Guidelines for General Healthcare Settings Designated as Non-Ebola Treatment Centers (Non-ETU)

Personal protective equipment (PPE) is specialized clothing or equipment worn by healthcare workers for protection against germs like Ebola. Examples of PPE include

• goggles to protect eyes
• face mask to protect nose and mouth
• head cover to protect the head from contamination when removing mask or face shield
• gloves to protect hands
• waterproof gown to protect skin and clothing
• boots to protect legs and feet
• apron to provide maximal protection to the front of the body against contaminated fluids

Table 1. PPE specifications

Basic PPE

Basic PPE protects the parts of the body that are at highest risk for contamination: hands, eyes, nose, and mouth. It is the minimum level of protective wear required for healthcare workers before interacting with patients.

Basic PPE includes

• face shield, single pair of gloves, scrubs, and boots

Extended PPE

Extended PPE is a higher level of protection required for healthcare workers when taking care of any patient who has bleeding, vomiting, diarrhea, or other body fluids or is suspected or confirmed as having Ebola.

Extended PPE includes

• Impermeable gown, double gloves, head cover, face mask, face shield, and boots

Extended for Cleaners PPE

Because cleaners handle waste material that may be contaminated with the Ebola virus they must wear Extended PPE specified for cleaners. 

Extended for cleaners PPE includes

•  impermeable gown, double gloves (inner glove is an examination glove, outer glove is a thick rubber glove), head cover, face mask, face shield, boots and a waterproof apron

Table 2. Recommended PPE for Healthcare Workers in General Healthcare Settings in Countries with Ebola Outbreaks

Table 2. Recommended PPE for Healthcare Workers in General Healthcare Settings in Countries with Ebola Outbreaks

• Ebola is spread through direct contact (through broken skin or mucous membranes) with
  • blood or body fluids (such as urine, saliva, feces, vomit, and semen) of a person who is sick with Ebola
  • objects (like needles and syringes) that have been contaminated with the virus
  • infected animals
• PPE acts as a barrier to protect eyes, nose, mouth, skin, and clothing from contact with a patient’s body fluids which may contain germs that can be spread to the healthcare worker or other patients.

• PPE should be worn BEFORE contact with EVERY patient.
• The type of PPE worn depends on the level of risk of exposure to body fluids and if the patient being seen is suspected to have Ebola.
• All healthcare workers are advised to wear at least Basic PPE (boots, gloves, face shield (or goggles, or face mask, if face shield is unavailable) BEFORE performing any patient care.

• Gloves
• Face shield (preferred) or goggles and face mask
• Gum boots

1. Put on gum boots*
2. Take off jewelry*
3. Wash hands with soap and water OR mild chlorine solution (0.05%) OR alcohol-based hand sanitizer
4. Put on face shield (goggles and face mask if face shield not available)
5. Put on gloves

*Recommendation: Remove all jewelry.  Change from street shoes into boots when arriving at work. Store jewelry and other personal items in non-patient care areas. Remove boots at the end of the workday and before leaving the healthcare facility.

Requirement: Remove gloves and wash hands AFTER every patient contact. Put on new gloves BEFORE seeing the next patient.

1. Inspect and disinfect the boots with a disposable towel soaked in strong (0.5%) chlorine bleach solution
2. Take off gloves
3. Take off face shield/goggles and face mask
   1. If continuing to see patients, face shield and goggles or facemask do not need to be removed and replaced unless visible soiled
4. Immediately after removing equipment, wash hands with soap and water OR dilute (0.05%)  chlorine solution OR alcohol-based hand sanitizer

Requirement: Only remove boots at the end of the workday but wipe down boots when visibly soiled during the day. After removing boots at the end of the day, place in a designated bucket of strong chlorine bleach solution specially intended for rinsing boots.

Healthcare workers treating patients in  isolation areas within PHUs and healthcare workers who are working in a situation where they may come into contact with body fluids (e.g., blood, vomit, feces, sweat, urine, etc.) should wear extended PPE.

