PPE Use (What, Who, Why, When, and How) – Session Materials

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Date of session: 05/30/2023

Facilitator

Aufra C. Araujo, PhD

Centers for Disease Control and Prevention

DLSbiosafety@cdc.gov

Didactic Speaker

Peter C. Iwen, PhD, D(ABMM), F(AAM)

Director

Nebraska Public Health Laboratory University

piwen@unmc.edu

Aufra Araujo: Good afternoon, good morning, and good evening, everyone. My name is Aufra Araujo, and I want to extend a warm welcome from the Centers for Disease Control and Prevention in Atlanta, Georgia. I am a PhD Health Scientist in CDC’s Division of Laboratory Systems, and I am the facilitator for this Extension for Community Healthcare Outcomes, or ECHO, Biosafety session.

Thank you for joining our fifth session. The topic for this interactive discussion is PPE, Personal Protective Equipment. You are familiar with it. So we are going to talk about PPE Use – What, Who, Why, When, and How. Our subject matter expert is Dr. Peter Iwen, the Director of the Nebraska Public Health Laboratory.

Alright, during our session today, we would love to have all of our participants turn on their cameras, but we understand if you are unable to do so. One of our goals for the ECHO Biosafety Project is to build a community of practice and increase networking between biosafety professionals. Putting on cameras help with putting name and face together.

So for this now, I would stop sharing, and I’d like to have a quick icebreaker. Let’s see. We are just coming back from a holiday weekend here in the U.S. I say here in the U.S. because we may have few folks attending this meeting from overseas. But we just came back from Memorial Day weekend. And you all know by now I love to see your faces and ask the question.

The question today is, have you traveled recently? How far have you traveled, how many miles, to where? Do you wish you were still there? So if you were so inclined, turn on your camera, open your mic, and share away with us.

Maybe I would start sharing while you were building courage to turn on your camera or unmute, or entering– you can also add in the chat your answer. I just came back from Brazil two weeks ago. And now you know my accent. I’m originally from Brazil. I just came back from Sao Paulo, and I was visiting with my sister there. So I don’t know. I’m very competitive. I may be the one who traveled the farthest away from Atlanta all the way to Sao Paulo. Let me know in the chat, or open up your mic, turn on your camera, and share with us.

Peter Iwen: I’d be curious to know if anybody participated in the APHL, the Association of Public Health Lab, meetings in Sacramento just recently.

Aufra Araujo: Yeah, that’s another interesting question. If you traveled to APHL, have you participated at the meeting? Alright, woo, bicycle ride, about 25 miles. That’s Joyce. Wow, that sounds exciting, Joyce.

Nick Crosby: So this is Nick from Utah Public Health Lab. I did go to APHL, and then as soon as I got back, I had to pack up and got to go to Southern Colorado for a nice little national park vacation.

Aufra Araujo: Oh wow, sounds awesome. Thanks for sharing, Nick. Cool. Anybody else? Drove– who is that– Bobbie drove from Connecticut to Maine to dig a well. Wow. Do you wish you were still there, Bobbie, digging a well?

Bobbie Macierowski: No, I do not wish that. There’s still more to go. Very rocky.

Aufra Araujo: Wow. But that sounds like fun for a weekend or something.

Bobbie Macierowski: Yeah, it was good. Hard work is good. Thank you.

Aufra Araujo: Alright, thank you. Erin– oh, Erin was at APHL, as well, traveling from Wisconsin to California. Awesome. Anybody else? Come on, here in the room. I know George traveled. Yeah. Sabrina, you can share. You are the closest one, I guess.

Sabrina DeBose: Yeah, I traveled downtown Atlanta to the Jazz Fest. That was exciting.

Aufra Araujo: Jazz festival is exciting. Well, alright. Let’s go back to sharing the screen here. What happened? Thank you, everyone, for participating so we get to know one another and learn more about each other. Before we proceed, I want to briefly mention some technical details related to our ECHO Biosafety session.

Please use the video capabilities of whatever device you are using for this session as much as you can. All audience microphones are now muted. During the discussion, please unmute yourself to speak. If you are experiencing technical difficulties during the session, please send a private message to George Xiang, who is labeled as CDC ECHO Tech. He will do his best to respond to your issue as they may arise.

If you are connecting to Zoom by phone only at the time of discussion, please announce yourself by name and institution when beginning to speak. Briefly, how do these ECHO sessions differ from other presentations? These sessions are different from webinars in that the main feature is the discussion of case or clinical laboratory challenges.

Our subject matter experts hope to share some solutions that are translatable to all of you in your individual laboratories. We encourage your participation in the discussion by sharing your knowledge and experience. Each laboratory is unique. Your skill set is also unique. So please contribute to the discussion.

Here is a brief overview of today’s session. I will introduce our subject matter expert, Dr. Peter Iwen, who will provide a didactic presentation and real case discussion. Then Commander Sabrina DeBose, from the CDC Division of Laboratory Systems, will summarize today’s discussion. Closing comments and reminders will follow, and we will adjourn this session.

Today’s session is being recorded. If you do not wish to be recorded, please disconnect now. Closed captioning is provided for this session. Please find the link in the checkbox. Alright, now to the best part.

Now it’s my pleasure to introduce Dr. Peter Iwen. Dr. Iwen is a clinical microbiologist with an undergraduate degree in Bacteriology from North Dakota State University in Fargo and both master’s and doctoral degrees in Infectious Diseases and Molecular Diagnostics from the University of Nebraska Medical Center. In addition to directing the Nebraska Public Health Laboratory, he is a professor in the College of Medicine and campus Senior Biosafety Officer at the UNMC. He also co-directs an American Society for Microbiologists Committee on Postgraduate Educational Programs, or CPEP. This is a training fellowship for postdoctoral students. His research focuses on the development and evaluation of diagnostic assays for the identification of microbial pathogens. Alright, Dr. Iwen, the floor is yours.

