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Guidelines on rational use of Personal Protective Equipment (PPE)
https://www.mohfw.gov.in/

Description
Posted: Tuesday, May 19, 2020

Ministry of Health and Family Welfare Directorate General of Health Services [Emergency Medical Relief]

Novel Coronavirus Disease 2019 (COVID-19): Guidelines on rational use of Personal Protective Equipment

1. About this guideline

This guideline is for health care workers and others working in points of entries (POEs), quarantine centers, hospital, laboratory and primary health care / community settings. The guideline uses setting approach to guide on the type of personal protective equipment to be used in different settings.

2. Introduction

Coronaviruses are a large family of viruses, some causing illness in people and others that circulate among animals, including camels, cats and bats. Rarely, animal coronaviruses can evolve and infect people and then spread between people such as has been seen with MERS and SARS.

The outbreak of Novel coronavirus disease (now named COVID-19) was initially noticed from a seafood market in Wuhan city in Hubei Province of China in mid-December, 2019, has spread to more than 185 countries/territories worldwide including India.

3. Mode of transmission

There is clear evidence of human-to-human transmission of . It is thought to be

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The causative agent for COVID-19, earlier termed provisionally as novel Coronavirus has been

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officially named as SARS-CoV-2.

transmitted mainly through respiratory droplets that get generated when people cough, sneeze, or

SARS-CoV-2

exhale. SARS-CoV-2 also gets transmitted by touching, by direct touch and through contaminated

surfaces or objects and then touching their own mouth, nose, or possibly their eyes. Healthcare

associated infection by SARS-CoV-2 virus has been documented among healthcare workers in many

countries.

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The people most at risk of COVID-19 infection are those who are in close contact with a

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suspect/confirmed COVID-19 patient or who care for such patients.

4. Personal Protective Equipment (PPE)

Personal Protective Equipments (PPEs) are protective gears designed to safeguard the health of workers by minimizing the exposure to a biological agent.

4.1 Components of PPE Components of PPE are

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goggles, face-shield, mask, gloves, coverall/gowns (with or without aprons),

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head cover and shoe cover. Each component and rationale for its use is given in the following

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paragraphs:

4.1.1 Face shield and goggles

Contamination of mucous membranes of the eyes, nose and mouth is likely in a scenario of droplets

generated by cough, sneeze of an infected person or during aerosol generating procedures carried out

in a clinical setting. Inadvertently touching the eyes/nose/mouth with a contaminated hand is another

likely scenario. Hence protection of the mucous membranes of the eyes/nose/mouth by using face

shields/ goggles is an integral part of standard and contact precautions. The flexible frame of

goggles should provide good seal with the skin of the face, covering the eyes and the surrounding

areas and even accommodating for prescription glasses.

4.1.2 Masks

Respiratory viruses that includes Coronaviruses target mainly the upper and lower respiratory tracts.

Hence protecting the airway from the particulate matter generated by droplets / aerosols prevents

human infection. Contamination of mucous membranes of the mouth and nose by infective droplets

or through a contaminated hand also allows the virus to enter the host. Hence the droplet

precautions/airborne precautions using masks are crucial while dealing with a suspect or confirmed

case of COVID-19/performing aerosol generating procedures.

Masks are of different types. The type of mask to be used is related to particular risk profile of the

category of personnel and his/her work. There are two types of masks which are recommended for

various categories of personnel working in hospital or community settings, depending upon the work

environment:

1. Triple layer medical mask 2. N-95 Respirator mask

4.1.2.1 Triple layer medical mask

A triple layer medical mask is a disposable mask, fluid-resistant, provide protection to the wearer from droplets of infectious material emitted during coughing/sneezing/talking.

4.1.2.2. N-95 Respirator mask

An N-95 respirator mask is a respiratory protective device with high filtration efficiency to airborne particles. To provide the requisite air seal to the wearer, such masks are designed to achieve a very close facial fit.

Such mask should have high fluid resistance, good breathability (preferably with an expiratory valve), clearly identifiable internal and external faces, duckbill/cup-shaped structured design that does not collapse against the mouth.

If correctly worn, the filtration capacity of these masks exceeds those of triple layer medical masks. Since these provide a much tighter air seal than triple layer medical masks, they are designed to protect the wearer from inhaling airborne particles.

4.1.3 Gloves

When a person touches an object/surface contaminated by COVID-19 infected person, and then touches his own eyes, nose, or mouth, he may get exposed to the virus. Although this is not thought

to be a predominant mode of transmission, care should be exercised while handling objects/surface potentially contaminated by suspect/confirmed cases of COVID-19.