Equipment

• Gloves (two pairs)
• Waterproof gown
• Head cover (if available)
• Face shield (preferred) or goggles
• Face mask
• Gum boots

Healthcare workers should don extended PPE in a designated area, preferably, with a qualified observer who can ensure the steps are followed correctly and in the right order. At minimum, a poster depicting the sequence of donning and doffing of PPE should be available in this area.

Always follow this exact order.

1. Put on gum boots*
2. Take off jewelry*
3. Wash hands soap and water OR dilute chlorine solution (0.05%) OR alcohol-based hand sanitizer
4. Put on first pair of gloves
5. Put on gown
6. Cut a small hole in the cuff of the gown and slip thumb through the hole
7. Put on head cover
8. Put on face mask (or goggles)
9. Put on face shield
10. Put on outer pair of gloves

*Recommendation:  Remove all jewelry.  Change from street shoes into boots when arriving at work. Store jewelry and other personal items in non-patient care areas. Remove boots at the end of the workday and before leaving the healthcare facility.

The risk of indirect exposure to infected body fluids is likely highest when removing PPE. Follow an ordered process for removing PPE reduces the risks of exposure.

Healthcare workers should always remove the most soiled outer garments first and decontaminate gloved hands with strong (0.5%) chlorine solution between each step.

Always follow this exact order.

1. Wash gloved hands with strong (0.5%) chlorine solution and splash some of the chlorine solution on top of the tap when handwashing is complete
2. Remove the outer pair of gloves slowly and carefully and dispose of them into the designated waste container
3. Wash gloved hands with strong (0.5%) chlorine solution and splash some of the chlorine solution on top of the tap when handwashing is complete
4. Carefully remove and dispose of gown in the designated waste container
5. Wash gloved hands with strong (0.5%) chlorine solution and splash some of the chlorine solution on top of the tap when handwashing is complete
6. Inspect boots for visible blood or body fluids
   1. If they are dirty, wipe visible fluid off with a disposable towel and throw it into the designated waste container
   2. Use another towel soaked in strong (0.5%)  chlorine solution to wipe the boots down
7. Wash gloved hands with strong (0.5%) chlorine solution and splash some of the chlorine solution on top of the tap when handwashing is complete
8. Remove the face shield carefully by lifting the elastic strap over your head and throw it into the container it into the designated waste container
   1. If wearing goggles instead of face shield, lift the elastic strap over your head and dip goggles twice in strong (0.5%) chlorine
   2. Next, rinse in clean water and dry in the sun
9. Wash gloved hands with strong (0.5%) chlorine solution and splash some of the chlorine solution on top of the tap when handwashing is complete
10. Remove the face mask carefully by untying the bottom tie, followed by the top tie and then discard
    1. If the ties are elastic bands around the ears, pull the front of the mask off slowly and carefully and throw into the designated waste container
11. Wash gloved hands with strong (0.5%) chlorine solution and splash some of the chlorine solution on top of the tap when handwashing is complete
12. Remove the inner gloves slowly without letting the outside of the gloves touch bare skin and put into the container for burnable waste
13. Step into strong (0.5%) chlorine foot bath upon exiting the isolation area
14. Wash hands with soap and clean water or dilute (0.05%) chlorine solution

Requirement: Only remove boots at the end of the day but wipe down boots when visibly soiled during the day. After removing boots at the end of the day, place in a designated bucket of strong chlorine bleach solution specially intended for rinsing boots.

Cleaning staff of healthcare facilities should wear the Cleaners’ PPE at all times when cleaning, including during environmental clean-up, disinfection, and waste disposal.

Equipment needed:

• Gloves (two pairs: outside=thick rubber gloves, inside=regular gloves)
• Waterproof gown
• Plastic apron
• Head cover (if available)
• Face shield (preferred) or goggles
• Face mask
• Gum boots

Cleaning staff in healthcare facilities should don Cleaners’ PPE in a designated area, preferably, with a qualified observer who can ensure the steps are followed correctly and in the right order. At minimum, a poster depicting the sequence of donning and doffing of PPE should be available in this area.

Always follow this exact order.