Peter Iwen: Thank you, Aufra. My pleasure to be here. And, of course, let’s come from a vacation holiday and jump right in, right? So we’re going to be talking about a topic today that most of us probably have a fairly decent amount of information available to them. I’m just going to kind of add in the high points.

What we’re going to do today is I’ve made my session a little bit different than probably some of the previous other sessions in that I’ve added knowledge-based questions throughout my presentation. So you’re all going to be able to participate. And I will continue the discussions according to how the questions are set up as we go through this. So next slide, please.

So you get the title: Who, What, Why, When, and How for PPE. Next slide.

So the learning objectives here first to identify biosafety practices associated with the use of PPE as it pertains to laboratory safety. The second bullet there is to examine biosafety concepts pertaining to the appropriate use of PPE. There’s a right and wrong use process for PPE that we need to consider as we talk about this discussion. And then be able to describe alternative methods for the use of PPE, applying the risk assessment process. Next slide, please.

So here’s what. What is PPE? Next slide.

We’re going to get our first knowledge-based question. Question number one. Are we going to be able to pull it up, Aufra? OK, so what best describes PPE? So put, hit your answer here, and we’ll just see if we’re all in the same pages of what is PPE. We’ll give you just a few seconds to answer this. Hit submit when you hit your right answer that you think is right.

Well, I think we pretty much all know what PPE is. Any piece of protective clothing or equipment that is worn. I thought some people might just click respirator and leave it at respirator. The biosafety cabinet, well, that wouldn’t be a correct answer. But anyway, any piece of protective clothing or equipment would be the answer for PPE. Next slide, please.

So there’s the answer. Alright, everybody pretty much got this one right. Next, let’s go on to the next slide.

Got another question to ask. Here’s the answer for the first question. Next question, please.

Oh, we got a picture. I forgot I put a picture in here. So ten items used in personal protective equipment.

Some of these probably would not pertain to a laboratory, but clothing, certainly. Respiratory protection equipment, eye and face protection, head protection not so much. I don’t think we got things falling on our head when we’re working in the clinical lab. Maybe hearing protective devices.

I don’t think we need a harness in most cases. Skin protection, certainly. Maybe in a higher level of containment, you would have protective footwear, booties, for instance. Hopefully, you’re not working out in the sun in your laboratories but disposable protective clothing. So this kind of gives you an overview of what is, according to OSHA, what is protective equipment. Next slide, please.

So we have another question to ask. PPE is considered a point of contact safety control measures since PPE is it the first line of defense to prevent exposure? Does it reduce the likelihood of exposure to the hazard since the hazard is not able to be removed? When properly used, does it eliminate the hazard? Or can remove any given hazard before a laboratory comes in contact, or is it considered the primary containment in most situations? So what answer do you think pertains to this question?

So the correct answer is B, reduces the livelihood of exposure to the hazard since the hazard is not able to be removed. Many of you picked A, is the first line of defense to prevent exposure. One person picked D. I’m glad no one picked E because it is not considered the primary containment in most situations. Let’s go on to the next slide.

So basically, a point of contact control means that the hazard is not able to be removed. There is a hazard. And what PPE does is it reduces the likelihood of exposure to the hazard, but it does not eliminate the hazard, and it is considered a secondary containment under most circumstances. Now, there are some exceptions. Next slide, please.

And I’ll show you some exceptions of where it might be considered the primary barrier of containment. So if you look at the 6th edition of the BMBL, it does give some description of what PPE is under the standard microbiological practices and also under the safety equipment sections for the different laboratory levels of containment.

The exception of PPE as a primary barrier might be in cases where there’s fieldwork, where you can’t put your work within a primary containment, such as a biosafety cabinet, certain animal studies, animal necropsies, activities related to operations, maintenance, services, and support of lab equipment facilities. I just want to talk a little bit about that part because we all have service contractors.

We do service on our equipment, for instance, in the laboratory, and we have people come from the manufacturers working on equipment. And that would be considered, in many cases, a primary barrier of protection when these people work on our instruments within the laboratory. Or you might have somebody come into your lab and work on the facility itself. So that would be the exception to the rule as a primary barrier. But in most cases, PPE is secondary. Next slide, please.

I just wanted to give you some scenarios of secondary containment, PPE, and patient care about containment units. You may recognize that there are these biocontainment units out there now where they care for patients that has a high-consequence pathogen. This is my staff, as we worked in one of these units in the laboratories that were associated with the unit. And you might notice here that the PPE that is being used might be a little different than what we might use, for instance, in a level 2 laboratory. It might even be a little bit different than what you use in a BSL-3 laboratory.

You will notice here that we have disposable gowns, wrap-arounds. We have our masks. We also have head protection. You’ll notice that the gloves are taped on with duct tape. Duct tape has a lot of uses, by the way. In this case, we were double-gloved. You can’t see it, but we also had scrubs underneath our gowns. And we also used rubber clogs on our feet that were actually decontaminated, and we did shower out from these units. So this is a little higher protection, using personal protective equipment. Next slide, please.

This is a scenario from our microbiology section of our public health lab. And we do use, in many circumstances, BSL-3 practices in BSL-2 containment facilities. The personal protective equipment here is typical that you might see in a BSL-3 laboratory with a respirator, double gloved, wraparound gowns. We are actually in the laboratory here processing samples for SARS-CoV-2. Early on, we used– we still do today– use BSL-3 practices to process our specimens. We do use this laboratory also to process specimens that might contain West Nile virus, such as our mosquito processing. We also use it for processing samples that might contain monkeypox virus. This is a BSL-2 lab using PPE that has BSL-3 practices. Next slide, please.

