Frequently Asked Questions for Guidance on Personal Protective Equipment in U.S. Healthcare Settings During Management of Patients Confirmed to have Selected Viral Hemorrhagic Fevers or Patients Suspected to have Selected Viral Hemorrhagic Fevers Who are Clinically Unstable or have Bleeding, Vomiting or Diarrhea
This guidance refers only to the following viral hemorrhagic fevers: Ebola, Marburg, Lassa, Crimean Congo Hemorrhagic Fever (CCHF) and the South American Hemorrhagic Fevers (i.e., those caused by Junin, Machupo, Chapare, Guanarito and Sabia viruses). Refer to the pathogen-specific pages for further information about the individual pathogens (e.g., signs and symptoms, incubation periods, routes of transmission, diagnosis, treatments).
What manufacturer of PPE should we use?
CDC does not recommend a specific manufacturer of PPE. You should select PPE from any manufacturer that meets the specifications outlined in the Guidance on Personal Protective Equipment (PPE) in U.S. Healthcare Settings during Management of Patients Confirmed to have Selected Viral Hemorrhagic Fevers or Patients Suspected to have Selected Viral Hemorrhagic Fevers who are Clinically Unstable or Have Bleeding, Vomiting, or Diarrhea.
Should tape be used to secure the gown sleeves to the inner gloves?
Facilities may elect to use tape to secure gloves to a garment, however, facilities should note that experience in some facilities suggests taping can increase the risk of contamination by making the doffing process more difficult and cumbersome. If tape is used, care should be taken during PPE removal so that the tape does not tear the PPE. Additionally, take care to ensure the tape does not touch the worker’s skin as removal of tape may cause micro-abrasions. CDC does not promote or discourage the use of tape but rather advises facilities that opt to use tape to practice seeing what kind of tape and application approaches (such as folding the tape over at the end to create a tab to facilitate removal) work best.
Are thumb hooks (or thumb loops) a mandatory option for the gown or coverall?
Thumb hooks can be useful to help secure the cuff of the gown or coverall, but they are not mandatory.
Can PPE be altered (e.g., cut a thumb loop into the sleeve, cut off a hood from coverall)?
Altering PPE may affect the integrity of the garment so the user should consult the manufacturer of the PPE to determine if any alterations are acceptable that will maintain the usability of the PPE.
How do we know if the gown or coverall that our hospital wants to purchase is impermeable or fluid- resistant?
Gown and coverall product information should state the standards to which the garments conform, including those for impermeability or fluid resistance. To ensure that the products you have meet the standards, you can also ask the manufacturers if their product has met test standards for impermeability or fluid resistance and where that testing was performed. At a minimum, the gown or coverall must meet the requirements outlined in the Guidance on Personal Protective Equipment (PPE) in U.S. Healthcare Settings during Management of Patients Confirmed to have Selected Viral Hemorrhagic Fevers or Patients Suspected to have Selected Viral Hemorrhagic Fevers who are Clinically Unstable or Have Bleeding, Vomiting, or Diarrhea.
If you are purchasing surgical gowns and certain types of isolation gowns (such as AAMI PB70 level 3 and level 4 gowns), ask the manufacturer if they have received FDA clearance. Surgical gown manufacturers are required to submit performance data through the FDA clearance process while this is not required by isolation gown and coverall manufacturers. Standards testing or FDA clearance will provide you with assurances that the gown or coverall meets its rated protection. Third party testing by an ISO 17025 certified laboratory may provide additional confidence in the testing results. You must also ensure that the protection rating is appropriate for the intended use. For more details on the international standards, test methods, and specifications for garments, see the technical document Considerations for Selecting Protective Clothing used in Healthcare for Protection Against Microorganism in Blood and Body Fluids
Why does CDC recommend that gowns and coveralls be impermeable or fluid-resistant but does not recommend additional PPE components (e.g., boot covers, surgical hood, apron) be fluid-resistant or impermeable as well?
