For General Healthcare Settings in West Africa: Personal Protective Equipment (PPE) Recommended for Low Resource Settings

Key Points

• PPE is specialized clothing or equipment worn by healthcare workers for protection against viruses like Ebola.
• This guidance covers the types of PPE, specifications for wearing PPE, and common mistakes when wearing PPE.

When worn correctly, personal protective equipment (PPE) acts as a barrier to protect the user's eyes, nose, mouth, skin, and clothing from contact with body fluids that may contain Ebola.

Personal protective equipment (PPE) is specialized clothing or equipment worn by healthcare workers (HCWs) to protect against infection with microorganisms like Ebola virus. When worn correctly, PPE reduces the risk of exposure to contaminated body fluids and surfaces and can help prevent the spread of disease.

The following guidance is not designed for Ebola treatment units (ETUs). It is designed for general healthcare facilities where people are seen for a variety of medical concerns.

In countries with Ebola outbreaks, there is a risk that patients with EVD will seek care at a general (non-ETU) healthcare facility. Patients with EVD may enter a general healthcare facility and receive care before their illness is recognized or diagnosed, exposing healthcare workers and patients to Ebola. Infection control is critical to prevent the transmission of Ebola in healthcare facilities.

PPE is designed to prevent infectious agents, including viruses like Ebola, from entering a person’s body through broken skin or through the eyes, nose, or mouth. Wearing PPE alone is not sufficient to protect against infection or spreading infection. However, by learning and following proper infection control practices, which include carefully putting on and especially taking off PPE, HCWs can protect themselves and others. CDC recommends following a strict step-by-step procedure for putting on and removing PPE.

The process of putting on and removing PPE is just as important as the type of PPE being worn. Even the best and most complete PPE can still be a source of infection if taken off incorrectly. This is true in both ETUs and general healthcare settings.

The PPE that is available and the standards used for PPE differ by country. The PPE recommended here may differ from CDC’s recommendations for U.S. healthcare settings.

How is Ebola Spread?

• Ebola is spread through direct contact, such as contact with broken skin or mucous membranes, or by injection. It is not spread through air or water. The following are all sources of possible Ebola transmission:
  • Blood or body fluids (such as vomit, feces, urine, saliva, sweat, breast milk, or semen) of a person who is sick with or who has died from Ebola,
  • Objects (like needles and syringes) that have been contaminated with infected body fluids,
  • Infected fruit bats or primates (apes and monkeys), and
  • Possibly from contact with semen from a man who has recovered from Ebola (for example, by having oral, vaginal, or anal sex).

Why Wear PPE?

PPE acts as a barrier to protect the user’s eyes, nose, mouth, skin, and clothing from contact with body fluids that may contain Ebola.

What is PPE?

PPE is specialized clothing or equipment worn by healthcare workers for protection against viruses like Ebola. Examples of PPE include

• PVC or rubber boots to protect legs and feet
• Gloves to protect hands
• Impermeable gown or coveralls to protect skin and clothing
• Apron to provide maximal protection to the front of the body against contaminated body fluids
• Face mask to protect nose and mouth
• Goggles or face shield to protect eyes
• Head cover to protect the head from contamination when removing mask or face shield

Table 1. PPE Specifications

PPE component	Specification
Boots	PVC (or rubber), anti-slip profile, knee high or overshoes
Gloves	Nonsterile nitrile and non-sterile surgical gloves. Fit both right and left hand (ambidextrous)
Gown or coveralls	Moisture-proof, nonwoven, four cloth layers, sterile, disposable, and with elastic cuffs.
Head cover	Impermeable head cover that includes neck protection
Face mask	Surgical mask
Eye protection	Face shield: crystal-clear plastic with foam cushion, fog resistant, full-face length, disposable. Goggles can be used if face shields are not available.
Apron	Impermeable, reusable
Cleaners’ gloves	Second layer of reusable thick heavy-duty gloves (such as dishwashing gloves) for handling high-risk body fluids and environmental contamination