We do not have available to us a BSL-4 laboratory in Omaha. But I have gone and done training in a BSL-4 laboratory. That’s me wearing this full body, air-supplied positive pressure suit. Fortunately, we do not have these labs in Nebraska, which I’m glad we don’t have to pay and keep these facilities going.

But this is another type of PPE that could be worn under circumstances that put you at high risk to risk group for pathogens, for instance. So this is just an example for that. Moving on to the next slide, I have another question to ask.

This is more the regulatory side of PPE. And the question is, which one of the following requires both NIOSH certification and FDA clearance?

And we have the five answers there. Is it surgical face mask, filtering facepiece respirator, a PAPR, a cloth covering, or none of the above? And the answer is B, a filtering facepiece respirator. Surgical face mask, PAPRs, cloth coverings, none of the above, none of them have this requirement for both NIOSH and FDA clearance. Now I want to just emphasize one thing here also is that I’m one of the people that thinks this way, but we call things that are not as highly protective masks, such as a surgical face mask. While we call the N95 as being technically a respirator. Moving on to the next slide, we’ll talk a little bit about what is NIOSH and what is FDA clearance.

NIOSH stands for the National Institute for Occupational Safety and Health. NIOSH was established by the OSHA basically as a research agency, and it does conduct research and makes recommendations to OSHA, and it is governed by the CDC.

So NIOSH basically recommends best scientific practices. And you will see on masks that are sold sometimes, or the laboratory, as saying NIOSH approved. OSHA, on the other hand, stands for Occupational Safety and Health Administration. This is governed by the Department of Labor, and they make requirements that are set by law. So the masks that we use are both approved by NIOSH and OSHA in the clinical laboratories. Next slide, please.

So what is the difference between an N95 surgical respirator versus an N95 standard respirator? Well, they are very similar in appearance. Both can effectively filter airborne biological particles if and when they’re properly worn. The key difference between these two is that the surgical N95 respirator is fluid resistant. And it is fluid resistant technically through the number of layers of filtering matrix that is present on those respirators.

The surgical N95 is sterile. Not all standard N95s are sterile. And, of course, the cost. Surgicals are much higher priced than the standard in N95 respirators. But both are highly protective, and both can be used in the clinical laboratory. Next slide, please.

This is just explaining what an N95 mask is all about. It removes 95% of 0.3+ micron particles. Just wanted to make a point here to say that most viruses, or all the viruses that I’m aware of, are much smaller than 0.3 microns. More in the reference, the largest virus that I’m aware of is the pox virus at 0.25 microns. So how are these protective against viruses?

Well, we think of virus transmission as either being in a droplet or an aerosol, which are much, much larger. This will protect you against any of the bacteria, however. Some of these respirators have valves that helps reduce breathing resistance. Not all of them do. I don’t think any of the masks that we use in our laboratory actually have these breathing-resistant valves associated with them. And the material is tough, but it’s flexible.

The N is a letter class that stands for non-oil, meaning that if you’re using non-oil-based particles present, then you can use this mask. There is a mask that has a rating that’s called R, that is resistant to oils. And P, that is oil-proof. Most of us would use an N95 in the labs.

Masks ending in 95%, of course, have this 95% efficiency. There are masks that have a 99% efficiency as well. And there are also masks that have 100%, considered 100% efficiency. That is the same as a HEPA quality filter. Again, the cost of these gets to be very prohibitive for the laboratory since you really don’t need this quality of a mask. And the 0.3 microns, again, filters out most of the particles, large droplets that we would encounter in the clinical laboratory as protection. Next slide, please.

Another question. All of the following are OSHA standards that employees should adhere to prevent a work exposure to illness except. This might be a little more of a tricky question. So thinking of the OSHA standards, the 1910 standard, if you were to read it. It’s a pretty long document. Which of these would really not be found in the OSHA standard?

Well, the correct answer is E, the Select Agent Standard. OSHA standards do have a PPE Standard listed. They do have a Respiratory Protection Standard. Most of you were aware of that. Bloodborne Pathogens Standard, most of you were aware of that. And there is a General Duty Clause I’m going to talk about here in a moment in OSHA standard.

Select Agent Standard, that would be more associated with the 42 CFR Part 73 document, a code of federal regulations dealing with select agents. So the answer is the one that is not in OSHA is the Select Agent Standard. Next slide, please. We’ll talk a little bit about the General Duty Clause that’s in OSHA.

And this basically is a pretty much catch-all that says that each employer shall furnish to each employee a place of employment which is free from recognized hazards that are causing or likely to cause death or serious physical harm to employees. For instance, they are to supply personal protective equipment. Next slide, please.

And this does talk about, this is the document, the standard part of OSHA that talks about personal protective equipment at the bottom there, including equipment for eyes, face, head, and extremities, clothing, respiratory devices, shields, and barriers shall be provided, used, and maintained in the laboratory. And again, this is the employer that needs to supply this. The employer also needs to supply a method for fit testing. So next slide, please.

So fit testing– again, this is the OSHA standard– must be performed initially before the employee is required to wear the respirator in the workplace and must be repeated at least annually. And it gives examples of conditions at the bottom which would require additional fit testing. If there were some changes, for instance, in the facial structure through weight loss, cosmetic surgery, facial scarring, installation of dentures, et cetera. So there are times when annual is– you need to do it more often. Alright, so at least annually. Next slide, please.

So what about this fit-testing process? Well, there’s two ways to do it. One would be through a qualitative method dependent on the wearer’s senses. I know the one that we have used here at our clinic and hospital and public health lab was always the taste one for saccharin. There is an odor threshold one. But OSHA does not recommend using irritant smoke tests anymore for doing these qualitative tests.

More recently, we have gone to a quantitative fit testing method using a controlled negative pressure apparatus, where you do bending and talking and head side-to-side, head up and down, et cetera. I might mention that many of the smaller clinical laboratories out in rural Nebraska, for instance, do not have access to fit testing processes, and it is very difficult for them to get this process done.