Nitrile gloves are preferred over latex gloves because they resist chemicals, including certain disinfectants such as chlorine. There is a high rate of allergies to latex and contact allergic dermatitis among health workers. However, if nitrile gloves are not available, latex gloves can be used. Non- powdered gloves are preferred to powdered gloves.

4.1.4 Coverall/Gowns

Coverall/gowns are designed to protect torso of healthcare providers from exposure to virus. Although coveralls typically provide 360-degree protection because they are designed to cover the whole body, including back and lower legs and sometimes head and feet as well, the design of medical/isolation gowns do not provide continuous whole-body protection (e.g., possible openings in the back, coverage to the mid-calf only).

By using appropriate protective clothing, it is possible to create a barrier to eliminate or reduce contact and droplet exposure, both known to transmit COVID-19, thus protecting healthcare workers working in close proximity (within 1 meter) of suspect/confirmed COVID-19 cases or their secretions.

Coveralls and gowns are deemed equally acceptable as there is a lack of comparative evidence to show whether one is more effective than the other in reducing transmission to health workers. Gowns are considerably easier to put on and for removal. An apron can also be worn over the gown for the entire time the health worker is in the treatment area. Coveralls/gowns have stringent standards that extend from preventing exposure to biologically contaminated solid particles to protecting from chemical hazards.

4.1.5 Shoe covers

Shoe covers should be made up of impermeable fabric to be used over shoes to facilitate personal protection and decontamination.

4.1.6. Head covers

Coveralls usually cover the head. Those using gowns, should use a head cover that covers the head and neck while providing clinical care for patients. Hair and hair extensions should fit inside the head cover.

The specifications for all the PPEs are at Annexure-A.

5. Rational use of PPE

The PPEs are to be used based on the risk profile of the health care worker. The document describes the PPEs to be used in different settings.

5.1. Point of Entry

S. No. Setting Activity Risk Recommended Remarks PPE

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1

Health Desk

Provide information to travellers

Low risk

Triple layer medical mask

Gloves

Minimum distance of one meter needs to be maintained.

2

Immigration counters, customs and airport security

Provide services to the passengers

Low risk

Triple layer medical mask

Gloves

Minimum distance of one meter needs to be maintained.

3

Temperature recording station

Record Temperature with hand held thermal recorder.

Low risk

Triple layer medical mask

Gloves

 

4

Holding area/ Isolation facility of APHO/ PHO

Interview & Clinical examination by doctors/ nurses

Moderate Risk

N-95 masks Gloves

 

5

Isolation facility of APHO

Clinical management (doctors, nurses)

Moderate Risk

N-95 masks Gloves

 

Attending to severely ill passenger

High risk

Full complement of PPE

When aerosol generating procedures are anticipated

5

Sanitary staff

Cleaning frequently touched surfaces/ Floor/ cleaning linen

Moderate risk

N-95 mask Gloves

 

6

Administrative staff

Providing administrative support

No risk

No PPE

No contact with patients of COVID- 19. They should not venture into areas where suspect COVID-19 cases are being managed.

5.2. Hospital Setting

5.2.1. Out Patient Department (Respiratory Clinic / Separate screening area)#

S. No Setting Activity Risk Recommended Remarks PPE

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1

Triage area

Triaging patients

Provide triple layer mask to patient.

Moderate risk

N 95 mask Gloves

Patients get masked.

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2

Screening area help desk/ Registration counter

Provide information to patients

Moderate risk

N-95 mask Gloves

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3

Temperature recording station

Record temperature with hand held thermal recorder

Moderate Risk

N 95 mask Gloves

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4

Holding area/ waiting area

Nurses / paramedic interacting with patients

Moderate Risk

N 95 mask Gloves

Minimum distance of one meter needs to be maintained.

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5

Doctors chamber

Clinical management (doctors, nurses)

Moderate Risk

N 95 mask Gloves

No aerosol generating procedures should be allowed.

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6

Sanitary staff

Cleaning frequently touched surfaces/ Floor/ cleaning linen

Moderate risk

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7

Visitors

accompanying young children and elderlies

Support in

navigating various service areas

Low risk

N-95 mask Gloves

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Triple layer medical

mask

No other visitors

should be allowed to accompany patients in OPD settings. The visitors thus allowed should practice hand hygiene

# All hospitals should identify a separate triage and holding area for patients with Influenza like illness. If there is no triage area / holding area for patients due to resource constraints, such hospitals will follow the above guidance for general OPD.

5.2.2. S. No.

2

In-patient Services

Setting Activity Risk Recommended Remarks PPE

ICU/ Critical Critical care High risk Full complement of Aerosol generating

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1

Individual isolation rooms/ cohorted isolation rooms

Clinical management

Moderate risk

N 95 mask Gloves

Patient masked. Patients stable. No aerosol generating activity.

