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Coronavirus disease 2019 (COVID-19), caused by the COVID-19 virus, was first detected in Wuhan, China, in December 2019. On 30 January 2020, the
WHO Director-General declared that the current outbreak constituted a public health emergency of international concern.
ThisdocumentsummarizesWHO’srecommendationsforthe rational use of personal protective equipment (PPE) in healthcare and community settings, as well as during the handling of cargo; in this context, PPE includes gloves, medical masks, goggles or a face shield, and gowns, as well asfor specific procedures, respirators (i.e., N95 or FFP2 standard or equivalent) and aprons. This document is intended for those who are involved in distributing and managing PPE, as well as public health authorities and individualsinhealthcareandcommunitysettings,anditaims to provide information about when PPE use is most appropriate.
WHOwillcontinuetoupdatetheserecommendationsasnew information becomesavailable.
Preventive measures for COVID-19 disease
Based on the available evidence, the COVID-19 virus is transmitted between people through close contact and droplets, not by airborne transmission. The people most at risk of infection are those who are in close contact with a COVID-19 patient or who care for COVID-19 patients.
Preventiveandmitigationmeasuresarekeyinbothhealthcare and community settings. The most effective preventive measures in the communityinclude:
performing hand hygiene frequently with an alcohol-basedhandrubifyourhandsarenot visibly dirty or with soap and water if hands aredirty;
avoiding touching your eyes, nose andmouth;
practicing respiratory hygiene by coughingor sneezing into a bent elbow or tissue and then immediately disposing of thetissue;
wearing a medical mask if you haverespiratory symptoms and performing hand hygiene after disposing of themask;
maintaining social distance (a minimum of 1m) from individuals with respiratorysymptoms.
Additional precautions are required by healthcare workersto protectthemselvesandpreventtransmissioninthehealthcare setting.Precautionstobeimplementedbyhealthcareworkers caring for patients with COVID-19 disease includeusing
PPEappropriately;thisinvolvesselectingtheproperPPEand being trained in how to put on, remove and dispose ofit.
PPE is only one effective measure within a package that comprisesadministrativeandenvironmentalandengineering controls, as described in WHO’s Infection prevention and control of epidemic- and pandemic-prone acute respiratory infections in health care (1). These controls are summarized here.
Administrative controls include ensuring the availability of resources for infection prevention and control measures, such as appropriate infrastructure, the development ofclear infection prevention and control policies, facilitated access to laboratory testing, appropriate triage and placement of patients, adequate staff-to-patient ratios and training ofstaff.
Environmental and engineering controls aim at reducing the spread of pathogens and reducing the contamination of surfaces and inanimate objects. They includeprovidingadequatespacetoallowsocialdistance of at least 1 m to be maintained between patients and between patients and healthcare workers and ensuring the availability of well-ventilated isolation rooms for patientswithsuspectedorconfirmedCOVID-19disease.
COVID-19 is a respiratory disease that is different from Ebola virus disease, which is transmitted through infected bodily fluids. Due to these differences in transmission, the PPE requirements for COVID-19 are different from those required for Ebola virus disease. Specifically, coveralls (sometimes called Ebola PPE) are not required when managing COVID-19 patients.
Disruptions in the global supply chain of PPE
The current global stockpile of PPE is insufficient, particularly for medical masks and respirators; the supply of gowns and goggles is soon expected to be insufficient also. Surging global demand − driven not only by the number of COVID-19 cases but also by misinformation, panic buying and stockpiling− will result in further shortages of PPE globally. The capacity to expand PPE production is limited, and the current demand for respirators and masks cannotbemet,especiallyifthewidespread,inappropriateuse of PPEcontinues.
Recommendations for optimizing the availability of PPE.
In view of the global PPE shortage, the following strategies can facilitate optimal PPE availability (Fig. 1).
Fig. 1. Strategies to optimize the availability of personal protective equipment (PPE)
Minimize the need forPPE
The following interventions can minimize the need for PPE while protecting healthcare workers and other individuals from exposure to the COVID-19 virus in healthcare settings.
