<h4>Background</h4>In epidemics of highly infectious diseases, such as Ebola, severe acute respiratory syndrome (SARS), or coronavirus (COVID-19), healthcare workers (HCW) are at much greater risk of infection than the general population, due to their contact with patients' contaminated body fluids. Personal protective equipment (PPE) can reduce the risk by covering exposed body parts. It is unclear which type of PPE protects best, what is the best way to put PPE on (i.e. donning) or to remove PPE (i.e. doffing), and how to train HCWs to use PPE as instructed.<h4>Objectives</h4>To evaluate which type of full-body PPE and which method of donning or doffing PPE have the least risk of contamination or infection for HCW, and which training methods increase compliance with PPE protocols.<h4>Search methods</h4>We searched CENTRAL, MEDLINE, Embase and CINAHL to 20 March 2020.<h4>Selection criteria</h4>We included all controlled studies that evaluated the effect of full-body PPE used by HCW exposed to highly infectious diseases, on the risk of infection, contamination, or noncompliance with protocols. We also included studies that compared the effect of various ways of donning or doffing PPE, and the effects of training on the same outcomes.<h4>Data collection and analysis</h4>Two review authors independently selected studies, extracted data and assessed the risk of bias in included trials. We conducted random-effects meta-analyses were appropriate.<h4>Main results</h4>Earlier versions of this review were published in 2016 and 2019. In this update, we included 24 studies with 2278 participants, of which 14 were randomised controlled trials (RCT), one was a quasi-RCT and nine had a non-randomised design. Eight studies compared types of PPE. Six studies evaluated adapted PPE. Eight studies compared donning and doffing processes and three studies evaluated types of training. Eighteen studies used simulated exposure with fluorescent markers or harmless microbes. In simulation studies, median contamination rates were 25% for the intervention and 67% for the control groups. Evidence for all outcomes is of very low certainty unless otherwise stated because it is based on one or two studies, the indirectness of the evidence in simulation studies and because of risk of bias. Types of PPE The use of a powered, air-purifying respirator with coverall may protect against the risk of contamination better than a N95 mask and gown (risk ratio (RR) 0.27, 95% confidence interval (CI) 0.17 to 0.43) but was more difficult to don (non-compliance: RR 7.5, 95% CI 1.81 to 31.1). In one RCT (59 participants) coveralls were more difficult to doff than isolation gowns (very low-certainty evidence). Gowns may protect better against contamination than aprons (small patches: mean difference (MD) -10.28, 95% CI -14.77 to -5.79). PPE made of more breathable material may lead to a similar number of spots on the trunk (MD 1.60, 95% CI -0.15 to 3.35) compared to more water-repellent material but may have greater user satisfaction (MD -0.46, 95% CI -0.84 to -0.08, scale of 1 to 5). According to three studies that tested more recently introduced full-body PPE ensembles, there may be no difference in contamination. Modified PPE versus standard PPE The following modifications to PPE design may lead to less contamination compared to standard PPE: sealed gown and glove combination (RR 0.27, 95% CI 0.09 to 0.78), a better fitting gown around the neck, wrists and hands (RR 0.08, 95% CI 0.01 to 0.55), a better cover of the gown-wrist interface (RR 0.45, 95% CI 0.26 to 0.78, low-certainty evidence), added tabs to grab to facilitate doffing of masks (RR 0.33, 95% CI 0.14 to 0.80) or gloves (RR 0.22, 95% CI 0.15 to 0.31). Donning and doffing Using Centers for Disease Control and Prevention (CDC) recommendations for doffing may lead to less contamination compared to no guidance (small patches: MD -5.44, 95% CI -7.43 to -3.45). One-step removal of gloves and gown may lead to less ba

Background Personal protective equipment (PPE) compliance is important to reduce the rate of transmission of virulent pathogens to health care workers. Medical officer compliance with PPE protocol for COVID-19 was audited in a regional hospital in Australia early in the pandemic response. Methods Compliance was assessed based on the order and technique of donning and doffing PPE, with medical officers from multiple departments and levels of seniority audited. Results Average compliance from all participants was 58.61% with donning and 68.84% with doffing. Conclusion Medical Officer compliance with PPE donning and doffing was poor and additional training was required.

