Introduction


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WHO/EVD/Guidance/PPE/14.1









October 2014



Introduction

This document provides a summary of recommendations for personal protective equipment (PPE) to be
used by health workers providing clinical care for patients with filovirus infection (Ebola and Marburg). The
recommendations have been developed in accordance with the WHO Rapid Advice Guideline procedures.
The technical specifications accompanying these recommendations are available in Annex 1.


Principles guiding PPE use


Controls
Preventing virus transmission in health-care settings requires the application of procedures and protocols
referred to as “controls”. These are, in order of Infection Prevention and Control (IPC) effectiveness:
administrative controls, environmental and engineering controls, and personal protective equipment (PPE).
Although PPE is the most visible control used to prevent transmission, it must be used in conjunction with
administrative and engineering controls (such as facilities for barrier nursing and work organisation, water
and sanitation, hand hygiene infrastructure, waste management and ventilation). PPE must be correctly
selected and used in a safe manner; this is especially important when putting on and removing PPE, and
decontaminating PPE components.

Standard precautions
It is not always possible to identify patients with filovirus infection because early symptoms are non-specific.
For this reason, it is important that health workers use standard precautions consistently when
providing care to all patients, regardless of their diagnosis. Their rigorous implementation is crucial
for the control of outbreak situations.

Standard precautions include:


 hand hygiene


 point-of-care risk assessment for appropriate selection and use of PPE to avoid direct contact with
patients’ body fluids (including blood, stool, amniotic fluid, urine and respiratory secretions), mucous
membranes and non-intact skin


 respiratory hygiene (cough etiquette)


 prevention of needle-stick or sharps injuries


 safe waste management


 cleaning, disinfection (and sterilization, where applicable) of patient-care equipment and linen


 cleaning and disinfection of the environment.

For further details on standard precautions and best practices for infection prevention and control of filovirus
infection in health care settings, refer to Interim Infection Prevention and Control Guidance for Care of
Patients with Suspected or Confirmed Filovirus Haemorrhagic Fever in Health-Care Settings, with Focus on
Ebola (available at http://www.who.int/csr/resources/publications/ebola/filovirus_infection_control/en/).




RAPID ADVICE GUIDELINE



Personal protective equipment in the context


of filovirus disease outbreak response




Personal protective equipment in the context of filovirus disease outbreak response


2



Workforce health and wellbeing
Safeguarding the health and wellbeing of health workers at the work place, including the provision of hand
hygiene and appropriate PPE, is a priority for, and the responsibility of policy-makers, employers, managers
and the health workers themselves. Making optimum provisions for protecting the health and safety of the
work force is considered a basic responsibility of the employer:


 A risk assessment of the work place must be carried out by competent experts appointed by the
employer.


 All health workers at risk must be provided with adequate, effective and sustainable control measures
which are commensurate to the risk.


 Health workers should be informed of the risks they may face, and the mitigating effects of PPE when
used consistently and correctly. Compliance with all control measures is the responsibility of the health
worker.


 Policymakers and managers need to consider issues such as climate conditions and cultural norms to
ensure uptake of protection measures and maximise compliance.


 The recommended PPE must be available and accessible to health workers.

Implementation
Implementing these recommendations will require training that is suitable for different categories of health
workers (including supervisors), and takes into account, where necessary, local customs and cultural
acceptability. Adequate resources (human, material and financial) must be made available.



Resource management
Resource management includes stock management, availability of different sizes and shapes of PPE,
placement of items for easy access, quality of items purchased and line management for reporting
shortages. Written protocols need to be in place for the management of used and potentially contaminated
medical devices, including safe discard and decontamination and re-use if recommended by the
manufacturer.






Personal protective equipment in the context of filovirus disease outbreak response


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Recommendations


Protection of the mucosae of the eyes, nose and mouth


Recommendation 1: All health workers should have the mucous membranes of their eyes, mouth
and nose completely covered by PPE while providing clinical care for patients
with filovirus disease in order to prevent virus exposure.



Strong recommendation. High quality evidence for protecting mucous membranes
compared to no protection.