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care
3 ICU /critical care

management Dead body packing

PPE
Full complement of PPE

activities performed.

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High risk

4

ICU/ Critical care

Dead body transport to mortuary

Low Risk

Triple Layer medical mask

Gloves

 

5

Sanitation

Cleaning frequently touched surfaces/ floor/ changing linen

Moderate risk

N-95 mask Gloves

 

6

Other Non- COVID treatment areas of hospital

Attending to infectious and non-infectious patients

Risk as per assessed profile of patients

PPE as per hospital infection prevention control practices.

No possibility of exposure to COVID patients. They should not venture into COVID-19 treatment areas.

7

Caretaker accompanying the admitted patient

Taking care of the admitted patient

Low risk

Triple layer medical mask

The caretaker thus allowed should practice hand hygiene, maintain a distance of 1 meter

5.2.3. Emergency Department

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S.No

2

Setting Emergency

Activity

Attending to severely ill patients of SARI

Risk

High risk

Risk

Low risk

Recommended PPE

Full complement of PPE

Recommended PPE

Triple layer medical mask
Gloves

Remarks

Aerosol generating activities performed.

Remarks

Driver helps in shifting patients to the emergency

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1

Attending emergency cases

Moderate risk

N 95 mask Gloves

When aerosol generating procedures are anticipated

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5.2.4. Pre-hospital (Ambulance) Services

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S. No. 1

Setting

Ambulance Transfer to designated hospital

Activity

Driving the ambulance

Transporting patients not on any assisted ventilation

Moderate risk

N-95 mask Gloves

 

Management of SARI patient while transporting

High risk

Full complement of PPE

When aerosol generating procedures are anticipated

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5.2.5. Other Supportive/ Ancillary Services

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S. No. 1.

2

Setting Laboratory

Mortuary

Activity

Sample collection and transportation Sample testing

While performing autopsy

Handling linen of COVID patients

Risk High risk High risk

High Risk

Moderate risk

Recommended PPE
Full complement of PPE

Full complement of PPE

Full complement of PPE

N-95 mask Gloves

Remarks

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Dead body handling

Moderate Risk

N 95 mask Gloves

No aerosol generating procedures should be allowed.
No embalming.

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No post-mortem unless until specified.

3

Sanitation

Cleaning frequently touched surfaces/ Floor/ cleaning linen in COVID treatment areas

Moderate risk

N-95 mask Gloves

 

4

CSSD/Laundry

5

Other supportive services

Administrative Financial Engineering Security, etc.

No risk

No PPE

No possibility of exposure to COVID patients. They should not venture into COVID-19 treatment areas.

5.3.

S. No.

Health Workers in Community Setting

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Setting Activity Risk

Recommended PPE

Remarks

1

ASHAs/ Anganwadi and other field staff

Field Surveillance

Low Risk

Triple layer mask Gloves

Maintain distance of one meter. Surveillance team to carry adequate triple layer masks to distribute to suspect cases detected on field surveillance

2

Doctors at supervisory level conducting field investigation

Field surveillance Clinical examination.

Medium risk

N 95 mask Gloves.

 

5.4
S. No. 1

Quarantine facility Setting

Persons being quarantined

Activity

Risk Low Risk

Recommended PPE
Triple layer mask

Remarks

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2

Healthcare staff working at quarantine facility

Health monitoring and temperature recording

Low Risk

Triple layer mask Gloves

 

Clinical examination of symptomatic persons

Moderate Risk

N-95 masks Gloves

 

3

Support staff

 

Low Risk

Triple layer mask Gloves

 

5.5
S. No. 1

Home Quarantine Setting

Persons being quarantined

Activity

Risk Low Risk

Recommended PPE
Triple layer mask

Remarks

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2

Designated family member

Taking care of person being quarantined

Low Risk

Gloves

While cleaning commonly touched surfaces or handling soiled linen

3

Other family

 

No Risk

No PPE required

Maintain a distance of at least 1 meter from person under home quarantine. Senior citizens in the household should stay away from such persons under home quarantine.

Points to remember while using PPE

  1. PPEs are not alternative to basic preventive public health measures such as hand hygiene, respiratory etiquettes which must be followed at all times.

  2. Always (if possible) maintain a distance of at least 1 meter from contacts/suspect/confirmed COVID-19 cases

  3. Always follow the laid down protocol for disposing off PPEs as detailed in infection prevention and control guideline available on website of MoHFW.

