinicians should wear nitrile gloves instead of latex gloves because the former resist chemicals and some disinfectants such as chlorine, and the latter can trigger contact allergic dermatitis.

More information about the WHO recommendations is available on the agency's Web site.

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