And it is also even difficult for us at the university because we have to have people come in on a monthly basis because of the annual processing of the staff, and it becomes a real issue for us to deal with. Alright, next slide.

I just had to throw this in. I’ve almost memorized this rainbow passage. But interestingly, you read this, it’s something that you read while going through the fit testing quantitative process. And it basically is considered a phenotypically balanced passage that reflects the sound and mouth movements of a person speaking English. That’s why this rainbow passage is used. I probably have said this a dozen times over the years during fit testing. But you think you’d memorize it. But anyway, I’m still looking for the pot of gold at the end of the rainbow, just to let you know that. Alright, moving on next slide, please.

Just a little bit about powered air-purifying respirators. This is a CDC NIOSH document. I know the printing is small. But it talks about, at the very bottom, these reusable components, replaceable filters or cartridges that you can include, the batteries that you include. They do provide eye protection. They do have low breathing resistance. They are loose-fitting.

And we do have people in our laboratories, in our level 3 laboratories, for instance, that do use PAPRs. One of the nice things about PAPRs is technically, you don’t have to undergo a fit testing for a PAPR, for our folks, anyway. People that want to have beards, for instance, can wear a PAPR. And the low breathing resistance means that you technically don’t need to do a medical evaluation during this process of wearing a PAPR.

I want to mention during the fit testing process that there is a medical evaluation done. OSHA does have a questionnaire. It’s called the OSHA Respiratory Medical Evaluation Questionnaire that can be filled out during the fit testing process that we fill out. It’s about six pages long. And that’s what we fill out before we get the fit testing process done. So there is a mandatory requirement when you get fit tested to go through an evaluation process, as well. Alright. Next slide, please.

Seven steps to correctly wear a respiratory respirator at work. This is from OSHA, just a document. One of the things we like to include– and I have some more slides to show you this– is we like to have visual images of the how and why, how to wear and how to take off our respirators in the laboratory. This is just giving an example. And I wanted to show you this, the importance of making sure, when you put on the respirator, that you make sure that it’s fitting properly and that your breathing points are all closed, and you’re not getting air coming through the sides and the top of the respirator. Alright, next slide, please.

So this is a question I just threw in because I know we’ve had this issue come up with our clinical labs during the time of the pandemic, where there was a shortage of N95 respirators. And people started using what was known as this KN95 respirator. What is the difference between N95 and KN95? Well, the difference between these respirators is the certification.

Technically they’re the same respirator. They filter out 95% of the particles. N95 is the U.S. standard, and the KN95 is the China standard. Only N95 respirators are approved for health care use in the U.S. if you’re working in health care environment. I know many of the clinical labs started using public health labs, as well, started using the KN95. Keep in mind that the KNN95 respirator has many of the same protective properties as N95. And they are acceptable to be used in, for instance, private clinical laboratories and in the public health laboratories. Alright, next slide, please.

OK, what about the who PPE? Next slide.

Who is responsible? I’ve already mentioned that your employer is responsible to provide you with PPE supplies to meet OSHA standards. And this is the regulation right here. It says, in red, it says the protective equipment, including personal protective equipment used to comply with this part of the guidance law, shall be provided by the employer at no cost to the employees.

But there’s also a side to this that you, the employee, is responsible for wearing the PPE appropriately. So it says here in the document, it says that each employee shall comply with Occupational Safety and Health Standards and all the rules, regulations, et cetera, pertaining to this OSHA act. So your employer supplies it. You are responsible to wear it appropriately. Alright, next slide.

We’re going to talk about the why is PPE important. And I have another question coming up. The question is when establishing controls in the laboratory to decrease hazards, which comes first– substitution, elimination, engineering controls, administrative controls, or PPE? So we’re talking about the hierarchy of controls here. Which comes first?

And most of you pick this one right, too. It is elimination. Engineering controls might pertain to, for instance, your biosafety cabinet. Administrative controls might pertain to your standard operating procedures. And PPE, personal protective equipment, is actually the last of these different hierarchy of controls. Next slide, please.

Well, this is an image from NIOSH showing you the hierarchy of controls from most effective to least effective. Elimination means physically remove the hazard. Get rid of it completely if you can. Alright, and if you can replace the hazard, great. Come up with an alternative. An example here might be working in, for instance, a student teaching laboratory using organisms that are nonpathogenic, for instance, in the laboratory.

Engineering controls isolate people from the hazard. This would be your primary containment, such as a biosafety cabinet. But we do recognize that sometimes, especially in our smaller laboratories, they may not even have biosafety cabinets. Administrative controls change the way people work. When we worked with samples from patients who had Ebola virus, we made sure that we didn’t handle needles and syringes, for instance.

In many cases, we just didn’t need to handle them in the clinical laboratory. Made sure that the blood culture bottles, for instance, were plastic and not glass, et cetera. But the least effective is actually protecting the worker with the personal protective equipment. That’s the last line of defense. It’s not the first. It’s the last line of defense. Next slide, please.

These hierarchies of control really get into what is a hazard versus what is a risk. And hazards talk about the potential source of harm. And we think of a hazard as either being a chemical, biological, physical, procedural, no BSC. You could put in here radiological. So these are the sources of harm. While the risk refers to basically the chance of getting harmed. In other words, what is the probability of the harm? What is the severity of harm? Severity of the harm, you might think of what is the risk group classification of the organisms that you’re working with.

Because then that talks about biosafety levels of containment, for instance. The hazards, hazard communication, is really the OSHA standards when we talk about the different levels of hazards. Next slide, please. Got another question for you.

We can’t talk about personal protective equipment prevention of laboratory-acquired infections. We really need to bring that up as we talk about PPE. And the following are all important to prevent laboratory-acquired infections except– good laboratory design, good laboratory practice, prevent aerosol production, required vaccination of all employees, proper disposal of infectious waste, or all of the above. Which one is the exception?