1. Put on gum boots*
2. Take off jewelry*
3. Wash hands soap and water OR dilute (0.05%) chlorine solution OR alcohol-based hand sanitizer
4. Put on first pair of gloves
5. Put on gown
6. Cut a small hole in the cuff of the gown and slip thumb through the hole
7. Put on head cover
8. Put on face mask (or goggles)
9. Put on face shield
10. Put on apron
11. Put on outer pair of thick rubber gloves

*Recommendation: Change from street shoes to gum boots and remove all jewelry (including wrist watches) as soon as arriving, to avoid repeating steps one and two every time Extended PPE is worn during the work day.

The risk of indirect exposure to infected body fluids is likely highest when removing PPE. Follow an ordered process for removing PPE reduces the risks of exposure.

Cleaning staff in healthcare facilities should always remove the most soiled outer garments first and decontaminate gloved hands with strong (0.5%) chlorine solution between each step.

Always follow this exact order.

1. Wash gloved hands with strong (0.5%) chlorine solution and splash some of the chlorine solution on top of the tap when handwashing is complete
2. Remove the outer pair of gloves slowly and carefully and dip the rubber gloves twice in a strong  (0.5%) chlorine solution and place in dilute (0.05%) chlorine solution
3. Wash gloved hands with strong (0.5%) chlorine solution and splash some of the chlorine solution on top of the tap when handwashing is complete
4. If wearing an apron, remove the apron
   1. If apron is disposable, place it into the container for burnable waste
   2. If it is reusable rubber, dip the apron twice into strong (0.5%) chlorine solution, and then put into weak (0.05%) chlorine solution
5. Wash gloved hands with strong (0.5%) chlorine solution and splash some of the chlorine solution on top of the tap when handwashing is complete
6. Carefully remove then dispose of the gown into the designated waste container
7. Wash gloved hands with strong (0.5%) chlorine solution and splash some of the chlorine solution on top of the tap when handwashing is complete
8. Inspect boots for visible blood or body fluids
   1. If they are dirty, wipe visible fluid off with a disposable towel and throw it into the designated waste container
   2. Use another towel soaked in strong (0.5%)  chlorine solution to wipe the boots down
9. Wash gloved hands with strong (0.5%) chlorine solution and splash some of the chlorine solution on top of the tap when handwashing is complete
10. Remove the face shield carefully by lifting the elastic strap over your head and throw it into the container it into the designated waste container
    1. If wearing goggles instead of face shield, lift the elastic strap over your head and dip goggles twice in strong (0.5%) chlorine
    2. Next, rinse in clean water and dry in the sun
11. Wash gloved hands with strong (0.5%) chlorine solution and splash some of the chlorine solution on top of the tap when handwashing is complete
12. Remove the face mask carefully by untying the bottom tie, followed by the top tie and then discard
    1. If the ties are elastic bands around the ears, pull the front of the mask off slowly and carefully and throw into the designated waste container
13. Wash gloved hands with strong (0.5%) chlorine solution and splash some of the chlorine solution on top of the tap when handwashing is complete
14. Remove the inner gloves slowly without letting the outside of the gloves touch bare skin and put into the container for burnable waste
15. Step into strong (0.5%) chlorine foot bath upon exiting the isolation area
16. Wash hands with soap and clean water or dilute chlorine solution (0.05%)

Requirement: Only remove boots at the end of the day but wipe down boots when visibly soiled during the day. After removing boots at the end of the day, place in a designated bucket of strong chlorine bleach solution specially intended for rinsing boots.

• DO strictly follow the steps in sequence when donning and doffing PPE
  • PPE only works when it is donned, worn, and doffed correctly every time
• DO always wash hands BEFORE and AFTER removing gloves
• DO remove gloves and wash hands AFTER every patient contact and put on new gloves BEFORE seeing the next patient
• DO NOT touch your face, adjust or touch the PPE, or pick up objects (mobile phone, pens, books, patient files, etc.), leave the patient-care area, eat, drink, visit the latrine, use a mobile phone, or handle personal belongings when wearing the PPE
  • BEFORE doing any of these activities, remove all PPE and wash hands
• DO Discard the face mask at the end of your work day, when visibly soiled, or when taking a break from patient care activities. The face shield does not need to be changed between every patient contact
  • DO NOT store a used face shield for later re-use
• DO place goggles in a bucket of strong chlorine solution (0.5%) for cleaning and drying after removal

Annex 1:

The West African climate is known for high temperatures throughout the year. PPE worn in these settings, in the absence of central cooling, significantly increases the risk of heat stress. PPE wearers can become excessively hot and may require more physical effort to perform duties due to the extra weight of the protective materials. As a result providers wearing PPE must be educated on this risk of heat-related illness.