Recommendation 2: All health workers should use either a face shield or goggles while providing


clinical care for patients with filovirus disease in order to prevent virus
exposure.



Strong recommendation. Very low quality evidence for the comparative effectiveness
of face shields and goggles for the prevention of filovirus transmission to health
workers.

Rationale and remarks
Protection of the mucous membranes of the eyes, nose and mouth is an integral part
of standard and contact precautions. Contamination of mucous membranes is
probably the most important mode for filovirus transmission. Hence, PPE to protect
mucosae is essential. These devices should be taken off as late as possible during
the PPE removal process, preferably at the end, to prevent inadvertent exposure of
the mucous membranes.



There is currently no scientific evidence comparing the effectiveness of face shields
and goggles, worn with an appropriate head cover (see recommendations 11 and
12), for the prevention of filovirus transmission to health workers. Their effectiveness
was considered equal and either device could be used as determined by other
factors, including the personal preference of the health worker and local availability
of good quality items which meet the specifications provided separately. Face
shields and goggles, however, should not to be used together.



Considerations include:


 Fogging: Fogging affects both face shields and the goggles, although it may
affect face shields to a lesser degree. Fogging reduces visibility and may thus
compromise both the ability of the health worker to provide patient care and his
or her safety. Industrial-type anti-fogging sprays may be useful but their
effectiveness can be reduced in hot and humid climates. Goggles with
ventilation may help to reduce fogging, but vents should not allow blood and
body fluids to contaminate the internal surface or the eye.


 Visibility: Face shields allow more of the face to be visible to the patient,
facilitating communication and interaction between patient and health workers.
Face shields provide a wider range of view for the health worker, which is
usually considered safer. Goggles that allow panoramic vision also offer similar
advantages.


 Prescription glasses: Health workers who wear prescription glasses should be
given the choice between goggles and face shields, while ensuring an adequate
fit and avoiding fogging.






Personal protective equipment in the context of filovirus disease outbreak response


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Recommendation 3: Health workers should wear a fluid-resistant medical/surgical mask with a
structured design that does not collapse against the mouth (e.g. duckbill, cup
shape) while caring for patients with filovirus disease in order to prevent virus
exposure.



Strong recommendation, low quality evidence when comparing medical/surgical
mask with particulate respirator for transmission of filovirus infections.


Recommendation 4: Health workers should use a fluid-resistant particulate respirator while caring
for patients with filovirus disease during procedures that generate aerosols of
body fluids in order to prevent virus exposure.

Strong recommendation, moderate quality evidence when evidence on aerosol-
generating procedures for other pathogens is also considered.

Rationale and remarks
The purpose of the medical/surgical mask is to protect the nasal and mouth mucosa
from splashes and droplets of infectious material. Since filoviruses are not
transmitted through the airborne route in humans, respiratory protection with a
particulate respirator is not required.



Structured (e.g. duckbill, cup shape) medical/surgical masks are considered more
comfortable than particulate respirators by end users. In hot and humid climates, a
structured (e.g. duckbill, cup shape) mask that does not collapse against the mouth
when wet through respiration or transpiration is safer than a mask without this
design.



A medical/surgical mask should always be worn with appropriate eye protection
(either with a face shield or goggles; see recommendations 1 and 2 above). The
mask/respirator should be fluid resistant when used with goggles. Fluid resistance is
not required if mask/respirator is used together with a face shield. Wearing more
than one mask at the same time does not provide additional protection and is not
recommended.
Not all N95 particulate respirators are necessarily fluid resistant; only N95 respirators
labelled as ‘surgical N95 respirator’ are tested for fluid resistance.


Gloves


Recommendation 5: All health workers should wear double gloves while providing clinical care for
patients with filovirus disease in order to prevent virus exposure.

Strong recommendation. Moderate quality evidence for double gloving as compared
to single glove use.

Rationale and remarks
Double gloves are recommended compared to single gloves to decrease the
potential risk of virus transmission to the health worker due to glove holes and
damage to gloves from disinfectants such as chlorine; double gloving may also
reduce the risk from needle-stick injuries and contamination of hands when removing
PPE. The confidence in effectiveness was assessed as moderate based on
accumulated evidence for transmission of other blood-borne pathogens such as HIV
and hepatitis viruses.



