blog

In her recent Research article published on F1000Research, Saskia den Boon and colleagues surveryed health workers views around personal protective equipment during the West Ebola outbreak in 2014-2015. In this guest blog, Saskia describes the findings of this survey and how they were used to inform WHO guidelines.

In August 2014 the outbreak of Ebola virus disease (EVD) in West Africa was declared a Public Health Emergency of International Concern. At that point in time the number of cases was rapidly increasing each week. Ultimately there would be 28,616 cases and 11,310 deaths. Health workers were disproportionally affected with 881 cases and 513 deaths by late 2015.

Personal Protective Equipment

A rapid review of the efficacy and comparative effectiveness of various components of PPE showed insufficient evidence to draw conclusions about comparative effectiveness of various types of PPE

Personal Protective Equipment (PPE) forms an effective barrier from contaminated fluids, protecting health workers from exposure to the Ebola virus. PPE is one of the more visible aspects of Infection Prevention and Control. At the start of the Ebola outbreak there was confusion about the requirements for PPE. Countries affected by the Ebola outbreak requested WHO to develop technical recommendations on appropriate PPE.

WHO thus faced the challenge of developing evidence-based recommendations in a very short time span. A rapid review of the efficacy and comparative effectiveness of various components of PPE showed insufficient evidence to draw conclusions about comparative effectiveness of various types of PPE. In this situation, the guideline development group considered information on the values and preferences of health workers as particularly important for contextualization and adequate decision making.

Online survey of international health workers

We developed an online survey targeting international health workers employed by Médicins Sans Frontières and WHO as first line responders to the Ebola outbreak in West Africa. Although we recognized that our study findings would not reflect the experiences and perspectives of local health workers or those deployed by other organizations, this was a pragmatic decision allowing us to carry out the survey in a limited time while not distracting health workers actively working in the field.

Fogging of goggles and face shields

WHO is continuing to address the challenges of developing evidence-based guidance during emergency situations

We found that health workers felt at low or extremely low risk regardless of the type of PPE used. Health workers were generally confident that they were using PPE correctly. However, a number of challenges with items of PPE were identified.

Eye protection, particularly goggles, were frequently affected by fogging, affecting visibility. Survey participants also noted that goggles did not cover sufficient skin of the face, were of poor quality or of poor fit. Eye protection was found to impair communication and the ability to provide care. Goggles were considered less comfortable than face shields.

Nose and mouth protection, both medical mask and respirator, were reported to cause difficulty breathing when wet, for example due to sweat or condensation. Respirators and medical masks impaired communication. Gloves sometimes slipped down causing some health workers to tape them to the gown or coverall. This, in turn, occasionally led to tearing when removing the tape.

Heat and dehydration

Heat and dehydration were a significant or major issue for the majority of individuals, irrespective of whether they were using a gown or coverall. Many survey participants indicated the need for lighter suits with better ventilation. In several instances the available coveralls were too small. A number of health workers indicated that they had difficulty taking off the coverall.

Specific issues included having to remove the face shield first, leaving the eyes and face unprotected while undressing from the coverall, and problems taking off the coverall over large rubber boots. Waiting for cleaning and drying of reusable items such as goggles and boots added logistical challenges.

Survey participants made several suggestions that could make a major contribution to health worker safety and comfort, such as providing a sufficient range of sizes, choice of equipment, and adequate training on how to put on and take off PPE in the conditions that will be faced in the field.

WHO health emergency guidelines

The WHO rapid advice guideline on PPE took four months to develop including the time to carry out the rapid review of the evidence of comparative effectiveness and our survey on values and preferences of health workers. WHO is continuing to address the challenges of developing evidence-based guidance during emergency situations, recognizing that guidance may sometimes be needed in a matter of days or weeks. WHO has recently published a guideline development framework and toolkit for health emergency interim guidelines.