Novel Coronavirus Disease 2019 (COVID-19): Guidelines on rational use of Personal Protective Equipment
1. About this guideline
This guideline is for health care workers and others working in points of entries (POEs), quarantine centers, hospital, laboratory and primary health care / community settings. The guideline uses setting approach to guide on the type of personal protective equipment to be used in different settings.
2. Introduction
Coronaviruses are a large family of viruses, some causing illness in people and others that circulate among animals, including camels, cats and bats. Rarely, animal coronaviruses can evolve and infect people and then spread between people such as has been seen with MERS and SARS.
The outbreak of Novel coronavirus disease (now named COVID-19) was initially noticed from a seafood market in Wuhan city in Hubei Province of China in mid-December, 2019, has spread to more than 185 countries/territories worldwide including India.
The causative agent for COVID-19, earlier termed provisionally as novel Coronavirus has been officially named as SARS-CoV-2.
3. Mode of transmission
There is clear evidence of human-to-human transmission of SARS-CoV-2. It is thought to be transmitted mainly through respiratory droplets that get generated when people cough, sneeze, or exhale. SARS-CoV-2 also gets transmitted by touching, by direct touch and through contaminated surfaces or objects and then touching their own mouth, nose, or possibly their eyes. Healthcare associated infection by SARS-CoV-2 virus has been documented among healthcare workers in many countries.
The people most at risk of COVID-19 infection are those who are in close contact with a suspect/confirmed COVID-19 patient or who care for such patients.
4. Personal Protective Equipment (PPE)
Personal Protective Equipments (PPEs) are protective gears designed to safeguard the health of workers by minimizing the exposure to a biological agent.
4.1 Components of PPE
Components of PPE are goggles, face-shield, mask, gloves, coverall/gowns (with or without aprons), head cover and shoe cover. Each component and rationale for its use is given in the following paragraphs:
4.1.1 Face shield and goggles
Contamination of mucous membranes of the eyes, nose and mouth is likely in a scenario of droplets generated by cough, sneeze of an infected person or during aerosol generating procedures carried out in a clinical setting. Inadvertently touching the eyes/nose/mouth with a contaminated hand is another likely scenario. Hence protection of the mucous membranes of the eyes/nose/mouth by using face shields/ goggles is an integral part of standard and contact precautions. The flexible frame of goggles should provide good seal with the skin of the face, covering the eyes and the surrounding areas and even accommodating for prescription glasses.
4.1.2 Masks
Respiratory viruses that includes Coronaviruses target mainly the upper and lower respiratory tracts. Hence protecting the airway from the particulate matter generated by droplets / aerosols prevents human infection. Contamination of mucous membranes of the mouth and nose by infective droplets or through a contaminated hand also allows the virus to enter the host. Hence the droplet precautions/airborne precautions using masks are crucial while dealing with a suspect or confirmed case of COVID-19/performing aerosol generating procedures.
Masks are of different types. The type of mask to be used is related to particular risk profile of the category of personnel and his/her work. There are two types of masks which are recommended for various categories of personnel working in hospital or community settings, depending upon the work environment:
1. Triple layer medical mask
2. N-95 Respirator mask
4.1.2.1 Triple layer medical mask
A triple layer medical mask is a disposable mask, fluid-resistant, provide protection to the wearer from droplets of infectious material emitted during coughing/sneezing/talking.
4.1.2.2. N-95 Respirator mask
An N-95 respirator mask is a respiratory protective device with high filtration efficiency to airborne particles. To provide the requisite air seal to the wearer, such masks are designed to achieve a very close facial fit.
Such mask should have high fluid resistance, good breathability (preferably with an expiratory valve), clearly identifiable internal and external faces, duckbill/cup-shaped structured design that does not collapse against the mouth.
If correctly worn, the filtration capacity of these masks exceeds those of triple layer medical masks. Since these provide a much tighter air seal than triple layer medical masks, they are designed to protect the wearer from inhaling airborne particles.
4.1.3 Gloves
When a person touches an object/surface contaminated by COVID-19 infected person, and then touches his own eyes, nose, or mouth, he may get exposed to the virus. Although this is not thought to be a predominant mode of transmission, care should be exercised while handling objects/surface potentially contaminated by suspect/confirmed cases of COVID-19.
Nitrile gloves are preferred over latex gloves because they resist chemicals, including certain disinfectants such as chlorine. There is a high rate of allergies to latex and contact allergic dermatitis among health workers. However, if nitrile gloves are not available, latex gloves can be used. Nonpowdered gloves are preferred to powdered gloves.
4.1.4 Coverall/Gowns
Coverall/gowns are designed to protect torso of healthcare providers from exposure to virus. Although coveralls typically provide 360-degree protection because they are designed to cover the whole body, including back and lower legs and sometimes head and feet as well, the design of medical/isolation gowns do not provide continuous whole-body protection (e.g., possible openings in the back, coverage to the mid-calf only).
By using appropriate protective clothing, it is possible to create a barrier to eliminate or reduce contact and droplet exposure, both known to transmit COVID-19, thus protecting healthcare workers working in close proximity (within 1 meter) of suspect/confirmed COVID-19 cases or their secretions
Coveralls and gowns are deemed equally acceptable as there is a lack of comparative evidence to show whether one is more effective than the other in reducing transmission to health workers. Gowns are considerably easier to put on and for removal. An apron can also be worn over the gown for the entire time the health worker is in the treatment area. Coveralls/gowns have stringent standards that extend from preventing exposure to biologically contaminated solid particles to protecting from chemical hazards.
4.1.5 Shoe covers
Shoe covers should be made up of impermeable fabric to be used over shoes to facilitate personal protection and decontamination.
4.1.6. Head covers
Coveralls usually cover the head. Those using gowns, should use a head cover that covers the head and neck while providing clinical care for patients. Hair and hair extensions should fit inside the head cover.
The specifications for all the PPEs are at Annexure-A.
5. Rational use of PPE
The PPEs are to be used based on the risk profile of the health care worker. The document describesthe PPEs to be used in different settings.
5.1. Point of Entry
S. No
Setting
Activity
Risk
Recommended
PPE
Remarks
1
Health Desk
Provide
information to
travellers
Low risk
Triple layer medical
mask
Minimum distance
of one meter needs
to be maintained.
2
Immigration
counters,
customs and
airport security
Provide services
to the passengers
Low risk
Triple layer medical
mask
Gloves
Minimum distance
of one meter needs
to be maintained.
3
Temperature
recording
station
Record
Temperature with
hand held thermal
recorder
Low risk
Triple layer medical
mask
Gloves