Consider using telemedicine to evaluate suspected casesofCOVID-19disease(2),thusminimizingthe need for these individuals to go to healthcare facilities forevaluation.
Use physical barriers to reduce exposure to the COVID-19 virus, such as glass or plastic windows. This approach can be implemented in areas of the healthcare setting where patients will first present, such as triage areas, the registration desk at the emergency department or at the pharmacy window where medication iscollected.
Restricthealthcareworkersfromenteringtherooms of COVID-19 patients if they are not involved in directcare.Considerbundlingactivitiestominimize the number of times a room is entered (e.g., check vitalsignsduringmedicationadministrationorhave food delivered by healthcare workers while theyare performingothercare)andplanwhichactivitieswill be performed at thebedside.
Ideally,visitorswillnotbeallowedbutifthisisnotpossible, restrict the number of visitors to areas where COVID-19 patientsarebeingisolated;restricttheamountoftimevisitors are allowed to spend in the area; and provide clear instructionsabouthowtoputonandremovePPEandperform handhygienetoensurevisitorsavoidself-contamination(see https://www.who.int/csr/resources/publications/putontakeoffPPE/en/).
Ensure PPE use is rationalized andappropriate
PPE should be used based on the risk of exposure (e.g., type of activity) and the transmission dynamics of the pathogen (e.g., contact, droplet or aerosol). The overuse of PPE will have a further impact on supply shortages. Observing the following recommendations will ensure that the use ofPPErationalized.
The type of PPE used when caring for COVID-19 patients will vary according to the setting and type of personnel and activity (Table1).
Healthcare workers involved in the direct care of patients should use the following PPE: gowns, gloves,medicalmaskandeyeprotection(gogglesor faceshield).
Specifically, for aerosol-generating procedures (e.g., tracheal intubation, non-invasive ventilation, tracheostomy, cardiopulmonary resuscitation, manualventilationbeforeintubation,bronchoscopy) healthcare workers should use respirators, eye protection,glovesandgowns;apronsshouldalsobe used if gowns are not fluid resistant(1).
Respirators (e.g., N95, FFP2 or equivalent standard) have been used for an extended time duringprevious publichealthemergenciesinvolvingacuterespiratory illness when PPE was in short supply (3). Thisrefers to wearing the same respirator while caring for multiple patients who have the same diagnosis without removing it, and evidence indicates that respirators maintain their protection when used for extended periods. However, using one respirator for longerthan4hourscanleadtodiscomfortandshould be avoided(4−6).
Among the general public, persons with respiratory symptoms or those caring for COVID-19 patients at home should receive medical masks. For additional information, see Home care for patients with suspected novel coronavirus (COVID-19) infection presenting with mild symptoms, and management of their contacts(7).
Forasymptomaticindividuals,wearingamaskofany type is not recommended. Wearing medical masks when they are not indicated may cause unnecessary cost and a procurement burden and create a false sense of security that can lead to the neglect of other essential preventive measures. For additional information, see Advice on the use of masks in the community, during home care and in healthcare settings in the context of the novel coronavirus (2019-nCoV) outbreak(8).
Coordinate PPE supply chainmanagement mechanisms.
The management of PPE should be coordinated through essentialnationalandinternationalsupplychainmanagement mechanisms that include but are not restrictedto:
using PPE forecasts that are based on rational quantification models to ensure the rationalizationof requested supplies;
monitoring and controlling PPE requests from countries and largeresponders;
promoting the use of a centralized request management approach to avoid duplication of stock and ensuring strict adherence to essential stock management rules to limit wastage, overstock and stockruptures;
monitoring the end-to-end distribution ofPPE;
monitoring andcontrolling the distribution of PPE from medical facilitiesstores.
Handling cargo from affected countries
The rationalized use and distribution of PPE when handling cargo from and to countries affected by the COVID-19 outbreak includes following these recommendations.
Wearing a mask of any type is not recommended when handling cargo from an affectedcountry.