Well, the exception, the correct answer is B. F could be close, as well. The requirement for vaccination of all employees. That’s probably a hot-button topic. Requiring, for instance, your employees to be vaccinated against COVID became a huge issue for many facilities. We at our facility here in Nebraska don’t have a requirement for vaccinations. Go on to the next slide, please.

We figure it’s very difficult to make people get vaccinated against certain agents. The Institutional Biosafety Committee at my university offers immunizations where appropriate. But we do require that if a person refuses to be vaccinated, such as for Hep B or for SARS-CoV-2, influenza would be another one. We have Neisseria meningitidis, which is another one. We do offer it free to the employees that are at risk. But if they refuse to take the vaccine, we make them sign a vaccine declination statement saying, I’ve been offered the vaccine, but I refuse to take it.

So I don’t know. Institutions, I’m sure, vary on this question. But in many cases, there is not a requirement for vaccination. But there’s a recommendation for vaccination. Next slide, please.

I’m sure we could make that a topic of discussion. When should PPE be used? Another question, question seven. Next slide, please.

I hope you all get this one correct. An employer is required to assess the workplace to determine if a hazard necessitating the use of PPE is present or likely to be present only if an injury occurs. True or false. Well, the answer is false. Assessing the workplace, the risk assessment process should be done probably as an ongoing basis, but at least annually. So next slide, please.

So who is required to perform the risk assessments to determine the need for PPE? And again, this is an OSHA requirement. Employer must certify, in writing, that a workplace hazard assessment has been completed as required in 1910.132. And I would say that many of us are well aware of the risk assessment process and how it’s done. Identifying the hazard. Determine who’s at risk. Evaluate the risk. Determine the controls. Implement controls. And then doing an ongoing review and update as necessary.

So you don’t just do this once and stop. You continually do these things. You put a new test in your laboratory; you need to do a risk assessment process. Putting this in writing sometimes is something that is not always intuitive to do. We, in our facility, actually put in the PPE requirements into our SOPs for the various testing. So that is our written documentation that an assessment has been done, and that’s the process that we use. Next slide, please.

Training. There’s also a training requirement. Personal protective equipment-related training must cover the following items except– when and what kind of PPE is necessary, how to properly don, doff, adjust, wear, and maintain PPE, how to properly dispose of the PPE, the limitations of the PPE or the brand name of the PPE. What do you think is the best answer here?

Well, OSHA’s going to provide an answer again. And the answer, most of you got this correct, is the brand name of the PPE. Knowing what the PPE is, the brand name, is important from an individual standpoint. You might only be able to wear a certain brand name of PPE. But it’s not from the whole laboratory standpoint. Next slide, please.

So OSHA actually has this written training– when is PPE necessary, what PPE is necessary, how to properly don, doff, adjust, and wear PPE, and why to include limitations of the PPE and the proper care, maintenance, and useful life and disposal of the PPE. So it’s written out. Next slide.

We’re going to do one more question here. I think we got a couple more, I guess. Evaluation of safe work practices to include the use of PPE should be done when? When should it be done? Only after an exposure incident, at least annually, when CLIA is going to be on-site for an inspection, semi-annually, not required. What is the correct answer?

So workplace practices evaluation how often? Well, most of you got this correct, too– at least annually, at least. Meaning that it can be done more frequently under certain circumstances but at least annually. Next slide.

We’re on the last part of this. How should PPE be used? Question number ten, next question.

We’re going to talk about doffing, donning and doffing. What would be a typical sequence for donning PPE? While we’re talking about how should you put on gowns, face shield, gloves, respirator – what’s the proper sequence?

And we’re going to then ask another question about doffing PPE. What would be the proper sequence? So putting on PPE, again, we’re going to go to a visual here. Well, E is the correct answer– gown, respirator, face shield, gloves. There’s a little bit of question about what order people use in maybe their facility. Next slide.

And again, we like to use visuals, having these in the laboratory. Hand hygiene is a good part, is a very important part of this, as well. Putting on the gown, putting on your respirator, putting on your eye protection, putting on your gloves– one pair or double pairs, depending on what you have as your risk assessment process. Next slide, please.

And making sure when you put on your respirator that there’s no gaps, the face mask fits properly. I think you can pretty much figure out when your face mask doesn’t fit properly, especially if you’ve got eye protection on or wear glasses and they fog up, and you can’t see what’s going on. That’s an interesting process, as well. So next slide, please.

Question 11. What would be the typical sequence for doffing or taking off your PPE? Again, I will expect there to be some differences in here. Correct answer is C– gloves, face shield, gown, respirators. There’s a little bit of a difference here in what process might be used in their facility. Next slide.

Again, I think the important part is having a visual. Taking off gloves, eye protection, gown, respirators last. Alright, and then, of course, the very last is washing your hands– hygiene, hand hygiene.

Alright, final question, question number 12. And then, we’re going to get into some further discussion questions. What is the standard for how long a single pair of gloves can be used? And again, this is a standard, And this certainly could vary a lot depending on your facility– two, three, or four hours, remove only if contaminated, until the task is completed, wearing them all day. Wow, that’s pretty tough. I don’t think that’s the one that works for me. What do you think? And I’m looking for a standard.

And you could say, by the way, that you might be double-gloved, and you might be removing one pair. But the inner pair, how long should you be able to wear the inner pair of gloves? And the standard is actually, OK, two. I don’t think there’s a right or wrong answer here– three, four, remove only of contaminated. OK, until the task is completed, alright. The documents I’m reading say about four hours is the standard. But this could vary all over the place.

And I’m thinking if you’ve ever worn gloves for four hours, you know what it feels like to wear gloves for four hours if your hands sweat. It gets very uncomfortable. Next slide. I think we’re going to go into some group discussion questions.