4
Holding area/
Isolation
facility of
APHO/ PHO
Interview &
Clinical
examination by
doctors/ nurses
Moderate
Risk
N-95 masks
Gloves

5
Isolation
facility of
APHO
Clinical
management
(doctors, nurses)

Attending to
severely ill
passenger
Moderate
Risk


High risk
N-95 masks
Gloves


Full complement of
PPE




When aerosol
generating
procedures are
anticipated
6
Sanitary staff
Cleaning
frequently
touched surfaces/
Floor/ cleaning
linen
Moderate
risk
N-95 mask
Gloves

7
Administrative
staff
Providing
administrative
support
No risk
No PPE
No contact with
patients of COVID19. They should not
venture into areas
where suspect
COVID-19 cases are
being managed.
5.2. Hospital Setting
5.2.1. Out Patient Department (Respiratory Clinic / Separate screening area)#
S. No
Setting
Activity
Risk
Recommended
PPE
Remarks
1
Triage area
Triaging patients
Provide triple
layer mask to
patient.
Moderate
risk
N 95 mask
Gloves
Patients get masked
2
Screening area
help desk/
Registration
counter
Provide
information to
patients
Moderate
risk
N-95 mask
Gloves

3
Temperature
recording
station
Record
temperature with
hand held thermal
recorder
Moderate
Risk
N 95 mask
Gloves

4
Holding area/
waiting area
Nurses /
paramedic
interacting with
patients
Moderate
Risk
N 95 mask
Gloves
Minimum distance
of one meter needs
to be maintained.
5
Doctors
chamber
Clinical
management
(doctors, nurses)
Moderate
Risk
N 95 mask
Gloves
No aerosol
generating
procedures should
be allowed.
6
Sanitary staff
Cleaning
frequently
touched surfaces/
Floor/ cleaning
linen
Moderate
risk
N-95 mask
Gloves