Although there is some degree of decreased tactile sensation, impaired dexterity,
and discomfort related to double gloving, studies demonstrate that in most cases the
feeling of impaired tactile sensation is overcome within a few days, even when
performing delicate surgery.



Preferably, the outer glove should have a long cuff, reaching well above the wrist,
ideally to the mid- forearm. In order to protect the wrist area from contamination, the




Personal protective equipment in the context of filovirus disease outbreak response


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inner glove should be worn under the cuff of the gown/coverall (and under any
thumb/finger loop) whereas the outer glove should be worn over the cuff of the
gown/coverall.



Use of tape to attach gloves to gowns/coveralls should be avoided, as this may
interfere with safe gown/coverall and glove removal because of the need for
additional manipulation and the risk of tearing of the gown/coverall, potentially
resulting in contamination. There is no evidence that more than two gloves on each
hand provide further protection; this has the potential to interfere with dexterity and
add complexity to glove removal, and is not considered safe.



Best IPC practice dictates that gloves should be changed between patients.
However, feasibility issues (i.e. provision of clean gloves and waste disposal within
the patient treatment and isolation area) were of concern. Because of this, the GDG
did not reach consensus on the recommendation for changing gloves between
patients inside the clinical area. Nine members were in favour of changing gloves
between patients, two were against, and two members abstained.



The following 2- step procedure could help facilitate changing gloves safely while
providing clinical care for patients with filovirus disease: 1) disinfect the outer gloves
before removing them safely and 2) keep the inner gloves on and disinfect them
before putting on a fresh outer pair. Alcohol-based hand rubs are preferred when
disinfecting hands and gloved hands. If a glove becomes compromised, it should be
changed using the procedure described above.



Sterile gloves are not required except when performing a sterile procedure as per
standard IPC recommendations. Adaptations of the gloving procedures described
above may be required for specific surgical and obstetric procedures.



Recommendation 6: Nitrile gloves are preferred over latex gloves for health workers providing


clinical care for patients with filovirus disease in order to prevent virus
exposure.
Strong recommendation. Moderate quality evidence on effectiveness and safety of
nitrile gloves over other alternatives.



Rationale and remarks
Nitrile gloves are recommended because they resist chemicals, including certain
disinfectants such as chlorine, and nitrile is more environmentally friendly than latex.
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. Non-
powdered gloves are preferred to powdered gloves.




Gown/coverall


Recommendation 7: Health workers should wear protective body wear in addition to regular on-
duty clothing, (e.g. surgical scrubs), while caring for patients with filovirus
disease in order to prevent virus exposure

Strong recommendation, high quality evidence for using protective body wear as
against using no protection, based on accumulated evidence from other infections
with similar modes of transmission.



Recommendation 8: Compared with other forms of protective body wear, the choice of PPE for


covering clothing should be either a disposable gown and apron, or a
disposable coverall and apron; the gown and the coverall should be made of
fabric that is tested for resistance to penetration by blood or body fluids or to
blood-borne pathogens.




Personal protective equipment in the context of filovirus disease outbreak response


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Conditional recommendation, very low quality evidence comparing effectiveness of
gowns and coveralls



Recommendation 9: The choice of apron should be, in order of preference:


 Disposable, waterproof apron
 If disposable aprons are not available, heavy duty, reusable waterproof


aprons can be used if appropriate cleaning and disinfection between
patients is performed.



Strong recommendation, very low quality evidence comparing effectiveness of
disposable and reusable apron

Rationale and remarks
Protective body wear is recommended as part of contact precautions based on
evidence and is applicable in filovirus disease as well. Coveralls and gowns are
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, in particular, to take off, making them a safer
alternative when removing PPE. They are generally more familiar to health workers
and hence more likely to be used and removed correctly. These factors also facilitate
training in their correct use. Heat stress is significantly less for gowns and they are
more likely to be available in areas commonly affected by filovirus disease. An
additional consideration is that, in some cultures, gowns may be more acceptable
than coveralls when used by women.