Sabina, are you going to be leading this part of the discussion? We can go on to the next slide. I’m happy to lead this. These questions here are meant for us to discuss as a group. There is no right or wrong answer to any of these, Aufra.

Aufra Araujo: Yes, Peter, please lead the discussion.

Peter Iwen: I’d be happy to do that. I’d be interested, this topic here has come up quite a bit with the pandemic. But the question is, describe which barrier would be most likely to occur in your institution to the adherence to wearing personal protective equipment. What’s to prevent you from wearing personal protective equipment? Supply shortage, the inability to get fit tested, the lack of education and training, peer pressure, your laboratory colleagues aren’t wearing it, I’m not going to wear it, or the lack of dexterity. Wearing double gloves, for instance, is cumbersome when you’re trying to do technical details with your hands.

I’d be interested to know what would be the most likely for your institution and welcome any comments that you might have.

Aufra Araujo: So now, everyone, please enter your answers in chat or, even better, unmute and turn on your camera and share your thoughts.

Peter Iwen: I’d be interested to know issues that people had during or still have during the pandemic. Joyce says lack of dexterity. Well, I can go along with that one, especially when you get into your level 3 facility, and you got all of this stuff on, and you’re trying to work in a biosafety cabinet. It is difficult. It is difficult. Other thoughts? Chelsea says lack of dexterity, as well.

Anna Liddicoat: Hi Peter, this is Anna Liddicoat in North Carolina. I have a comment. One of the things that I noticed not only within my own laboratory but in sentinel labs that I’ve visited and in other laboratories that I’ve worked, in safety glasses, eye protection is a big one. A lot of institutions have either very strict policies on eye protection or it’s kind of very lackadaisical. So–

Peter Iwen: I get it. I get it.

Anna Liddicoat: And I think a lot of that could be peer pressure. They see their counterparts not wearing eye protection, and so they don’t wear it. I also see kind of supply being an issue. People wear glasses, and so they can’t necessarily find eye protection that fits over their glasses. So it’s a couple of different things. And it’s something that we actively try to work on. And we’ll look at our risk assessment and say, do we need eye protection? And we want to get to the science of it, as well.

Peter Iwen: Yeah. And I think maybe, Anna, you could respond to this, as well. But people get a false sense that if you’re working in a biosafety cabinet, your eyes are protected.

Anna Liddicoat: Yes. I think there is definitely some of that going on, as well. They see that dash, and they’re like, I have the barrier.

Peter Iwen: Right. And if you’ve never had anything splash up from underneath the biosafety cabinets, it’s happened.

Anna Liddicoat: Sure.

Peter Iwen: So, other thoughts anybody else want to share? I could share that the fit testing, especially in these frontline laboratories that we deal with in rural Nebraska, do not have access to fit testing processes, which makes it very difficult. Supply shortages is certainly an issue for them, as well. Other thoughts.

It’s probably all the above is what I’m thinking that we all deal with, or certain laboratories deal with these issues. Let’s go on to the next slide.

Given the limited resources of N95 masks early in the COVID-19 pandemic, what percent of the time did you extend the use of or reuse the respirator? Or did you not ever have to reuse your respirators? Did you have enough available? I’d be interested in people’s thoughts.

Chelsea says never. Anybody– how many of you folks actually ended up reusing respirators? You could put a thumbs up if you have. Kalpana says greater than 40% of the time. Alright, so we went from one extreme to the next. Michael says zero.

Let’s go on to the next question because that’s going to add to this discussion, I think. What would you consider the greatest adherence to reuse of a respirator? Storage, you could go to D and say no place to safely doff, so you take it off. What are you going to do with it? The integrity of the respirator. And I’ll be interested, Joyce, when you say integrity, what kind of issues did you have trying to reuse the respirator? Any thoughts?

OK, we didn’t reuse, but they will misshapen. I agree. I think the issue for us, because we did reuse some of our respirators in our clinical lab in the public health lab, was that the strap would break. That strap doesn’t– taking it on and off, it doesn’t last very long. Manufacturer– well, manufacturer says these are single-use. Guess what? Now we’re using them over and over again.

No decontamination process, well, sure. We started, I know, reusing masks in our patient care biocontainment unit. But we were actually processing them through an ultraviolet light process. If you don’t have masks, you don’t have masks. You’ve got to come up with something to be able to use them. Anybody else have an issue with trying to reuse their respirators during the pandemic?

I think the biggest issue here is that we are using them outside of what NIOSH and FDA has said that they could be used. Because they are for single use only. So that is a big issue. Alright, next slide.

When buying personal protective equipment, all the following are appropriate except. OK, now you’re going to pick out your PPE for your laboratory, carry out a risk assessment, are they user-friendly and fit correctly, consider the medical condition of the wear, have they passed regulatory requirements and safety tests, you survey the lab, staff, to determine which respirator brand would be used. What might be an exception here that you probably don’t want to do?

Certainly, we look to see, does it pass regulatory requirements and safety tests? We take into consideration are people going to wear it? Will it fit properly with the person? We also look at where they’re being used for risk assessment. I think the one that I would say would be the more exception here would be surveying the staff to determine which respirator brand would be used.

And Kalpana said E, as well. Everybody is a little bit different. You need to know what’s available to your laboratory. But we have people that, I think we use three different brands in our lab. We use the 1860. We use the 1870+. I think there’s an 8210, if I remember correctly. And then we certainly have some people who can’t use those types of respirators, and then they have to use PAPR.

So we go through all the different things. But I think the point of this question is that one brand is not the process for the clinical lab staff. In other words, multiple brands may be needed, as well. Alright, moving on. I had through some other topics. And if we had some time, I’d be interested in a discussion on these topics. Next slide.

