Operational Considerations for Personal Protective Equipment in the Context of Global Supply Shortages for Coronavirus Disease 2019 (COVID-19) Pandemic: non-US Healthcare Settings

This document provides specific operational considerations that healthcare settings and healthcare authorities can review in the context of global supply shortages of personal protective equipment (PPE), to help with decision making in order to provide needed surge capacity during the COVID-19 response.

This document is organized by the type of PPE indicated for use in direct clinical care of suspected or confirmed patients with COVID-19. Medical masks, gowns and eye protection are addressed within this document, due to widespread supply shortages. Respirators are only described briefly, with references to other sources of information where available. Finally, examination gloves are not addressed within this document; the use of examination gloves should always adhere to standard IPC practice.

For each type of PPE, a brief description is provided as well as operational considerations under each of several potential strategies for scenarios of:

1. Limited supplies: where recommended PPE for direct clinical care is still available, but the supply is insufficient to enable full adherence to standard IPC practice. Strategies to conserve supplies under this scenario include:
   • Extended use: by one HCW among multiple patients with COVID-19 (one donning and doffing)
   • Reuse: by one HCW among multiple patients with COVID-19 (multiple donning and doffing)

2. No PPE available: where recommended PPE for direct clinical care is NOT available, in the context of acute supply shortages. Strategies under this scenario include potential alternatives to recommended PPE as a last resort during a crisis where standard PPE is not available.

Considerations in the context of limited supplies:

Using reusable PPE where options exist such as cloth gowns and reusable goggles.

• If this strategy is adopted:
  • Manufacturer’s instructions for reprocessing including cleaning and disinfecting should be followed and support staff augmented as needed to ensure that equipment is reprocessed after each use.
  • Systems should be established to 1) routinely inspect, 2) maintain by such means as replacing missing fastening ties, and 3) replace reusable PPE when they are damaged, such as when gowns become thin or ripped (upon which time they should be disposed).

Using PPE beyond the manufacturer-designated shelf life or expiration date for a limited time.  

• This strategy is not consistent with standard practice and therefore not recommended, but if adopted:
  • The items should be inspected prior to use to be sure they are in good condition with no degradation, tears, or wear that could affect performance.

Medical Masks

Medical masks (also known as surgical masks or medical facemasks): Medical masks reduce the transfer of saliva and respiratory droplets to others and help block blood and other potentially infectious materials from the skin, mouth, or nose of the wearer. Medical masks may or may not have some level of fluid-resistance and do not seal tightly to the wearer’s face. They have multiple layers of different nonwoven fabric materials, which are fused together. They are available in different thicknesses and with different ability to protect from contact with splashes and droplets. They are designed for single-use and will deteriorate with prolonged use, exposure to moisture and exposure to standard levels of disinfection such as chemicals, heat, and radiation.  EU MDD Directive 93/42/EEC Category III or equivalent, EN 14683 Type II, IIR, ASTM F2100 minimum Level 1 or equivalent are indicated for use for direct clinical care of patients with COVID-19.

1) Limited Supplies

Extended use: Extending use of medical masks for one HCW to use on multiple patients with COVID-19 (multiple single-rooms when seen in succession or cohort of patients) during a single shift.

• This strategy is not consistent with standard practice and therefore not recommended, but if adopted:
  • If the mask becomes moist, damaged, visibly soiled, or difficult to breathe through it should be removed using appropriate technique and disposed following local protocols.
  • If the mask is removed for any other reason such as taking a break or completing a shift, it should be disposed of following local protocols.
  • The potential number of hours of extended use would be dependent on local and individual factors such as humidity and shift length. In practice, this would likely be a maximum of six hours.
  • This emergency strategy (extended use) should be prioritized over reuse or any other approaches.

Reuse:  Reprocessing and reusing medical masks for one HCW to use on multiple patients with COVID-19 for a limited time-period (multiple shifts).

• This strategy is not consistent with standard practice and therefore not recommended, but if adopted:
  • It would be important to establish standardized methods and protocols for ensuring the effectiveness of the process and that the integrity of the medical mask is maintained after reprocessing.
  • It would be important to closely inspect the mask prior to each reuse, given that the number of times a medical mask could potentially be reprocessed is unknown, and it is expected that the masks would quickly deteriorate. Some medical masks may not be able to be reused such as those that fasten to the provider via ties (and may not be able to be undone without tearing).
  • If the mask becomes damaged, soiled or difficult to breathe through, it should be removed from circulation and disposed following local protocols.
• Note: The effectiveness of reprocessing methods to inactivate coronavirus (or other enveloped virus) on a medical mask and on preserving the integrity of the mask has not been established to date.
• Note: Many potential reprocessing methods are resource-intensive and may not be feasible in many low- and middle-income countries nor at a facility-level (Darnell et al, 2004; Feldmann et al, 2019).
• Note: See respirator section below for additional data on potential reprocessing methods for respirators.

2) No Medical Masks Available

Potential alternatives: Using 1) a face shield only or 2) a combination of a non-medical, approved fabric mask and face shield.

• This strategy is not consistent with standard practice and therefore not recommended, but if adopted:
  • It would be important to take into consideration the limited ability of face shields to fully protect against droplets and the lack of evidence on effectiveness of non-medical fabric masks against respiratory viruses (Institute of Medicine, 2006).
  • Efforts should be made to obtain standardized masks made of fabrics that are approved by national or sub-national authorities and offer some level of filtration as well as a hydrophobic outer layer to allow some level of fluid resistance.
  • Given the uncertain effect of reprocessing on the integrity of a non-medical fabric mask, the masks should be removed using appropriate technique for disposal following local protocols whenever needed such as when they become moist, visibly soiled, or damaged and upon exiting the isolation area per standard practice.
• Note: Non-medical fabric masks are not considered PPE and their ability to protect HCWs is currently unknown; some studies suggest that it may lead to a false sense of protection and even increase influenza-like illness relative to wearing a medical mask (MacIntyre et al, 2015). Caution should be exercised when considering this option.

Gowns

Gowns: Non-sterile, long-sleeved hospital gowns (isolation gowns or surgical gowns) are indicated for use for direct care of patients with COVID-19. These are available in both disposable and reusable options. Disposable gowns are generally made of a spun bound synthetic material. Reusable (washable) gowns are typically made of cotton or cotton-blend fabrics; gowns made of these fabrics can be safely laundered and reused if they are in good condition.

1) Limited Supplies

Extended use:  Extending the use of gowns (disposable or reusable options) for one HCW to use on multiple patients with COVID-19 (multiple single-rooms when seen in succession or cohort of patients) during a single shift.

• This strategy is not consistent with standard practice and therefore not recommended, but if adopted:
  • If it becomes visibly soiled, the gown must be removed using appropriate technique for reprocessing (See reprocessing guidance below) or disposal following local protocols (followed by appropriate donning of a new gown).
  • If it is removed for any other reason such as taking a break or completing a shift, the gown should be sent for reprocessing or disposed of following local protocols
• Note: this emergency strategy (extended use) should be prioritized over the use of alternatives.