During the start of the COVID-19 pandemic, shortages of personal protective equipment (PPE) necessitated unprecedented and non-validated approaches to conserve PPE at healthcare facilities, especially in high income countries where single-use disposable PPE was ubiquitous. Our team conducted a systematic literature review to evaluate historic approaches for conserving single-use PPE, expecting that lower-income countries or developing contexts may already be uniquely conserving PPE. However, of the 50 included studies, only 3 originated from middle-income countries and none originated from low-income countries. Data from the included studies suggest PPE remained effective with extended use and with multiple or repeated use in clinical settings, as long as donning and doffing were performed in a standard manner. Multiple decontamination techniques were effective in disinfecting single use PPE for repeated use. These findings can inform healthcare facilities and providers in establishing protocols for safe conservation of PPE supplies and updating existing protocols to improve sustainability and overall resilience. Future studies should evaluate conservation practices in low-resource settings during non-pandemic times to develop strategies for more sustainable and resilient healthcare worldwide. Introduction The emergence of SARS-CoV-2 (COVID-19) strained healthcare resources worldwide. Healthcare facilities and hospitals across the world reported severe shortages of supplies, particularly personal protective equipment (PPE) including masks and respirators, gowns, gloves, and eye protection. These shortages were driven by an unprecedented increase in consumption, compounded by factory closures along the global supply chain [ 1 ]. As a result, many hospitals and medical centers worldwide developed individual approaches to manage limited supplies based on guidance from the World Health Organization and data from previous outbreaks [ 2 , 3 , 4 , 5 , 6 , 7 ]. Repeated donning and doffing Fit test failures caused by greater stress on respirator components such as head straps Yes (up to 5 times) Contamination as metric Simulation as a tool for assessing and evolving your current personal protective equipment: lessons learned during the coronavirus disease (COVID-19) pandemic (Lockhart 2020 [ 38 ]) Gowns (reusable) Contamination through PPE, simulated particles visualized with UV light None: switched from reusable to disposable gowns after simulation Careful doffing. A cluster-randomized trial conducted by MacIntyre et al. [ 49 ] found that hospital staff who wore N95 respirators throughout work shifts had fewer cases of clinical respiratory illness compared with staff who wore N95s only for high-risk procedures or when providing direct patient care under infection isolation precautions. Studies also found that N95 respirators were still effective barriers after donning and doffing. A study based in an infectious disease hospital in Brazil found that N95 respirators could be used by healthcare workers during shifts up to 12 hours and reused for up to five days [ 35 ]. Disinfecting personal protective equipment with pulsed xenon ultraviolet as a risk mitigation strategy for health care workers (Jinadatha 2015 [ 51 ]) Plastic face shield, gown material, glass carriers Canine parvovirus (surrogate for Ebola) Lab-based Pulsed xenon ultraviolet (PX-UV) Effectiveness of PX-UV disinfection on different surfaces measured by viral culture; amount of UV that penetrates PPE material when 1 m away from UV source A >4 log virus reduction was found on inoculated glass, face shield and gown materials. UV light penetrance did not exceed safety limits for exposure. Predicted Mode of Transmission: Fomites General Efficacy of face masks and respirators in preventing upper respiratory tract bacterial colonization and co-infection in hospital healthcare workers (MacIntyre 2014 [ 71 ]) Surgical masks and N95 respirators Rate of bacterial colonization of upper respiratory tract Clinical (randomized) Compared with control and mask groups, N95 respirators were significantly more protective from bacterial colonization PPE efficacy—measured by filtration factor Pathogen Type: Bacteria. Pathogen Type: Non-disease specific Professional and home-made face masks reduce exposure to respiratory infections among the general population (van der Sande 2008 [ 76 ]) Filtering facepiece masks (FFP2), surgical masks, homemade masks measurement of aerosol particles Lab FFP2 were most effective in blocking aerosols, followed by surgical masks, and then homemade masks Safety testing improvised COVID-19 personal protective equipment based on a modified full-face snorkel mask (Greig 2020 [ 77 ]) Full-face snorkel mask (novel PPE) Fit testing Lab Novel mask failed quantitative fit testing. Authors do not recommend using novel PPE without quantitative filtration testing Simulation as a tool for assessing and evolving your current personal protective equipment: lessons learned during the coronavirus disease (COVID-19) pandemic (Lockhart 2020 [ 38 ]) Surgical masks, N95s, gowns, eyewear Permeability of PPE under study to liquid, risk of self-contamination Lab Contamination beneath protective gowns is highly possible even with meticulous donning and doffing 3.4.2. Cloth, Homemade, and Novel Masks Studies evaluating the efficacy of cloth or homemade masks in preventing the spread of respiratory viruses are also shown in Table 3 . It also highlights that surgical masks, which are lower in cost compared with N95 respirators, are effective in reducing the risk of infection from pathogens spread via respiratory droplets and fomites. Future research should prioritize (i) assessing the type and effectiveness of PPE conservation practices in developing contexts, (ii) the development of low-cost PPE that can be disinfected and reused, (iii) the creation of protocols for healthcare systems to safely reuse and disinfect existing single-use PPE

