Guidelines for use of personal protective equipment (PPE) during the COVID-19 pandemic when demand exceeds supply

Updated on April 19, 2020

With some medical products in short supply requests have emerged that all medical professionals, including veterinarians, conserve personal protective equipment (PPE) until supplies become more readily available.

Postponing elective procedures that require the use of PPE is one way of conserving.  Conservation strategies can also include safely extending the use of disposable PPE, re-using disposable PPE, or increased use of washable PPE. 

Guidance has been developed to control personnel exposure to occupational hazards utilizing a hierarchy to achieve feasible and effective controls. Multiple control strategies may be implemented concurrently, sequentially, or both to minimize exposure.  This hierarchy is frequently represented as:

Hierarchy of Controls Chart Image
(adapted from CDC)

Elimination (physically removing the hazard) and substitution (replacing the hazard) are not typically options in the healthcare setting to prevent infectious disease transmission. However, engineering and administrative controls and PPE can often be used to reduce or avoid exposures to transmissible pathogens in healthcare facilities. Prompt detection, effective triage, and isolation of potentially infectious patients are essential control measures to prevent unnecessary pathogen exposure of patients, healthcare personnel (HCP), and visitors in a given facility.

The best way to prevent disease transmission is to use a combination of interventions from across the hierarchy of controls. This results in a greater degree of protection than a single method and provides backup in the event one control intervention fails, becomes less effective, or even unavailable.

Veterinarians should increase focus on engineering and administrative controls before considering how they can safely extend the life of disposable PPE during times of a national shortage.

The FDA has issued guidance in a letter to healthcare providers regarding surgical mask and gown conservation strategies.  Three levels of capacity strategies are described:

  • Conventional capacity strategies: supply levels are adequate to provide patient care without any change in routine practice
  • Contingency capacity strategies: limited supply levels may change patient care, but may not have a significant impact on patient care and healthcare provider safety
  • Crisis or alternate strategies: may need to be considered if surgical mask or gown demand exceeds the supply

For detailed information on the first two strategies listed above, please refer to the FDA guidance. The third strategy, when demand exceeds supply, is the focus of the following section.

    To assist veterinarians who may be facing extreme shortages of PPE and who may need to consider re-using disposable PPE, such as surgical and exam gloves, or may need to improvise by making surgical masks, we offer the following resources:

    NIH study validates decontamination methods for reuse of N95 respirators

    • It should be noted that as of April 15, 2020, this is a pre-print study which has not yet been peer-reviewed.
    • It is unknown how the information from this study may apply to surgical masks

    CDC decontamination and reuse of filtering facepiece respirators (FFRs)

    • While this resource specifically discusses decontamination of FFRs (N95s), some of the information may translate to decontamination of surgical masks.

    Bossemeyer, D., McIntosh, N., & Tietjen, L. (2003). Infection Prevention, Guidelines for Healthcare Facilities with Limited Resources. Baltimore, Maryland: JHPIEGO Corporation

    • Chapter 4, page 2: What to do when supplies of gloves are limited
    • Chapter 14: Reprocessing Disposable Items
    • Appendix C: Processing Surgical Gloves (see excerpt that follows):
      • The risk in reusing surgical gloves is that processed gloves have more inapparent tears than new ones and therefore provide less protection to the wearer. Sterilization (autoclaving) and high-level disinfection (steaming) of gloves, when correctly performed, however, can provide a high-quality product. In addition, double gloving for high-risk procedures can be done. Therefore, processing surgical gloves constitutes an appropriate reuse of disposable items where resources are limited.
      • STEP 1: Before removing soiled surgical gloves, immerse hands briefly in a container filled with 0.5% chlorine solution.

      • STEP 2: Remove gloves by turning inside out and soak them in the chlorine solution for 10 minutes. (Performing Steps 1 and 2 ensures that both surfaces of the gloves are decontaminated.)

      • STEP 3: Wash gloves in soapy water, cleaning inside and out.

      • STEP 4: Rinse gloves in clean water until no soap or detergent remains. (Residual soap or detergent can interfere with sterilization or HLD.)

      • STEP 5: Test gloves for holes by inflating them by hand and holding them under water. (Air bubbles will appear if there are holes.)

      • STEP 6: Gently air-dry gloves inside and out before proceeding with sterilization. (Gloves which remain wet for long periods of time will absorb water and become tacky.) After decontamination, cleaning and drying, gloves must be packaged prior to sterilizing by autoclaving. First, fold the cuffs of the gloves out toward the palm so that after sterilization they can be put on easily and without contamination. Next, put gauze or paper inside each glove and under the fold of the cuff and wrap the gloves as shown in Figure C-1. (Do not tie tightly or wrap glove packs with rubber bands.)  Autoclave at 121°C(250°F) for 30 minutes and at a pressure of 106 kPa (15 lb/in2).