Protective body wear that is fluid resistant is recommended to mitigate against the
possibility that infected body fluids could penetrate and contaminate the underlying
clothes or skin with possible subsequent unrecognized transmission via the hands to
the mucous membranes of the eyes, nose or mouth.



An apron should be worn over the gown or coveralls; it is easier to remove a soiled
apron compared to gowns and coveralls. An apron is generally worn for the entire
time the health worker is in the treatment area. If the apron is visibly soiled, a
disposable apron should be removed and changed.
Feasibility issues, such as availability of new aprons and waste disposal within
isolation areas, must be addressed. Health workers wearing a reusable apron should
leave the ward to clean, disinfect and remove the apron.




Footwear


Recommendation 10: All health workers should wear waterproof boots (e.g. rubber/ gum boots)
while caring for patients with filovirus disease in order to prevent virus
exposure.
Strong recommendation. Very low quality evidence comparing boots with other types
of foot wear.

Rationale and remarks
Waterproof boots are preferred over closed shoes because they are easier to clean
and disinfect and because they provide optimal protection when floors are wet. In
addition, rubber boots can protect from sharps injuries. If boots are not available,
health workers must wear closed shoes (slip-ons without shoelaces and fully
covering the dorsum of the foot and ankles). Shoe covers, nonslip and preferably
impermeable, should ideally be used over closed shoes to facilitate decontamination.
Boots do not need to be removed on leaving the PPE removal area provided they
have been cleaned and disinfected; the same pair of boots can be worn until the end
of that day’s work or shift.





Personal protective equipment in the context of filovirus disease outbreak response


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Head cover


Recommendation 11: All health workers should wear a head cover that covers the head and neck
while providing clinical care for patients with filovirus disease in order to
prevent virus exposure.



Conditional recommendation. Low quality evidence for effectiveness of head cover in
preventing transmission



Recommendation 12: The head cover is suggested to be separate from the gown or coverall, so that


these may be removed separately.
Conditional recommendation. Low quality evidence comparing different types of
head covers.

Rationale and remarks
The purpose of head covers is to protect the head and neck skin and hair from virus
contamination and the possibility of subsequent unrecognized transmission to the
mucosae of the eyes, nose or mouth. Hair and hair extensions need to fit inside the
head cover.



Recommendation 11 is conditional since there is no evidence to support use of a
head cover over a hood (covering the shoulders) or hair cap for preventing
transmission of infection. The need for covering all skin surfaces including the back
of the neck was discussed in detail during the GDG meeting. There was no
consensus among the GDG: nine experts were of the opinion that all skin surfaces
should be covered, three disagreed and one was absent during voting.



Recommendation 12 is conditional since there was no comparative evidence of
effectiveness in preventing transmission between a separate head cover and a head
cover that is integrated in the coverall. When a separate head cover is not available,
a coverall with hood can be worn provided that the hood is put on after eye, nose
and mouth protection so that mucosal protection is maintained after taking off the
hooded coverall.





Personal protective equipment in the context of filovirus disease outbreak response


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Annex 1: PPE technical specifications



Item Technical specifications


Goggles
Recommendation 2




 Good seal with the skin of the face
 Flexible frame to easily fit all face contours without too much pressure
 Covers the eyes and the surrounding areas and accommodates for


prescription glasses


 Fog and scratch resistant
 Adjustable band to secure firmly so as not to become loose during clinical


activity


 Indirect venting to reduce fogging
 May be re-usable (provided appropriate arrangements for decontamination


are in place) or disposable


 Quality compliant with the below standards, or equivalent:
- EU standard directive 86/686/EEC, EN 166/2002


- ANSI/ISEA Z87.1-2010


Face shield
Recommendation 2




 Made of clear plastic and provides good visibility to both the wearer and
the patient


 Adjustable band to attach firmly around the head and fit snuggly against
the forehead


 Fog resistant (preferable)
 Completely covers the sides and length of the face
 May be re-usable (made of material which can be cleaned and disinfected)


or disposable


 Quality compliant with the below standards, or equivalent:
- EU standard directive 86/686/EEC, EN 166/2002