Background: Healthcare associated infections are a leading cause of illness and death in the United States and across the world. Environmental surfaces are considered non-critical, although recent evidence suggests that the built environment may contribute to the transmission of pathogens. Ineffective cleaning and disinfecting of environmental non-critical surfaces may increase risk of transmitting nosocomial pathogens leading to hospital acquired infections among hospital patients.Objective: This systematic review identifies elements of cleaning and disinfecting protocols, synthesizing the evidence to evaluate cleaning protocols that effectively reduce surface contamination and minimize risk of hospital acquired illness.Methods: A systematic literature review was conducted with a clearly formulated research question and systematic approach to identify publications, select relevant studies, critically appraise the research through analysis of reported data, and reported the results according to the Cochrane methodology.Results: In total, 245 studies were initially identified with 19 studies meeting inclusion criteria. Emerging categories include chemical application methods, chemical application time, cleaning type and frequency, and interventions for training and monitoring.Conclusions: Establishing adequate cleaning protocols for hospital environments is a complex process which requires consideration of multiple components including mechanical action, chemical application materials, types of cleaning, chemical contact times, education and training of EVS staff, cleaning monitoring and feedback, no-contact cleaning methods, and self-disinfecting surfaces. Recommendations for protocol development based on the study results are provided. jha.sciedupress.com Journal of Hospital Administration 2019, V ol. 8, No. 6 REVIEWS Cleaning and disinfecting protocols for hospital environmental surfaces: A systematic review of the literature Keyanna P. Taylor1, Debra D. Harris ∗2 1Public Health, Baylor University, Waco, TX, United States 2College of Health and Human Sciences, Baylor University, Waco, TX, United States Received: July 28, 2019 Accepted: September 23, 2019 Online Published: October 22, 2019 DOI: 10.5430/jha.v8n6p27 URL: https://doi.org/10.5430/jha.v8n6p27 ABSTRACT Background: Healthcare associated infections are a leading cause of illness and death in the United States and across the world. Environmental surfaces are considered non-critical, although recent evidence suggests that the built environment may contribute to the transmission of pathogens. Ineffective cleaning and disinfecting of environmental non-critical surfaces may increase risk of transmitting nosocomial pathogens leading to hospital acquired infections among hospital patients. Objective: This systematic review identifies elements of cleaning and disinfecting protocols, synthesizing the evidence to evaluate cleaning protocols that effectively reduce surface contamination and minimize risk of hospital acquired illness. The aim of this systematic review was to evaluate the components of cleaning protocols for environmental surfaces in hospital settings since the publication of the CDC guide- lines.[6, 8] While there are specific guidelines and recommen- dations published including and since the CDC guidelines, there are no comprehensive guidelines available to inform the cleaning and disinfecting of environmental surfaces. 28 ISSN 1927-6990 E-ISSN 1927-7008 jha.sciedupress.com Journal of Hospital Administration 2019, V ol. 8, No. 6 2. Low rates of cleaning, between 12.3% and 18% of rooms overall, were found for bedpan cleaning equipment, patient room and bathroom doorknobs/pulls, and toilet grab bars.[32, 33] Another study assessed the ability of a structured interven- tion program to improve the quality of cleaning and reduce environmental transmission of multidrug-resistant organisms (MDROs) within the intensive care unit. [34] At baseline, only 49.5% of surfaces were cleaned. After the intervention and multiple cycles of objective performance feedback to Published by Sciedu Press 33 jha.sciedupress.com Journal of Hospital Administration 2019, V ol. 8, No. No touch decontamination methods include aerosolized hydrogen peroxide, hydrogen peroxide vapor systems, ultraviolet light, and others.[83] No touch decontam- ination methods may be effective ways to reduce nosocomial pathogens on environmental surfaces, and should be further explored when establishing cleaning protocols.