Gloves are not required unless they are used for protection against mechanical hazards, such as may occur when manipulating roughsurfaces.
Importantly, the use of gloves does not replace the need for appropriate hand hygiene, which should be performed frequently, as describedabove.
When disinfecting supplies or pallets, no additional PPE is required beyond what is routinely recommended. To date, there is no epidemiological information to suggest that contact with goods or products shipped from countries affected by the COVID-19 outbreak have been the source of COVID-19diseaseinhumans.WHOwillcontinueto closely monitor the evolution of the COVID-19 outbreakandwillupdaterecommendationsasneeded.
Table 1. Recommended type of personal protective equipment (PPE) to be used in the context of COVID-19 disease, according to the setting, personnel and type of activitya
Setting
Target personnel or patients
Activity
Type of PPE or procedure
Healthcare facilities
Inpatient facilities
Patient room
Healthcare workers
Providing direct care to COVID-19 patients.
Medical mask Gown
Gloves
Eye protection (goggles or face shield).
Aerosol-generating procedures performed on COVID-19 patients.
Respirator N95 or FFP2 standard, or equivalent. Gown
Gloves
Eye protection Apron
Cleaners
Entering the room of COVID-19 patients.
Medical mask Gown
Heavy duty gloves
Eye protection (if risk of splash from organic material or chemicals).
Boots or closed work shoes
Visitorsb
Entering the room of a COVID-19 patient
Medical mask Gown
Gloves
Other areas of patient transit (e.g., wards, corridors).
All staff, including healthcare workers.
Any activity that does not involve contact with COVID-19 patients.
No PPE required
Triage
Healthcare workers
Preliminary screening not involving direct contactc.
Maintain spatial distance of at least 1 m.
No PPE required
Patients with respiratory symptoms.
Any
Maintain spatial distance of at least 1 m.
Provide medical mask if
tolerated by patient.
Patients without respiratory symptoms.
Any
No PPE required
Laboratory
Lab technician
Manipulation of respiratory samples.
Medical mask Gown
Gloves
Eye protection (if risk of splash)
Administrative areas
All staff, including healthcare workers.
Administrative tasks that do not involve contact with COVID-19 patients.
No PPE required
Outpatient facilities
Consultation room
Healthcare workers
Physical examination of patient with respiratory symptoms.
Medical mask Gown
Gloves
Eye protection
Healthcare workers
Physical examination of patients without respiratory symptoms.
PPE according to standard precautions and risk assessment.
Patients with respiratory symptoms.
Any
Provide medical mask if tolerated.
Patients without respiratory symptoms.
Any
No PPE required
Cleaners
After and between consultations with patients with respiratory symptoms.
Medical mask Gown
Heavy duty gloves
Eye protection (if risk of splash from organic material or chemicals).
Boots or closed work shoes
Waiting room
Patients with respiratory symptoms.
Any
Provide medical mask if tolerated.
Immediately move the patient to an isolation room or separate area away from others; if this is not feasible, ensure spatial distance of at least 1 m from other patients.
Patients without respiratory symptoms.
Any
No PPE required
Administrative areas
All staff, including healthcare workers.
Administrative tasks
No PPE required
Triage
Healthcare workers
Preliminary screening not involving direct contactc.
Maintain spatial distance of at least 1 m.
No PPE required
Patients with respiratory symptoms.
Any
Maintain spatial distance of at least 1 m.
Provide medical mask if
tolerated.
Patients without respiratory symptoms.
Any
No PPE required
Community
Home
Patients with respiratory symptoms.
Any
Maintain spatial distance of at least 1 m.
Provide medical mask if tolerated, except when
sleeping.
Caregiver
Entering the patient’s room,
but not providing direct care or assistance.
Medical mask
Caregiver
Providing direct care or when handling stool, urine orwaste from COVID-19patient
being cared for athome.
Gloves Medical mask
Apron (if risk of splash)
Healthcare workers
Providing direct care or assistance to a COVID-19 patient at home
Medical mask Gown
Gloves
Eye protection
Public areas (e.g., schools,
shopping malls, train stations).