Currently these additional components are not consistently tested for impermeability or fluid resistance using the same standards applied to gowns and coveralls. Therefore, it would be difficult for users to ensure the garments met testing standards.
Can we use Hazmat suits instead of PPE?
The phrase “Hazmat suits” is often used to refer to the category of “coveralls,” which are included as an option in the PPE guidance. It is important to ensure that the coveralls you select for use meets the specifications outlined in the Guidance on Personal Protective Equipment (PPE) in U.S. Healthcare Settings during Management of Patients Confirmed to have Selected Viral Hemorrhagic Fevers or Patients Suspected to have Selected Viral Hemorrhagic Fevers who are Clinically Unstable or Have Bleeding, Vomiting, or Diarrhea.
It is also important not to focus on the specific type of equipment but its performance characteristics and suitability for use during the intended work, including ability of users to safely put on and remove the equipment. Additional details about the selection of coveralls vs. gowns can be found in Considerations for Selecting Protective Clothing used in Healthcare for Protection against Microorganisms in Blood and Body Fluids.
Are healthcare workers protected from blood, body fluids, and other potentially infectious materials when they wear any type of fluid-resistant garment?
Different types of gowns and coveralls have different standards for testing the penetration resistance of body fluids and viruses. It is important to choose the garment that meets the recommended specifications based on the patient’s clinical status and activities being performed. While a garment may be labeled as “fluid-resistant” that does not mean it will provide resistance to blood, body fluids, or viruses. Regardless of specification, protective garments must be used correctly in order to ensure intended protection.
A more in-depth explanation of the scientific evidence and national and international standards, test methods, and specifications for impermeable protective clothing used in healthcare is available in the Considerations for Selecting Protective Clothing used in Healthcare for Protection Against Microorganisms in Blood and Body Fluids. Specifications are outlined in the Guidance on Personal Protective Equipment (PPE) in U.S. Healthcare Settings during Management of Patients Confirmed to have Selected Viral Hemorrhagic Fevers or Patients Suspected to have Selected Viral Hemorrhagic Fevers who are Clinically Unstable or Have Bleeding, Vomiting, or Diarrhea.
When should a healthcare worker use an apron as part of the PPE ensemble? Should the apron or other PPE be disinfected or changed in the patient room if it becomes soiled with bodily fluids from the patient?
CDC recommends that healthcare workers wear an apron over their gown or coveralls any time a patient is vomiting or has diarrhea. An apron is recommended in those circumstances to minimize the soiling of underlying PPE and provide an easily discarded layer if the apron becomes soiled. An apron should also be used routinely if the facility is using a coverall that has an exposed, unprotected zipper in the front.
If there is significant soiling of the PPE, the healthcare worker should leave the patient care area and take off the PPE in the doffing area under the observation of a trained observer. Continuing to work in equipment that is soiled creates additional risks for contamination.
Healthcare workers preparing to remove PPE should ask the trained observer to visually inspect their PPE. The healthcare worker should then use U.S. Environmental Protection Agency (EPA)-registered hospital disinfectant wipes from List Q (for Ebola List L can also be used) to remove as much of the soil as possible in order to decrease the risk of contamination before beginning the doffing process. PPE must be removed slowly and deliberately in the correct sequence to reduce the possibility of self-contamination or other viral exposure.
Are there different combinations of PPE recommended depending on the healthcare location (emergency department or outpatient clinic) and purpose of entering the patient room (interview only, blood draw only, hands-on care) for patients suspected to have VHF?
PPE recommendations are based on the patient’s clinical status and activities being performed.
Recommendations for PPE to be worn when evaluating and caring for a confirmed patient or a patient suspected to have VHF who is clinically unstable or has obvious bleeding, vomiting or diarrhea, are provided in the Guidance on Personal Protective Equipment (PPE) in U.S. Healthcare Settings during Management of Patients Confirmed to have Selected Viral Hemorrhagic Fevers or Patients Suspected to have Selected Viral Hemorrhagic Fevers who are Clinically Unstable or Have Bleeding, Vomiting, or Diarrhea.