The heat burden when wearing PPE depends on many factors including: the length of the work shift, ambient temperature within the health facility, access to electrolyte replacement fluids, and pre-existing medical conditions. Initial heat stress tests suggest that the PPE included in the overall PPE ensemble affects the heat burden experienced by those wearing it.

National Institute for Occupational Safety and Health (NIOSH) provides recommendations for workers on how to limit the heat burden and prevent heat-related illnesses while wearing PPE in the document “Interim Guidance for Healthcare Workers Providing Care in West African Countries Affected by the Ebola Outbreak: Limiting Heat Burden While Wearing Personal Protective Equipment (PPE).”  

These recommendations include

• Take time to acclimatize
• Stay well-hydrated
• Watch for signs and symptoms of heat stroke
• Take time to rest and cool down

The World Health Organization discourages disinfectant spraying. The specific language is: “Do not spray (i.e. fog) occupied or unoccupied clinical areas with disinfectant. This is a potentially dangerous practice that has no proven disease control benefit.”  As currently, stated it is unclear whether this guidance applies to all settings and all forms of spraying. As part of the Médecins Sans Frontières doffing procedures, apron and boots are sprayed with 0.5% chlorine solution. Consistent recommendations for disinfecting boots are needed, under the assumption that healthcare workers will wear the boots for extended periods while working in Ebola Treatment Units and general healthcare settings. If disinfectant spraying of boots during the doffing process is discouraged, CDC recommends (while wearing gloves) using a clean disposable towel soaked in 0.5% chlorine solution to remove any visible waste from the body of the boot. Then use another clean disposable towel soaked in 0.5% chlorine to disinfect the soiled area. As healthcare workers leave the doffing area, they should walk through a 0.5% chlorine foot bath to ensure the soles of the boots are adequately disinfected.

According to World Health Organization,  the outer glove worn by healthcare workers should be a surgical glove. Surgical gloves are tight fitting at the wrist and serve to hold the gown sleeve in place, protecting the healthcare workers’  wrist from exposure. However, in practice, healthcare workers in West Africa may only have access to simple nitrile gloves as they cost less and are easier to size. For most people, the nitrile gloves will be loose at the wrist. If both the inner and outer gloves are nitrile, there is the potential that the gown sleeve will ride up the arm, exposing the healthcare worker’s wrist.

To address this issue, the World Health Organization guidance allows for taping of the outer glove to the gown. However, this recommendation may discourage healthcare workers from changing outer gloves between patients. Further discussion on this issue is needed to explore alternatives, such as taping the inner glove (instead of the outer glove) to the gown. CDC recommends taping the cuff of the surgical gown onto the inner glove to protect the healthcare worker’s wrist while enabling HCWs to more easily change the outer glove between patients.

ⁱCenters for Disease Control and Prevention (CDC). “Interim Guidance for Healthcare Workers Providing in West African Countries Affected by the Ebola Outbreak: Limiting Heat Burden While Wearing Personal Protective Equipment (PPE).” (2014). Unpublished.

ⁱⁱWorld Health Organization (WHO). “Infection prevention and control guidance for care of patients in health-care settings, with focus on Ebola.” Geneva, 2014. Available from: http://www.who.int/csr/resources/publications/ebola/filovirus_infection_control/en/

ⁱⁱⁱWorld Health Organization (WHO). “Facilitators Guide for Infection Prevention & Control In the Training of Cleaners & Hygienists & Others Working In Ebola Units.” Edited and complied by Dr. Thomas Kerkering.