Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff

• Published in: Cochrane database of systematic reviews 2020-05, Vol.5 (5), p.CD011621
• Main Authors: Verbeek, Jos H, Rajamaki, Blair, Ijaz, Sharea, Sauni, Riitta, Toomey, Elaine, Blackwood, Bronagh, Tikka, Christina, Ruotsalainen, Jani H, Kilinc Balci, F Selcen
• Format: Article
• Language: English
• Subjects: Betacoronavirus; Body Fluids; Computer Simulation; Coronavirus Infections - epidemiology; Coronavirus Infections - prevention & control; Coronavirus Infections - transmission; COVID-19; Gloves, Protective; Health & safety at work; Health Personnel; Hemorrhagic Fever, Ebola - prevention & control; Hemorrhagic Fever, Ebola - transmission; Humans; Infection Control - methods; Infectious disease; Infectious Disease Transmission, Patient-to-Professional - prevention & control; Lungs & airways; Occupational health outcome; Odds Ratio; Pandemics - prevention & control; Personal Protective Equipment; Pneumonia, Viral - epidemiology; Pneumonia, Viral - prevention & control; Pneumonia, Viral - transmission; Protective Clothing; Respiratory Protective Devices; SARS-CoV-2; Severe Acute Respiratory Syndrome - prevention & control; Severe Acute Respiratory Syndrome - transmission
• ISSN: 1469-493X; 1469-493X
• DOI: 10.1002/14651858.CD011621.pub5

In epidemics of highly infectious diseases, such as Ebola, severe acute respiratory syndrome (SARS), or coronavirus (COVID-19), healthcare workers (HCW) are at much greater risk of infection than the general population, due to their contact with patients' contaminated body fluids. Personal protective equipment (PPE) can reduce the risk by covering exposed body parts. It is unclear which type of PPE protects best, what is the best way to put PPE on (i.e. donning) or to remove PPE (i.e. doffing), and how to train HCWs to use PPE as instructed. To evaluate which type of full-body PPE and which method of donning or doffing PPE have the least risk of contamination or infection for HCW, and which training methods increase compliance with PPE protocols. We searched CENTRAL, MEDLINE, Embase and CINAHL to 20 March 2020. We included all controlled studies that evaluated the effect of full-body PPE used by HCW exposed to highly infectious diseases, on the risk of infection, contamination, or noncompliance with protocols. We also included studies that compared the effect of various ways of donning or doffing PPE, and the effects of training on the same outcomes. Two review authors independently selected studies, extracted data and assessed the risk of bias in included trials. We conducted random-effects meta-analyses were appropriate. Earlier versions of this review were published in 2016 and 2019. In this update, we included 24 studies with 2278 participants, of which 14 were randomised controlled trials (RCT), one was a quasi-RCT and nine had a non-randomised design. Eight studies compared types of PPE. Six studies evaluated adapted PPE. Eight studies compared donning and doffing processes and three studies evaluated types of training. Eighteen studies used simulated exposure with fluorescent markers or harmless microbes. In simulation studies, median contamination rates were 25% for the intervention and 67% for the control groups. Evidence for all outcomes is of very low certainty unless otherwise stated because it is based on one or two studies, the indirectness of the evidence in simulation studies and because of risk of bias. Types of PPE The use of a powered, air-purifying respirator with coverall may protect against the risk of contamination better than a N95 mask and gown (risk ratio (RR) 0.27, 95% confidence interval (CI) 0.17 to 0.43) but was more difficult to don (non-compliance: RR 7.5, 95% CI 1.81 to 31.1). In one RCT (59 participants) coveralls were mor