Recommendations for PPE to be worn when evaluating and caring for a person suspected to have VHF who is clinically stable and not exhibiting obvious bleeding, vomiting or diarrhea are provided in the Guidance on Personal Protective Equipment (PPE) in U.S. Healthcare Settings for Evaluating Patients Suspected to have Selected Viral Hemorrhagic Fevers Who Are Clinically Stable and Do Not Have Bleeding, Vomiting, or Diarrhea.
Recommendations for PPE to be worn by healthcare personnel acting as trained observers and doffing assistants are provided in the Guidance on Personal Protective Equipment (PPE) in U.S. Healthcare Settings during Management of Patients Confirmed to have Selected Viral Hemorrhagic Fevers or Patients Suspected to have Selected Viral Hemorrhagic Fevers who are Clinically Unstable or Have Bleeding, Vomiting, or Diarrhea.
Recommendations for PPE to be worn by EMS clinicians, emergency medical technicians, advanced EMTs, paramedics, and other medical first responders are provided in the Interim Guidance for Emergency Medical Services (EMS) Systems and 9-1-1 Emergency Communications Centers/Public Safety Answering Points (ECC/PSAPs) for Management of Suspected to have Selected Viral Hemorrhagic Fevers in the United States.
Should trained observers use a bleach-wipe on the healthcare worker’s PPE before it is doffed? Wouldn’t there be a substantial risk that the observer will get contaminated during this procedure?
The trained observer has the sole responsibility of ensuring that donning and doffing processes are followed properly and therefore should not assist the healthcare worker with any part of cleaning or removal of the healthcare worker’s PPE. One exception where a designated doffing assistant or “buddy” might be helpful is during the doffing of the PAPR, when assistance holding the belt pack can be useful. Healthcare workers wearing PPE that has become visibly soiled should disinfect the contaminated PPE surface before beginning the removal process.
Are coveralls that meet NFPA 1999 acceptable to protect healthcare workers when treating patients with VHF?
Yes. NFPA 1999 incorporates ASTM F1671 standard for fabric and seam viral penetration resistance as specified in the VHF PE guidance. NPFA 1999 also provides additional categories of performance requirements that are not addressed in the PPE guidance but are discussed in Considerations for Selecting Protective Clothing used in Healthcare for Protection against Microorganisms in Blood and Body Fluids.
Can a stethoscope be used with the PPE when caring for a patient with VHF?
No. A traditional stethoscope cannot be used with personal protective equipment (PPE) because the ears are covered. Alternative methods could be considered, including wireless technology-enabled stethoscope or portable Doppler ultrasound.
Should personal jewelry be removed when using PPE?
Yes. All personal items, including jewelry, watches, cell phones, pagers, and pens, must be removed before donning PPE. These personal items may tear or alter the fit of PPE garments.
Can prescription eyeglasses be worn under PPE?
Yes. Eyeglasses may be worn under PPE, but they should not interfere with the respirator, specifically the seal of the facepiece to the face of the user. They should be secured with a strap or tie so they do not come off during doffing. They do not need to be disinfected if they are fully protected by the PPE and not contaminated during the doffing process. If they are contaminated during doffing they should be disinfected.
Where are the instructional videos for donning and doffing PPE found?
Here are two alternative links from CDC’s website to the PPE training videos:
Continuous videos landing page: https://www.cdc.gov/vhf/ebola/hcp/ppe-training/comprehensive-ppe-training.html
Additional training resources are also available:
Online course: https://www.cdc.gov/vhf/ebola/hcp/ppe-training/index.html
CDC TRAIN is a gateway into TRAIN National, the most comprehensive catalog of public health learning products. TRAIN is one of the most widely used learning management systems and is a free service of the Public Health Foundation.
Are there criteria or standards for PPE training?