7
Visitors
accompanying
young children
and elderlies
Support in
navigating various
service areas
Low risk
Triple layer medical
mask
No other visitors
should be allowed to
accompany patients
in OPD settings. The
visitors thus allowed
should practice hand
hygiene
# All hospitals should identify a separate triage and holding area for patients with Influenza likeillness. If there is no triage area / holding area for patients due to resource constraints, such hospitals will follow the above guidance for general OPD.
5.2.2. In-patient Services
S. No.
Setting
Activity
Risk
Recommended
PPE
Remarks
1
Individual
isolation rooms/
cohorted
isolation rooms
Clinical
management
Moderate
risk
N 95 mask
Gloves
Patient masked.
Patients stable. No
aerosol generating
activity
2
ICU/ Critical
care
Critical care
management
High risk

Full complement of
PPE
Aerosol generating
activities performed.
3
ICU /critical
care
Dead body
packing
High risk
Full complement of
PPE

4
ICU/ Critical
care
Dead body
transport to
mortuary
Low Risk
Triple Layer medical
mask
Gloves

5
Sanitation
Cleaning
frequently
touched surfaces/
floor/ changing
linen
Moderate
risk
N-95 mask
Gloves

6
Other NonCOVID
treatment areas
of hospital
Attending to
infectious and
non-infectious
patients
Risk as
per
assessed
profile of
patients
PPE as per hospital
infection prevention
control practices.
No possibility of
exposure to COVID
patients. They
should not venture
into COVID-19
treatment areas
7
Caretaker
accompanying
the admitted
patient
Taking care of the
admitted patient
Low risk
Triple layer medical
mask
The caretaker thus
allowed should
practice hand
hygiene, maintain a
distance of 1 meter
5.2.3. Emergency Department
S.No
Setting
Activity
Risk
Recommended
PPE
Remarks
1
Emergency
Attending
emergency cases
Moderate
risk
N 95 mask
Gloves
When aerosol
generating
procedures are
anticipated
2
Attending to
severely ill
patients of SARI
High risk
Full complement of
PPE
Aerosol generating
activities performed.

5.2.4. Pre-hospital (Ambulance) Services
S. No
Setting
Activity
Risk
Recommended
PPE
Remarks
1
Ambulance
Transfer to
designated
hospital
Transporting
patients not on
any assisted
ventilation
Moderate
risk
N-95 mask
Gloves



Management of
SARI patient
while transporting
High risk
Full complement of
PPE
When aerosol
generating
procedures are
anticipated


Driving the
ambulance
Low risk
Triple layer medical
mask
Gloves
Driver helps in
shifting patients to
the emergency
5.2.4. Pre-hospital (Ambulance) Services
S. No
Setting
Activity
Risk
Recommended
PPE
Remarks
1
Ambulance
Transfer to
designated
hospital
Transporting
patients not on
any assisted
ventilation
Moderate
risk
N-95 mask
Gloves

2

Management of
SARI patient
while transporting
High risk
Full complement of
PPE
When aerosol
generating
procedures are
anticipated
5.2.5. Other Supportive/ Ancillary Services
S. No
Setting
Activity
Risk
Recommended
PPE
Remarks
1
Laboratory
Sample collection
and transportation

Sample testing
High risk


High risk
Full complement
of PPE

Full complement
of PPE

2
Mortuary
Dead body
handling

While performing
autopsy
Moderate
Risk

High Risk
N 95 mask
Gloves

Full complement
of PPE
No aerosol generating
procedures should be allowed.
No embalming.
No post-mortem
unless until specified.
3
Sanitation
Cleaning
frequently
touched surfaces/
Floor/ cleaning
linen in COVID
treatment areas
Moderate
risk
N-95 mask
Gloves

4
CSSD/Laundry
Handling linen of
COVID patients
Moderate
risk
N-95 mask
Gloves

5
Other
supportive
services
Administrative
Financial
Engineering
Security, etc.
No risk
No PPE
No possibility of
exposure to COVID
patients. They should
not venture into
COVID-19 treatment
areas.
5.3. Health Workers in Community Setting
S. No
Setting
Activity
Risk
Recommended
PPE
Remarks

Field Surveillance
Low Risk
Triple layer mask
Gloves
Maintain distance of
one meter.
Surveillance team to
carry adequate triple
layer masks to
distribute to suspect
cases detected on
field surveillance