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Personal Protective Equipment for Use in a Filovirus Disease Outbreak

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Personal Protective Equipment for Use in a Filovirus Disease Outbreak Personal protective equipment for use in a filovirus disease outbreak Rapid advice guideline Personal protective equipment for use in a filovirus disease outbreak Rapid advice guideline WHO Library Cataloguing-in-Publication Data Personal protective equipment for use in a filovirus disease outbreak: Rapid advice guideline. I.World Health Organization. ISBN 978 92 4 154972 1 Subject headings are available from WHO institutional repository © World Health Organization 2016 All rights reserved. Publications of the World Health Organization are available on the WHO website (http://www. who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; email: [email protected]). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO website (http://www.who.int/about/licensing/ copyright_form/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Design & layout: Sophie Guetaneh Aguettant Printed in Spain Contents Foreword v Acknowledgements vii Abbreviations and acronyms used in this document viii Executive summary ix 1. Background 1 2. Purpose and target audience 2 3. Methods of guideline development 3 3.1 Technical consultation 3 3.2 Conflict of interest assessment 4 3.3 Decision-making during the consultation 4 3.4 External peer review 4 4. PPE in the framework of infection prevention and control and health worker safety and well-being 5 4.1 Infection prevention and control 5 4.2 Safety and well-being of health workers 6 5. Evidence assessment 7 5.1 Biology and mode of transmission of Ebola virus 7 5.2 Rapid literature review 8 5.3 Literature review of values and preferences of health workers 10 5.4. Online survey of values and preferences of health workers 11 5.5 Guiding principles for decision-making 13 5.6 GRADE assessment and evidence-to-decision tables 13 6. Recommendations 14 6.1 Mucous membrane protection 14 6.2 Gloves 20 6.3 Clothing and covering for clothing 23 6.4 Footwear 28 6.5 Head cover 29 iii 7. Implementation 30 8. Gaps in knowledge and research agenda 31 9. Dissemination, evaluation and plans for updating 32 References 33 Annex 1. Contributors to this document 35 A. WHO Steering Group 35 B. Guideline Development Group 36 C. Consultants 36 D. Observers 36 E. External peer reviewers 37 F. Rapid review research team 37 G. Literature review of values and preferences of health workers on PPE 37 H. Online survey of values and preferences of health workers on PPE 37 Annex 2. Declarations and management of interests 38 Annex 3. Evidence-to-decision tables 40 Annex 4. How to put on and how to remove personal protective equipment - posters 52 iv Foreword Health workers are among the first to respond when an infectious pathogen threat- ens a community. Indeed, they are often among the first to be affected -- a cluster of cases of severe illness in health care workers can be the first sign that something unusual is going on. Before the cause of an outbreak has been identified and before infection-control measures have been put in place, health workers can find them- selves at heightened risk of infection. This was the case in 2014, when the Ebola epidemic began in West Africa. Many doctors, nurses and other health workers became infected in the workplace and died. Responding to an urgent request from Member States, the World Health Organization (WHO) undertook the development of a rapid advice guideline on Personal Protective Equipment, an important component of Infection Prevention and Control. The publication in October 2014 of the guideline summary marked the first time that WHO implemented a new, state-of-the-art approach to the development of evidence-informed, rapid advice guidelines. It was also the first time that a rapid advice guideline included technical specifications. Based on this and other experiences over the past two years, WHO is putting in place processes, procedures and methods for developing guidelines in response to public health emergencies, addressing the need for timely guidance containing valid, feasible recommendations, often in the context of sparse data and challeng- ing field conditions. In many countries, the health system depends heavily on just a few health workers. This human resource is precious. Infection, and worse, death, of just a few can drastically reduce a health system’s capacity to deliver basic care. Thus, any effort that protects a country’s health workers also protects its health system and its long term investment in health. Maximizing health gains while minimizing the risk for health workers and their families equates to health protection of the larger community as well. Dr Sylvie C. Briand, Director Pandemic and Epidemic Diseases Department (PED) Infectious Hazard Management (IHM) WHO Health Emergency programme (WHE) v vi Acknowledgements These guidelines were produced by the World Health Organization Department of Pandemic and Epidemic Diseases under the coordination of Constanza Vallenas and Nahoko Shindo. They were written by Saskia den Boon (contractor), Ying Ling Lin, Elizabeth Mathai, Yukiko Nakatani, Nahoko Shindo, Constanza Vallenas, and Adriana Velazquez. The following WHO staff members also made contributions: Benedetta Allegranzi, Jean- Christophe Aze, Yolanda Bayugo, Sophie Boisson, Sylvie Briand, Caroline Cross, Irene Dolan, Sergey Eremin, Pierre Formenty, Robert Fowler, Ivan Ivanov, François Jorda, Edward Kelley, Jean-Bosco Ndihokubwayo, Junko Okumura, Carmem Pessoa-Silvia, Dina Pfeiffer, Charlotte Rasmussen, Andreas Reis, Jose Rovira Vilaplana, Lara Schwarz, Mikiko Senga and Rebekah Thomas Bosco. Susan L Norris provided valuable guidance on the WHO process of rapid guideline development. WHO gratefully acknowledges the many individuals who contributed to the development of this document; a full list of contributors is given in Annex 1. These guidelines were developed using emergency funds for the Ebola outbreak made available by the World Health Organization. Additional funds were provided by the Government of Japan. Photo credits: © WHO/DCO, © WHO/ECM, Frederique Jacquerioz. Line drawings: Jessica Shull. vii Personal protective equipment for use in a filovirus disease outbreak Abbreviations and acronyms AIDS acquired immunodeficiency syndrome CDC Centers for Disease Control and Prevention (of the United States of America) CI confidence interval DOI declaration of interest ERG external review group ETU Ebola treatment unit EU European Union EVD Ebola virus disease GDG Guideline Development Group GRADE Grading of Recommendations Assessment, Development and Evaluation GRC Guideline Review Committee HIV human immunodeficiency virus IPC infection prevention and control mRNA messenger ribonucleic acid MSF Médecins sans Frontières (Doctors without Borders) NIOSH National Institute for Occupational Safety and Health OHRI Ottawa Hospital Research Institute PICO population, intervention, comparator, outcome PPE personal protective equipment PVC polyvinyl chloride RNA ribonucleic acid SARS severe acute respiratory syndrome WHO World Health Organization viii Rapid advice guideline Executive summary Background Filoviruses (Ebola and Marburg) are highly contagious pathogens, which cause severe and often fatal illness in humans. Health workers are at increased risk of infection with these viruses because of their close and prolonged con- tact with severely ill patients with a high viral load. The risk of transmission of Ebola virus can be reduced if appropriate measures are taken, including the use of personal protective equipment (PPE). The urgent need for clear standards for PPE use became acutely apparent during the unprecedented outbreak of Ebola virus disease (EVD) in certain western African countries in 2013–16. Methods of guideline development The present guidelines, which were developed between July and October 2014 in accordance with WHO rapid advice guideline procedures, are intended for health workers providing direct care to patients with known or suspected filovirus disease. A Guideline Development Group (GDG) was formed, com- prising 13 experts in a broad range of technical areas who were invited on the basis of their knowledge, experience and technical expertise. All GDG members completed a WHO declaration
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