The guidance specifies that all requirements of an OSHA-compliant respiratory protection program (under 29 CFR 1910.134) are to be met for all healthcare workers wearing respirators as part of a VHF-patient-care PPE ensemble, which includes training on the assigned respirator model being used. All healthcare workers wearing PPE must be trained on properly donning and doffing PPE and must demonstrate competency as assessed by their employer. OSHA’s Bloodborne Pathogens standard (29 CFR 1910.1030) includes specific training requirements. OSHA’s PPE standards (29 CFR 1910.132, 1910.133, 1910.134, and 1910.138) also provide information about hazard assessment, selection and use of appropriate PPE, training and other requirements necessary to protect workers from chemical hazards. Healthcare workers should also be able to effectively perform all patient care activities while wearing PPE. See Guidance for Donning and Doffing Personal Protective Equipment (PPE) During Management of Patients with Selected Viral Hemorrhagic Fevers in U.S. Hospitals for additional information.
What type of shoes should be worn under the boot covers when wearing PPE while caring for a patient with VHF?
Shoes should be closed-toe, soft-soled, with a closed back so they do not come off during doffing, and without holes or perforations. The shoes should also be made of a material that will not be compromised by the use of disinfectants.
What should be done with the shoes worn under the boot covers after PPE doffing?
The shoes should be disinfected as part of the doffing sequence. Disinfect washable shoes by wiping the outer surfaces with an EPA-registered disinfectant from List Q (for Ebola, List L can also be used).
Should facial hair be removed when using PPE?
The OSHA Respiratory Protection standard specifically requires employers not to permit respirators with tight-fitting facepieces to be worn by employees who have facial hair that comes between the sealing surface of the facepiece and the face or that interferes with valve function. See 29 CFR 1910.134(g)(1)(i). Healthcare workers must be fit tested to ensure that facial hair will not interfere with the safe use of an N95® filtering facepiece or other tight-fitting respirators with N95 level filtration efficiency such as an elastomeric half-mask respirator (EHMR). Tight-fitting respirators cannot be used by people with facial hair that comes between the sealing surface of the facepiece and the face; loose-fitting powered air purifying respirators (PAPRs) can be worn by those with facial hair.
When should an N95 respirator versus a medical mask be used for PPE when caring for a patient suspected or confirmed to have VHF?
Recommendations depend on the patient’s symptoms and clinical status.
Because of the possibility of suddenly needing to perform a potentially aerosol-generating procedure, an N95, or higher level of particulate filtration, respirator or a powered air purifying respirator (PAPR) should be worn when evaluating and caring for:
- A person who is suspected to have VHF and is
- Exhibiting obvious bleeding, vomiting, or diarrhea OR
- Clinically unstable and/or will require invasive or aerosol-generating procedures (e.g., intubation, suctioning, active resuscitation) OR
- An individual confirmed to have VHF.
A medical mask (also known as a surgical, laser, isolation, dental or medical procedure mask) is recommended when evaluating and caring for:
- A person who is suspected to have VHF and is
- Not exhibiting obvious bleeding, vomiting, or diarrhea AND
- Clinically stable and will not require invasive or aerosol-generating procedures (e.g., intubation, suctioning, active resuscitation).
Medical masks are not designed to protect against breathing in very small particle aerosols that may contain viruses and are not considered to be a respirator.
What are the advantages and disadvantages of N95 respirators compared to powered air-purifying respirators (PAPRs)?
Respiratory protection is recommended to protect healthcare workers in case there is a need for an aerosol-generating medical procedure in a setting where safely exchanging PPE is time consuming and logistically complex. Either a fit tested N95 filtering facepiece respirator or PAPR is appropriate for use during aerosol-generating procedures and can be used to safely care for patients with VHF in the U.S.
- N95 filtering facepiece respirators are disposable, while PAPRs need to be disinfected after each use.
- N95 filtering facepiece respirators can be easier to put on and remove for those who are not familiar with PAPRs.
- N95 filtering facepiece respirators require the use of a face shield which might not provide optimal protection against a splash from below (such as one that might occur when emptying waste).
- Some people might find PAPRs are more comfortable because of the air circulation in the hood.