1.2

(medium and large)*

1.3

Personal Protection Equipment (PPE) -Specifications (forContact&Airborneprecautions)

  • Nitrile

  • Non-sterile

  • Powder free

  • Outer gloves preferably reach mid-forearm (minimum 280 mm total length)

  • Different sizes (6.5 &7)

  • Quality compliant with the below standards, or equivalent:

EU standard directive 93/42/EEC Class I, EN 455
EU standard directive 89/686/EEC Category Ill, EN 374 ANSI/SEA 105-2011
ASTM D6319-10

Coverall

  • Impermeable to blood and body fluids

  • Single use

  • Avoid culturally unacceptable colors e.g. black

  • Light colors are preferable to better detect possible contamination

  • Thumb/finger loops to anchor sleeves in place

  • Quality compliant with following standard

a. Meets or exceeds ISO 16603 class 3 exposure pressure, or equivalent Goggles

  • With transparent glasses, zero power, well fitting, covered from all sides with elastic band/or adjustable holder.

  • Good seal with the skin of the face

  • Flexible frame to easily fit all face contours without too much pressure

  • Covers the eyes and the surrounding areas and accommodates for prescription glasses

  • Fog and scratch resistant

  • Adjustable band to secure firmly so as not to become loose during clinical activity

  • Indirect venting to reduce fogging

  • May be re-usable (provided appropriate arrangements for decontamination are in place) or disposable

  • Quality compliant with the below standards, or equivalent:

    1. EU standard directive 86/686/EEC, EN 166/2002

    2. ANSI/SEA Z87.1-2010

a. b. c. d.

Annexure A

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1.

1.1

PPE Kit Gloves

1.4.

N-95 Masks

  • Shape that will not collapse easily

  • High filtration efficiency

  • Good breathability, with expiratory valve

  • Quality compliant with standards for medical N95 respirator:

    a. NIOSHN95,EN149FFP2,orequivalent

  • Fluid resistance: minimum 80 mmHg pressure based on ASTM F1862, ISO 22609, or equivalent

  • Quality compliant with standards for particulate respirator that can be worn with full- face shield

    Shoe Covers

    • Made up of the same fabric as of coverall

    • Should cover the entire shoe and reach above ankles

      Face Shield

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1.5.

1.6.

3.

4.

Triple Layer Medical Mask

Made of clear plastic and provides good visibility to both the wearer and the patient Adjustable band to attach firmly around the head and fit snuggly against the forehead Fog resistant (preferable)
Completely covers the sides and length of the face

May be re-usable (made of material which can be cleaned and disinfected) or disposable
Quality compliant with the below standards, or equivalent:

a. EU standard directive 86/686/EEC, EN 166/2002 b. ANSI/SEA Z87.1-2010

Three layered medical mask of non-woven material with nose piece, having filter efficiency of 99% for 3 micron particle size.

a. ISI specifications orequivalent

Gloves

Nitrile
Non-sterile
Powder free
Outer gloves preferably reach mid-forearm (minimum 280mm total length) Different sizes (6.5 & 7)

Quality compliant with the below standards, or equivalent:

  1. EU standard directive 93/42/EEC Class I, EN 455

  2. EU standard directive 89/686/EEC Category Ill, EN 374

  3. ANSI/SEA 105-2011

  4. ASTM D6319-10

5. Body Bags - Specifications

  1. 1)  Impermeable

  2. 2)  Leak proof

  3. 3)  Air sealed

  4. 4)  Double sealed

  5. 5)  Disposable

  6. 6)  Opaque

  7. 7)  White

  8. 8)  U shape with Zip

  9. 9)  4/6 grips

  10. 10)  Size: 2.2 x 1.2 Mts

  11. 11)  Standards:

    1. a)  ISO 16602:2007

    2. b)  ISO 16603:2004

    c) IS016604:2004

d) ISO/DIS 22611:2003

All items to be supplied need to be accompanied with certificate of analysis from national/ international organizations/labs indicating conformity to standards

All items: Expiry 5 years

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* Due to scarcity of coveralls, and risk versus benefit, that as an emergency temporary measure in larger public interest, in present given circumstances, the fabric that cleared/passed ‘Synthetic Blood Penetration Resistance Test’ (ISO 16603) and the garment that passed ‘Resistance to penetration by biologically contaminated solid particles (ISO 22612:2005) may be considered as the benchmark specification to manufacture Coveralls.” The Coveralls should be taped at the seams to prevent fluid/droplets/aerosol entry.

The test for these two standards (ISO 16603 and ISO 22612:2005), which can be performed in Indian laboratories are as per WHO Disease Commodity Package (Version 4.0)


Contact Information
Other Details
 
https://www.mohfw.gov.in/pdf/GuidelinesonrationaluseofPersonalProtectiveEquipment.pdf

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