[84, 85] Self-disinfecting surfaces may be a potential method for reducing environmental contamination in hospital settings. This review addressed the complexities involved in devel- oping or selecting protocols for cleaning and disinfecting environmental surfaces and preventing HAI acquisition. ACKNOWLEDGEMENTS The authors disclosed receipt of the following financial sup- port for the research: This work was supported by the Health- care Surfaces Institute. CONFLICTS OF INTEREST DISCLOSURE The authors declare they have no conflicts of interest. REFERENCES [1] Han JH, Sullivan N, Leas BF, et al. Cleaning hospital room surfaces to prevent health care-associated infections: a technical brief. An- nals of Internal Medicine. 2015; 163(8): 598-607. PMid: 26258903. Copper surfaces reduce the rate of healthcare-acquired infections in the intensive care unit. Infect Control Hosp Epidemiol. 2013 May; 34(5): 479-86. PMid: 23571364. https://doi.org/10.1086/670207 [90] Schmidt MG, Attaway HH, Sharpe PA, et al. Sustained reduction of microbial burden on common hospital surfaces through introduc- tion of copper. J Clin Microbiol. 2012 Jul; 50(7): 2217-23. PMid: 22553242. https://doi.org/10.1128/JCM.01032-12 [91] Schmidt MG, von Dessauer B, Benavente C, et al. Copper sur- faces are associated with significantly lower concentrations of bac- teria on selected surfaces within a pediatric intensive care unit. Am J Infect Control. 2016 Feb; 44(2): 203-9.

Highly infectious disease epidemics such as COVID-19 put healthcare workers at higher risk of infection than regular people as they come into more potential contact with contaminated respiratory droplets and so caution is warranted in the use of personal protective equipment (PPE) to lessen risk. It is not clear what kind of PPE best offers protection and the best way to remove PPE. PPE is used by Healthcare workers in the COVID-19 virus disease situation. Its use is an integral part of the strategy to combat COVID-19 and prevent its spread. Optimal PPE use is hard and thus healthcare workers may alter the delivery of care because of improper PPE use. Preventing contamination of PPE during donning and doffing therefore becomes crucial and requires improvisation. Donning and doffing of PPE should include adherence to protocols as well as COVID- 19 specific design of PPE and further research into the risks, benefits, and best practices of PPE use. Lastly, training of users must be stressed to minimize protocol deviations and in turn guarantee the best protection to HCWs. While ranked as the lowest in infection control hierarchy due to its effectiveness as compared to other measures and high cost, PPE is nonetheless extremely important and often overlooked aspect during early outbreak stages of a pandemic where neither drugs nor vaccines are available and access to them is limited. This paper sheds light on the donning and doffing protocols that should be used as well as discuss

Background: Coronavirus Disease 2019 (COVID-19) is a respiratory infection with a high rate of transmission primarily via airborne route and direct contact. Proper use of personal protective equipment (PPE) is a proven and effective way to prevent COVID-19 spread in healthcare settings. This study was done aiming to assess the knowledge, attitude, and reported practice, and identify the associated factors regarding donning and doffing of PPE among frontline healthcare workers in Nepal. Methods: A cross-sectional study was conducted from 25th April to 30th July 2021 among 205 frontline healthca

Identifying the optimal amount of personal protective equipment (PPE) is a formidable challenge when faced with a new contagion such as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Unequivocally, there are dangers to health care workers (and by extension, their patients, colleagues, and communities) if not enough equipment is donned to safeguard them. And yet, there are also dangers to patients, colleagues, and the community if resources are overconsumed and result in hoarding, shortages, and inequitable distribution, all of which are occurring as the worldwide coronavirus disease 2019 (COVID-19) pandemic continues.Research to ascertain the precise PPE required to defend specifically against SARS-CoV-2 encompasses an area of active investigation that will likely remain unresolved for some time. While awaiting more definitive conclusions, we must look to past evidence to provide a reasonable basis on which protocols and policies might be refined. What follows is a narrative review of PPE efficacy and how existing evidence might apply to protecting health care workers against COVID-19. Findings are extrapolated from investigations in 4 general domains: early investigations into SARS-CoV-2, retrospective studies about severe acute respiratory syndrome coronavirus 1, prospective studies of influenza and other common respiratory viruses, and laboratory PPE studies.Available evidence suggests that contact and droplet precautions, in addition to eye protection and standard hygiene measures, should be adequate in the vast majority of clinical settings when caring for patients with SARS-CoV-2. Adherence to guidelines promoting appropriate levels of PPE should safeguard practitioners while mitigating against resource overuse.