- Tight-fitting respirators, including N95 filtering facepieces, cannot be used by people with facial hair if the hair interferes with the face seal of the respirator. PAPRs with loose-fitting hoods can be worn by those with facial hair.
- If using any respirator, a medical exam is required. If using N95 filtering facepiece respirators, all healthcare workers must be fit tested to ensure a proper fit and tight seal, and to ensure that facial hair does not interfere with the safe use of an N95 respirator. Loose-fitting PAPRs can be worn without fit testing.
- PAPRs with full shrouds can prevent unintended facial contamination by soiled gloves during patient care.
Are elastomeric half-mask respirators (EMHRs) an acceptable alternative to PAPRs or N95 respirators?
The CDC guidance recommends PAPRs and N95 filtering facepiece respirators as these are the types of respiratory protection most commonly used in U.S. hospitals and because both of these options have been used to safely care for patients with Ebola in the U.S. EHMRs with an N95 filtration efficiency or higher are an option provided: (1) they do not have exhalation valves or use adaptors to filter exhaled breath, (2) healthcare workers are fit tested for and trained in their use and are able to tolerate wearing them for the duration of use, (3) consideration is given to how they will work with the other recommended elements of VHF PPE, and (4) there is a protocol for disinfecting them after use. EMHRs, like PAPRs, require appropriate cartridges for the hazard(s) present, such as a particulate or particulate/chemical combination cartridge.
Is there a standard process for cleaning and disinfecting PAPRs?
PAPRs must be cleaned and disinfected in accordance with manufacturer recommendations; each PAPR has its own specifications. Healthcare employers should develop a detailed protocol for disinfection to ensure proper disinfection is completed. Facilities should have a designated location for trained staff to clean and disinfect PAPRs. Use an EPA-registered disinfectant from List Q (for Ebola List L can also be used).
Does a PAPR filter need to be removed and discarded after each use with a patient with VHF?
CDC-NIOSH recommends users follow the manufacturer’s guidance to determine the need to replace/dispose of a filter during PAPR decontamination. Several manufacturers have added specific instructions for cleaning, disinfecting, and decontamination after use with a patient suspected or confirmed to have VHF.
Where can employers find a list of NIOSH Approved® PAPRs and N95® respirators (filtering facepiece and EHRMs)?
While CDC-NIOSH does not endorse or recommend products, a searchable list of all NIOSH Approved respirators, including PAPRs and EHMRs, can be found at https://www2a.cdc.gov/drds/cel/cel_form_code.asp
A list of NIOSH Approved N95 filtering facepiece respirators can be found at https://www.cdc.gov/niosh/npptl/topics/respirators/disp_part/default.html
Is it necessary that a healthcare worker be fit tested for a N95 respirator? What happens if the respirator does not fit the worker?
OSHA’s Respiratory Protection Standard, 29 CFR 1910.134, requires fit testing before wearing an N95 respirator.
Certain medical procedures or other events might mechanically generate aerosols that could be infectious.
Experience in the care of patients hospitalized with VHF in the United States indicates that the level of care may change unexpectedly and could require the performance of an aerosol-generating procedure requiring the use of a NIOSH-approved and fit-tested respirator. Because donning and doffing PPE for care of these patients is a time-consuming process there might not be time for staff to leave the room to don proper PPE for an aerosol-generating procedure. Hence, CDC recommends that all healthcare workers who enter the room of a patient with VHF wear respiratory protection that would protect them during an aerosol generating procedure. This would include a NIOSH-approved, fit tested N95 or higher level particulate respirator such as a filtering facepiece respirator or EHMR or a PAPR.
If a respirator fails a fit test, the employer should fit test the employee using another respirator size or model until a respirator passing the fit test is found or provide the employee with a loose-fitting PAPR.
Do alcohol-based hand rub (ABHR) treatments affect the integrity of medical exam nitrile/latex gloves?