Types of PPE

Basic PPE protects the parts of the body that are at highest risk for contamination: hands, eyes, nose, and mouth. It is the minimum level of protective wear required for all healthcare workers before interacting with patients at non-ETUs. Basic PPE includes

• Boots
• Single pair of gloves
• Face shield (goggles and a face mask can be used if a face shield is not available)

Extended PPE is a higher level of protection required when healthcare workers may come into contact with a patient’s blood, vomit, diarrhea, or other body fluids, or when caring for any patient under investigation for EVD or patients with confirmed EVD. Extended PPE includes

• Impermeable gown
• Inner gloves (non-sterile nitrile preferred)
• Outer gloves (non-sterile surgical preferred)
• Head cover
• Face mask
• Face shield (goggles can be used if a face shield is not available)
• Boots

Cleaners’ PPE is a form of extended PPE designed for people who handle waste material that may be contaminated with the Ebola virus, such as cleaners and burial team members. Cleaners’ PPE includes

• Impermeable gown
• Inner gloves (non-sterile nitrile preferred)
• Outer gloves (thick, heavy-duty rubber glove)
• Head cover
• Face mask
• Face shield (goggles can be used if a face shield is not available)
• Boots
• Waterproof apron

Table 2. Recommended PPE for Healthcare Workers in General Healthcare Settings in Countries with Ebola Outbreaks

PPE Specification	Basic	Extended	Cleaners’
Shoe cover/Boots	Boots: anti-slip profile, knee high	Boots: anti-slip profile, knee high	Boots: anti-slip profile, knee high
Gloves	Use either: Examination gloves without powder, ambidextrous nitrile non-sterile, OR Surgical gloves, disposable	Double gloves: Inner gloves: examination gloves without powder, ambidextrous nitrile non-sterile, AND Outer gloves: surgical gloves, disposable	Double gloves: Inner gloves: examination gloves without powder, ambidextrous nitrile non-sterile, AND Outer gloves: heavy-duty rubber gloves
Gown	Not recommended	Surgical gown, impermeable	Surgical gown, impermeable
Head cover	Not recommended	Required	Required
Face mask	Not recommended if wearing a face shield, required if wearing goggles	Required	Required
Face shield or goggles	Face shield preferred, but goggles OK if face shield is not available	Face shield preferred, but goggles OK if face shield is not available	Face shield preferred, but goggles OK if face shield is not available
Apron	Not recommended	Not recommended	Surgical apron: rubber, long enough to cover top of boot

Common Mistakes with PPE

Common mistake	Corrective action
A nurse who has finished taking care of a patient removes a pair of gloves and leaves to go to lunch without stopping to wash hands.	Always wash hands with soap and water, alcohol-based hand sanitizer, or 0.05% mild chlorine solution after removing gloves. Hands can be contaminated during the process of removing gloves or through tiny holes in the gloves that may not be visible.
A cleaner is wearing full PPE and has just finished cleaning the latrine. The heat from working has caused the cleaner’s forehead to sweat. The cleaner lifts the face shield and wipes away the sweat with a gloved hand.	The cleaner’s gloves are contaminated from cleaning the latrine. Using a gloved hand could transfer Ebola from the glove’s surface, increasing the possibility of infection through the eyes, nose, or mouth. PPE should always be removed according to safe procedures and then hands should be washed before touching any part of the face.
A doctor is wearing gloves when examining a patient. The phone rings. The doctor reaches to answer the phone with a gloved hand.	The doctor has just contaminated the phone by touching it with the glove that was just in contact with the patient. The correct thing to do is wash hands, remove the gloves, and wash hands again before using the phone.

Click here for additional information on PPE and steps for putting on and taking off PPE.

*Healthcare Workers (HCWs) are all people, paid and unpaid, working in healthcare settings who have the potential for exposure to patients or to infectious materials. HCWs include, but are not limited to, physicians, nurses, technicians, emergency medical service personnel, pharmacists, laboratory personnel, autopsy personnel, students and trainees, and people not directly involved in patient care (clerical, dietary, housekeeping, laundry, security, and volunteers).