- ANSI/ISEA Z87.1-2010


Fluid-resistant
medical/surgical mask
Recommendation 3


 High fluid resistance
 Good breathability
 Internal and external faces should be clearly identified
 Structured design that does not collapse against the mouth (e.g. duckbill,


cup shape)


 Quality compliant with the below standards, or equivalent:
- EN 14683 Type IIR performance


- ASTM F2100 level 2 or level 3 or equivalent


Particulate respirator
Recommendation 4


 Shape that will not collapse easily
 High filtration efficiency
 Good breathability
 Quality compliant with standards for surgical N95 respirator:


- NIOSH N95, EN 149 FFP2, or equivalent


 Fluid resistance: minimum 80 mmHg pressure based on ASTM F1862,
ISO 22609, or equivalent


 Quality compliant with standards for particulate respirator worn with full-
face shield: Only to be used together with a face shield


- NIOSH N95, EN149 FFP2, or equivalent





Personal protective equipment in the context of filovirus disease outbreak response


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Item Technical specifications


Gloves
Recommendations 5 & 6


 Nitrile
 Non-sterile
 Powder free
 Outer gloves preferably reach mid-forearm (minimum 280mm total length)
 Different sizes
 Quality compliant with the below standards, or equivalent:


- EU standard directive 93/42/EEC Class I, EN 455


- EU standard directive 89/686/EEC Category III, EN 374


- ANSI/ISEA 105-2011


- ASTM D6319-10


Disposable gown
Recommendation 8


 Single use
 Length, mid-calf to cover the top of the boots
 Avoid culturally unacceptable colours e.g. black
 Light colours are preferable to better detect possible contamination
 Thumb/finger loops to anchor sleeves in place
 Quality compliant with either of two standards, depending on resistance of


materials:


- Option 1 (tested for resistance to fluid penetration): EN 13795 high
performance level, or AAMI level 3 performance, or equivalent


OR


- Option 2 (tested for resistance to blood-borne pathogen penetration):
AAMI PB70 level 4 performance, or equivalent


Disposable coverall
Recommendation 8


 Single use
 Avoid culturally unacceptable colours e.g. black
 Light colours are preferable to better detect possible contamination
 Thumb/finger loops to anchor sleeves in place
 Quality compliant with either of two standards, depending on resistance of


materials:


- Option 1 (tested for resistance to blood and body fluid penetration):
Meets or exceeds ISO 16603 class 3 exposure pressure, or equivalent


OR


- Option 2 (tested for resistance to blood-borne pathogen penetration):
meets or exceeds ISO 16604 class 2 exposure pressure, or equivalent


Note: For each of the two options mentioned above, different products may be
available. The coverall material described in Option 2 is associated with higher
heat stress and less breathability; this reduces continuous wearing time and
results in more frequent changes compared to Option 1.


Waterproof apron
Recommendation 9


 Disposable or single use
 Made of polyester with PVC-coated, or other waterproof material
 Straight apron with bib
 Minimum basis weight: 250g/m2
 Covering size: approximately 70-90cm width x 120-150cm height, or


standard adult size


 Either
- Option 1: Adjustable neck strap with back fastening at the waist


- Option 2: Neck strap allowing for tear-off with back fastening at the
waist




Personal protective equipment in the context of filovirus disease outbreak response


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Item Technical specifications


Heavy duty apron
Recommendation 9


 Heavy duty non-woven apron
 Straight apron with bib
 Fabric: 100% polyester with PVC coating, or 100% PVC, or 100% rubber,


or other fluid resistant material (e.g. rubber, PVC)


 Water proof, sewn strap for neck and back fastening
 Minimum basis weight: 300g/m2
 Covering size: approximately 70-90cm width x 120cm-150cm height
 Reusable (provided appropriate arrangements for decontamination are in


place)


Waterproof boots
Recommendation 10


 Nonslip, have a PVC sole which is completely sealed
 Knee-high, in order be higher than the bottom edge of the gown
 Optional light colour to better detect possible contamination
 A variety of sizes to improve comfort and avoid trauma to the feet


Hood or headcover
Recommendation 11


 Single use
 Preferably fluid resistant
 Adjustable and immovable once adjusted
 Facial opening constructed without elastic, reaching the upper part of the


gown or coverall


Surgical scrubs:
trousers and top


Surgical scrubs are for use as regular on-duty wear and are not considered
PPE. Details are provided for ease of procuring these items. Scrubs are
preferable to street clothes while the health worker is on-duty.