Current CDC guidance for the disinfection of gloved hands during PPE doffing allows for multiple applications of ABHR on medical exam gloves. NIOSH research shows that these recommendations should have little to no effect on the integrity of nitrile and latex gloves for up to 6 applications of ABHR containing 70% ethanol. However, the researchers also found that a 63% isopropanol-containing ABHR caused the nitrile and latex gloves tested to become sticky to touch after three or four applications and caused changes in the tensile properties of the nitrile gloves. Employers are encouraged to have healthcare workers responsible for managing patients with VHF practice PPE donning and doffing procedures, including hand hygiene. Switching the type of glove or the type of ABHR product used is necessary if decreased glove integrity (e.g., they start to tear or rip) or unusual changes (e.g., they become sticky, shrink, or harden) that would affect work-related tasks are observed during training and practice.
Why does CDC recommend two pairs of gloves for caring for patients with VHF?
Double-gloving provides an outer layer that allows convenient removal of a heavily soiled glove during direct patient care and during the PPE removal process. However, any additional layers of gloves (beyond double-gloving) may make it more difficult to perform patient care duties and can put healthcare workers at greater risk for injury (e.g., needlesticks), self-contamination during care or doffing, or other exposures to VHF. If healthcare facilities decide to add additional PPE or modify this PPE guidance, they must consider the risks and benefits of any modification, and train healthcare workers on correct donning and doffing in the modified procedures.
Do food-grade vinyl gloves provide adequate protection in dealing with bloodborne pathogens?
No. Medical-grade gloves provide a strong barrier to bloodborne pathogens, such as those found in blood, urine, saliva, and infectious waste from individuals with VHF. Food-grade gloves do not meet these requirements, which are set forth by the Food and Drug Administration.
What does CDC recommend to prevent contamination of the floor? Are a variety of techniques acceptable?
There are a number of different approaches to prevent the contamination of the floor. CDC’s guidance suggests the following steps: (1) remove the shoe cover, (2) disinfect the shoes, and (3) step into a clean area wearing disinfected shoes.
Some facilities have recommended using pads and chemical mats as effective. The facility should choose an option that works best in the specific environment. When approaches that require wetting the floor are incorporated, healthcare personnel must not be at risk for slipping during the doffing process.
If a caregiver is in a patient room for a long period of time, the caregiver may need to sit down. This may cause the back side of the gown to be contaminated. Will this affect doffing? (Or is the back side of the gown always considered contaminated?)
The room of a patient who has VHF is considered contaminated and anything that enters the room is also considered contaminated. CDC guidance suggests that the front of the gown is where the risk of contamination is highest, but the procedures for removing the PPE ensures the outside of the PPE being removed, including the back side, does not make contact with clothing, skin or mucous membranes.
Facilities should be aware that some isolation gowns do not have an overlap of fabric in the back when tied. Gowns with an overlap of fabric in the back should be selected to protect clothing from inadvertent soiling as recommended by CDC.
What is the protocol for removing the trained observer’s PPE after that person has helped someone doff? Does someone else have to “suit up” to help the observer doff?
Since the trained observer has not provided direct patient care and the likelihood of having contaminated PPE is low, there is no need to have another person put on PPE to monitor the removal of the observer’s PPE. One option that healthcare facilities have used is to have the healthcare worker who has just doffed PPE stand at a distance in a clean area and act as the trained observer who then observes the original trained observer doff their PPE using the same protocol.
How much PPE should our facility consider having on hand?
To determine the amount of PPE a hospital needs for a multi-disciplinary team managing a patient with VHF, facilities should consider various factors including: the acuity of patient, configuration of the healthcare team/roles and intended interaction with the patient, the length of shifts, number of required breaks for staff in PPE, the isolation unit location and support strategies, the waste management strategy, lab location, lab testing demand, and hospital protocols for products. Hospital inventory needs must be assessed on a case-by-case basis and should consider these and any other relevant factors.
N95 and NIOSH Approved are certification marks of the U.S. Department of Health and Human Services (HHS) registered in the United States and several international jurisdictions.