This came up, certainly. Why wear a surgical mask over your N95 respirator? Well, this became a topic of discussion. And it has to do with the need to conserve and reuse your N95 respirators early in the COVID-19 pandemic. Some public health agencies and associations said that cloth or procedural surgical masks could be worn over the N95 to prevent or reduce respirator microbial contamination. What are your thoughts on that? Have you ever done that?

I mean, some of you folks said that you did reuse your respirators. Did you put a surgical mask on the outside, as well? Anybody. We didn’t do it. But I know people that did. Kalpana says that yes, we did. And you disposed of your surgical mask and kept your N95. Michael says we never had to reuse your N95. So that’s great. I think we’re going to learn a lot from this pandemic as it pertains to PPE and reuse of PPE, et cetera.

I think the issue is to get your supply chain figured out, make sure these are available. Alright, so it is a thought question that you need to consider. And this is just something that may come up, and it is an alternative for the use of N95s to put a surgical mask on. Some people said it was OK to do that.

Alright, I have one final thought question to talk about. In frontline clinical laboratories, always becomes an issue for us. Because we at the public health lab actually go out and train our frontline colleagues on how to process samples that might contain something really bad like Ebola virus. You get a person under investigation for Ebola or Marburg, guess what? They’re not going to show up, probably, at your big facilities that can handle this. They might show up at your front-line laboratories.

And when we put together how to handle samples in these frontline laboratories, we included these statements in a table on how to process clinical samples. We created an article in the American Journal of Clinical Pathology, and we put this in there. And I’m going to read this to you, and I’d be interested in your thoughts.

It says here, “In situations in which aerosols and droplets are produced and respiratory protection, such as fit testing for an N95 respirator, are not available–” that’s a scenario in a lot of places that we work with– “a physical barrier, such as a splash shield while using a surgical mask may be considered.” We tried to give these facilities at least some type of a safety process in order to handle these specimens.

I wouldn’t say this is the best thing to do. But at least it’s some protection. So a physical barrier using a surgical mask may be considered. And then, we have the issue of when a biological safety cabinet is not available. Well, first off, having them available and not certified is an issue, as well. “But when a certified biological safety cabinet is not available and there is a potential for general aerosols or droplets, or if an instrument such as a centrifuge with safety cuffs or sealed rotors, or a point of care device, cannot be used inside a biological safety cabinet–”

Now, think of those scenarios in your mind. How many laboratories out there have centrifuges, for instance, that do not have safety cuffs or sealed rotors? We found out there’s a lot of out there. Then “–use extra precaution to provide a barrier between the specimen and personnel such as a mask–” like a surgical mask, “–or respirator plus other physical barriers, such as a splash shield and other appropriate PPE.”

So how do you determine what is appropriate? Well, that’s where the risk assessment process comes in. So again, there are facilities that cannot supply or have available the PPE that we all think should be available. But they’ve got to care for these patients under some circumstance from the laboratory standpoint. And this is the alternatives that we gave laboratories to consider.

So I would be interested in anybody else’s thoughts that they might have about working with front-line clinical laboratories as it pertains to personal protective equipment. Any thoughts out there? It’s a tough scenario sometimes. Alright, any questions in the chat that I need to address?

Aufra Araujo: Hi, sorry. I’m having trouble here unmuting. There is one question is from Leila Filson if I’m reading correctly. Is it written somewhere that PAPR-only wearers do not need medical evaluation? Is it written somewhere?

Peter Iwen: I think that it is written somewhere. And I’d be happy if she could supply me with an email address, I would look up to see. I don’t have it at the top of my head where you don’t need a medical surveillance for wearing a PAPR. But I’d be happy to look it up for anybody that would be interested. And maybe you could just share this with the group, offer later on.

Aufra Araujo: Yes.

Peter Iwen: I’ll see what I could find.

Aufra Araujo: I was going actually to suggest that. You can provide us that reference bit. And then, we can share our resource on the ECHO Biosafety web page once we upload your slides, as well.

Peter Iwen: Yeah. I will look and see what I can find on that. I just hope– it may be anecdotal information that I have. But I’ll try to find some document that has some type of standard. Yes. OK, any other questions, Aufra?

Aufra Araujo: No, nothing else.

Peter Iwen: OK. I think we’re getting close. We’re using up our time, I guess. Any other questions from the group that you’d like to share about personal protective equipment? But we have one more slide, just for thought. Show the next slide, Aufra.

It’s just a topic I thought it would be an interesting discussion topic– the prolonged use of medical masks, I’ll call it respirators, when properly worn, does not cause CO₂ intoxication nor oxygen deficiency. Well, I don’t think it causes an intoxication. But I think other folks would probably have experiences, as well. But when you wear a respirator, sometimes you do get lightheaded over time wearing a respirator. And I’m sure there’s issues with oxygen deficiency while we’re a respirator, as well.

If you really do have a lot of issues with this, the alternative really is to go to a PAPR. But I know we all don’t have those available, as well. But the issue is it does not cause CO₂ intoxication, even though I may disagree that it does cause oxygen deficiency in some cases. So any comments to that?

Shoolah Escott: Yes. This is Shoolah. Actually, when I used to have to wear a respirator for many hours at a time doing BSL-3 training, I ended up switching to one with a valve for that very reason. That made a big difference.

Peter Iwen: Yeah, Shoolah, I’m glad you brought that up because I think we’ve all experienced, many of us have experienced lightheadedness while wearing a mask, especially when you’re doing a lot of strenuous work. And, of course, the room is hot, and you’re under stress. There’s a lot of things that can go into this. So I appreciate you sharing that, as well. Next slide, Aufra.

I think it’s kind of the closing slides that we’re getting to here. What do you think of this image? This is people being interviewed in Sierra Leone when there was the Ebola outbreak occurring. And I just I just find this image very– I don’t know– intriguing. What do you see when you look at this image? Anybody want to offer a comment?