Individuals without respiratory symptoms
Any
No PPE required
Points of entry
Administrative areas
All staff
Any
No PPE required
Screening area
Staff
First screening (temperature measurement) not involving
direct contactc.
Maintain spatial distance of at least 1 m.
No PPE required
Staff
Second screening (i.e., interviewing passengers with fever for clinical symptoms suggestive of COVID-19
disease and travel history).
Medical mask Gloves
Cleaners
Cleaning the area where passengers with fever are being screened.
Medical mask Gown
Heavy duty gloves
Eye protection (if risk of splash from organic material or chemicals).
Boots or closed work shoes
Temporary isolation area
Staff
Entering the isolation area, but not providing direct assistance.
Maintain spatial distance of at least 1 m.
Medical mask
Gloves
Staff, healthcare workers
Assisting passenger being transported to ahealthcare facility.
Medical mask Gown
Gloves
Eye protection
Cleaners
Cleaning isolation area
Medical mask Gown
Heavy duty gloves
Eye protection (if risk of splash from organic material or chemicals).
Boots or closed work shoes
Ambulance or transfer vehicle
Healthcare workers
Transporting suspected COVID-19 patients to the referral healthcare facility.
Medical mask Gowns Gloves
Eye protection
Driver
Involved only in driving the patient with suspected COVID-19 disease and the driver’s compartment is separated from the
COVID-19 patient.
Maintain spatial distance of at least 1 m.
No PPE required
Assisting with loading or unloading patient with suspected COVID-19 disease.
Medical mask Gowns Gloves
Eye protection
No direct contact with patient with suspected COVID-19, but no separation between driver’s and patient’s
compartments.
Medical mask
Patient with suspected COVID-19 disease.
Transport to the referral healthcare facility.
Medical mask if tolerated
Cleaners
Cleaning after and between transport of patients with suspected COVID-19 disease to the referral healthcare facility.
Medical mask Gown
Heavy duty gloves
Eye protection (if risk of splash from organic material or chemicals).
Boots or closed work shoes
Special considerations for rapid response teams assisting with public health investigationsd
Community
Anywhere
Rapid response team investigators.
Interview suspected or confirmed COVID-19 patients or their contacts.
No PPE if done remotely (e.g., by telephone or video conference).
Remote interview is the preferred method.
In-person interview of suspected or confirmed COVID-19 patients without direct contact.
Medical mask
Maintain spatial distance of at least 1 m.
The interview should be conducted outside the house or outdoors, and confirmedor suspected COVID-19patients should wear a medical mask if tolerated.
In-person interview with asymptomatic contacts of COVID-19 patients.
Maintain spatial distance of at least 1 m.
No PPE required
The interview should be performed outside the house or outdoors. If it is necessary to enter the household environment, use a thermal imaging camera to confirm that the individual does not have a fever, maintain spatial distance of at least 1 m and do not touch anything in the
household environment.
aInadditiontousingtheappropriatePPE,frequenthandhygieneandrespiratoryhygieneshouldalwaysbeperformed.PPEshould be discarded in an appropriate waste container after use, and hand hygiene should be performed before putting on and after taking off PPE.
bThenumberofvisitorsshouldberestricted.IfvisitorsmustenteraCOVID-19patient’sroom,theyshouldbeprovidedwithclear instructions about how to put on and remove PPE and about performing hand hygiene before putting on and after removing PPE; this should be supervised by a healthcareworker.
cThis category includes the use of no-touch thermometers, thermal imaging cameras, and limited observation and questioning, all while maintaining a spatial distance of at least 1 m.
dAll rapid response team members must be trained in performing hand hygiene and how to put on and remove PPE to avoid self-contamination.
For PPE specifications, refer to WHO’s novel coronavirus (COVID-19) disease commodity packages at https://www.who.int/emergencies/what-we-do/prevention-readiness/disease-commodity-packages/dcp-ncov.