 Tightly woven
 Minimum linting
 Non-sterile, reusable or single use
 Top/tunic: short sleeves
 Trousers: drawstring waist enclosure
 Different sizes





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Annex 2: Background to the development of this guideline


Development of these recommendations included: development of a scoping document for approval by the
WHO Guideline Review Committee; development of key questions; a systematic review of the literature; a
literature review and an online survey on the values and preferences of expatriate health workers; an
evidence-to-recommendations exercise using the GRADE framework; and an expert consultation.

The research question for the systematic review was: What are the benefits and harms of double gloves, full
face protection, head cover, impermeable coveralls, particulate respirators, and rubber boots as PPE when
compared with alternative less robust PPE for health workers caring for patients with filovirus disease? The
systematic review yielded no comparative evidence for the different types of PPE.

An in-depth literature review on the values and preferences of health workers regarding PPE, but not
specifically focusing on filovirus disease, was carried out. An online survey was also conducted among
expatriate health workers with experience caring for patients with Ebola virus disease to obtain information
on their values and preferences regarding PPE. The responses to the survey included aspects such as
comfort, ease of use, and sense of protection (safety).

A thorough mandatory training on the use of PPE followed by mentoring for all users before engaging in any
clinical care is considered fundamental for preventing filovirus disease among health workers. In addition,
based on experience in the field, the ready availability of PPE items, along with their familiarity and
acceptability were considered important when selecting PPE. The use of disposable, rather than reusable,
items was generally preferred.





Personal protective equipment in the context of filovirus disease outbreak response


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Annex 3: Methods used for the development of this guideline


A Guideline Development Group (GDG) meeting was convened on 6 and 7 October 2014. The Group was
comprised of 13 experts who were invited based on their knowledge, experience and technical expertise.
According to WHO requirements for guideline development, members participated as independent experts
and did not represent any agency, institute or country. All GDG members completed WHO Declaration of
Interest forms, which were reviewed by the Steering Group prior to the meeting. None of the GDG members
declared any conflict of interests relating to the matter under discussion.

The biology of the virus and its modes of transmission were considered in the development of the
recommendations. There was sufficient information available to make strong recommendations on the use of
PPE and its specifications as barriers to transmission. Patients with filovirus infection usually have profuse
vomiting and diarrhoea. The GDG noted that the virus load is highest in blood, although bleeding is seen in
only a minority of patients. Other body fluids such as vomit, faeces, sweat, saliva, urine, amniotic fluid and
semen, may also contain virus (on occasion, high levels of virus can be found) and be involved in
transmission. The main route for acquisition of filovirus infection is through contact of infected blood or other
body fluids with the mucous membranes of the mouth, nose and eyes. Transmission can occur through
direct contact with these body fluids, or through contact with fomites (i.e. touching inanimate objects), such
as the floor, utensils and bed linens that have recently been contaminated with infected body fluids.
Transmission through intact skin has not been documented, but infection can be transmitted through non-
intact skin and through penetrating injuries of the skin, such as needle-stick injuries.

Based on this information, the experts agreed that it was most important to have PPE which protects the
mucosae – mouth, nose and eyes – from contaminated droplets and fluids. Hands are known to transmit
pathogens to other parts of the body or face and to other individuals. Therefore, hand hygiene and gloves
are essential, both to protect the health worker and to prevent transmission to others. Face cover, protective
foot wear, gowns or coveralls, and head cover were also considered essential to prevent transmission to
health workers.

A fundamental principle guiding the selection of different types of PPE was the effort to strike a balance
between the best possible protection against filovirus infection while allowing health workers to provide the
best possible care to patients with maximum ease, dexterity, comfort and minimal heat-associated stress.
Heat-associated stress while wearing impermeable PPE is of particular concern as it can place health
workers at increased risk of accidental exposure to filovirus.




Copyright 2016, Engineering World Health