No thoughts. Reporters are not in PPE. Yeah, you got it. I tell you, we had a scenario like this in our hospital when we had possible contamination. Yeah, definitely. When we had people admitted to our biocontainment unit, the staff wearing their PPE standing close to others without PPE.

We had some pathology residents who went up to retrieve a specimen from our biocontainment unit. The specimen was completely contained for processing in the pathology laboratories. But they walk through the hospital wearing this type of PPE carrying the specimen. Not very smart. We had a lot of educating to do in that case.

But of course, this to me would be– if I would have been a reporter, I would have been stepping way back. Let’s just put it that way. Alright, so again, things to think about. Next slide, Aufra.

I just want to say there’s a lot of resources out there. The CDC has a number of documents pertaining to PPE in the clinical laboratory. The Division of Laboratory Systems has a lot of documents. I wanted to put up here that there is an organization called the National Emerging Special Pathogens Training and Education Center, netec.org, that has a lot of training documents. Some of the slides I gave you actually were from this organization that is available. So you can pull up their website and look for their training. A lot of them have CEU attached to their training, as well. Next slide.

There’s another organization called HEROES, stands for Healthcare and Emergency Responder Organization Education through Simulation. That’s here at the University of Nebraska Medical Center that has a lot of training documentation, as well. This is more of a simulated type programs of how to set up training programs within your facility pertaining to such things as personal protective equipment. So just ideas.

Like I say, the CDC website has tons of training information, as well. So just keep that in mind. Alright. Next slide, I think it’s the final slide, just kind of a closing. Got to advertise a little bit, I guess, here.

So Aufra, I think that’s the last of the presentation.

Aufra Araujo: Yes, thank you so much, Dr. Iwen. This has been an excellent presentation and excellent overview of PPE. Now my colleague, commander Sabine DeBose, Safety Team Lead in CDC’s Division of Laboratory Systems, will summarize the discussion from today’s session.

Sabrina DeBose: Yes, thank you Aufra. Thank you, Dr. Iwen. So we did have a lot of discussion, and I will give us a brief overview about some classes. Alright, so our first question was, “Describe which barriers would most likely occur in your facility?” And a lot of the discussion centered around, there is a lack of dexterity when working in a biosafety cabinet. Safety glasses, especially eye protection, either they had really strict policies or no policies at all. There was a lack of availability of prescription safety glasses.

And also the importance of reviewing the policy to ensure that eye protection is required for the tasks that were being performed. There was also a lack of availability of fit testing in various parts of the United States, that was discussed during the conversations, and also lack of education and training.

Another point that I would like to highlight is when we have the question about the extended time of use or reusing respirators, we did have both extremes. We had one participant that said they never had to reuse, and also another that reported using it over 40 times. And let’s see, another one, the greatest adherence to reusing respirators is the integrity is compromised. And initially, there was no established decontamination procedures, and that they’re finding that the respirators were being reused outside of the intended use.

When buying PPE, all of the following should be considered. It’s important to survey the lab staff to determine which brand would be used, and laboratories should consider having multiple brands of PPE available. So once again, I want to say thank you, and that was a highlight of the discussion.

Aufra Araujo: Thanks, Sabrina. Peter, is there anything else you’d like to highlight that Sabrina didn’t mention?

Peter Iwen: No, Sabrina, you did a good job. I think, if anything else, we’ve kind of learned that there are some exceptions to the rule when it comes to personal protective equipment. But it all comes down to the risk assessment process in the laboratory as to what should be used and when they should be used.

And I just want to highlight to the folks here that everybody should be doing risk assessments to determine what is most appropriate to create a level of safety within their laboratories. And I would love to thank participants for joining in on this webinar, as well. Thank you.

Aufra Araujo: Yes, thank you so much Dr. Iwen. I appreciate your time and your sharing your expertise with this community of biosafety officers today. Thank you all for taking part in our discussion. This is really important so we can grow this community of practice.

Soon, you know what’s coming, the post-session survey. Please, please, please, do complete your survey as soon as you receive it. It only takes two minutes to respond. And we make adjustments to the presentation based on your response. So your comments are valuable, and we look forward to reading your answers.

If you have additional comments, please send an email to DLSbiosafety@cdc.gov. You’ll be able to access the resource from this session on our CDC ECHO Biosafety web page. And finally, let me just share the next slide.

We are excited to have our next session in June. It will be on Tuesday, June 27, at 12:00 PM Eastern time. The topic will be Laboratory Acquired Infections, which will be presented by Dr. Sheldon Campbell and Dr. David Peaper from the Yale School of Medicine.

Please visit the DLS ECHO Biosafety web page, again, to view all upcoming sessions and to view resource such as the slides and transcripts from all the previous sessions and this session, as well. Once again, Thank. You so much for your participation. Thank you, Dr. Iwen. Again, if you have any questions, reach out to us at DLSbiosafety@cdc.gov. And now we will adjourn. Thank you, and have a great day. We look forward to seeing you during our next session. Bye.

Additional Resources and Related Publications

1. Centers for Disease Control and Prevention. (2020, November 17). Biosafety in Microbiological and Biomedical Laboratories (BMBL) 6th Edition.
2. Centers for Disease Control and Prevention. What are Air-Purifying Respirators?
3. Centers for Disease Control and Prevention. (2021, October 21). Biological Risk Assessment: General Considerations for Laboratories.
4. Iwen PC, Stiles KL, Pentella MA. Safety Considerations in the Laboratory Testing of Specimens Suspected or Known to Contain the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). American Journal of Clinical Pathology, 2020 May; 153:567-570.
5. Centers for Disease Control and Prevention. Filtering out Confusion: Frequently Asked Questions about Respiratory Protection.
6. National Emerging Special Pathogens Training and Education Center. NETEC Home.
7. University of Nebraska Medical Center. About HEROES.
8. Centers for Disease Control and Prevention. (2023, May 17). CDC Laboratory Training.