    Dato VM, Hostler D, Hahn ME. Simple respiratory mask. emerg infect dis. 2006;12(6):1033-1034.

    • Podcast - Making a simple respiratory mask.  Dr. Virginia Dato, a physician board certified in public health and general preventive medicine, and Sarah Gregory discuss how to construct a simple respiratory face mask with easily available materials.

     

    The following Q&As are based on the information from this FDA document and sourced from CDC.  The use of PPE in veterinary medicine for protection of the wearer (e.g., infectious disease) is much less common than the use of PPE to protect the patient (e.g., surgery). 

    Q1. May disposable, single use PPE be re-used when supply levels are adequate (conventional capacity strategies)?
    A1.  Generally, no.  Most PPE is designed to be used only once by a single person prior to disposal. However, there are exceptions in limited situations identified by FDA, CDC, and OSHA which include gowns, surgical masks, N95 respirators, reusable face shields or goggles. Details for each are briefly mentioned below.

    Q2. Can we use expired gowns and surgical masks? Do they offer the protection needed?
    A2.  
    These products were designed to serve as protective barriers and thus FDA believes they may still offer some protection even when they are used beyond the manufacturer’s designated shelf life or expiration date. The user should visibly inspect the product prior to use and if there are concerns (such as degraded materials or visible tears) the product should be discarded.

    Q3. Can we use surgical masks and gowns on more than one procedure?
    A3. 
     Gowns may be worn to see multiple patients with the same infectious disease diagnosis or exposure when they are maintained in a common area.

    Gowns may be worn for multiple surgeries where the surgical procedure has a low risk of contamination. 

    In all cases, if the gown becomes contaminated, replace it.

    Surgical masks may be worn for extended periods (re-used) during care for multiple patients where they are used to protect the patient from droplets from the surgeon. If the mask becomes wet or contaminated, replace it.

    Q4. Can reusable cloth gowns be used in a shortage?
    A4. 
    FDA cleared or approved reusable cloth gowns can be used. Adequate laundering, or sterilization if available, can reduce the level of pathogen contamination to a negligible level, thus lowering the overall risk of disease.

    Q5. What is an N95 respirator and what do I need to know to use one properly?
    A5.  
    An N95 respirator is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles.

    The 'N95' designation means that when subjected to careful testing, the respirator blocks at least 95 percent of very small (0.3 micron) test particles. If properly fitted, the filtration capabilities of N95 respirators exceed those of face masks. However, even a properly fitted N95 respirator does not completely eliminate the risk of illness or death.

    N95 respirators are rarely used in veterinary medicine and most veterinarians are unfamiliar with how they are to be used. A recent 2020 survey of veterinarians across the U.S. showed that 83% of surveyed veterinarians did not stock any N95 respirators. AVMA is not recommending the routine use of N95 respirators however there may be specific situations where it may be considered (e.g. house call veterinarian under extreme circumstances needing to enter the home of a positive COVID-19 patient). If you find yourself in a situation where an N95 mask is needed, please refer to the additional information section below for further information on proper use.

    Q6. What does reuse mean?
    A6. 
    CDC defines reuse as:1 the practice of using the same N95 respirator for multiple encounters with patients but removing it (‘doffing’) after each encounter. The respirator is stored in between encounters to be put on again (‘donned’) prior to the next encounter with a patient. When N95 respirator reuse is practiced or recommended, restrictions are in place which limit the number of times the same respirator is reused, this is “limited reuse”. Limited reuse has been recommended and widely used as an option for conserving respirators during previous respiratory pathogen outbreaks and pandemics.(2310-12)  

    Q7. How do I minimize the need to reuse N95 respirators?
    A7. 
    CDC recommends the following steps to minimize use of N95 respirators:

    • Minimize the number of individuals who need to use respiratory protection through the preferential use of engineering and administrative controls;
    • Use alternatives to N95 respirators (e.g., other classes of filtering facepiece respirators, elastomeric half-mask and full facepiece air purifying respirators, powered air purifying respirators) where feasible;
    • Implement practices allowing extended use and/or limited reuse of N95 respirators, when acceptable; and
    • Prioritize the use of N95 respirators for those personnel at the highest risk of contracting or experiencing complications of infection.

    Q8. How may I reuse N95 respirators?
    A8. 
    If reuse of N95 respirators is permitted in the locality, healthcare facilities should provide staff with clearly written procedures to:

    • Follow the manufacturer’s user instructions
    • Conduct a user seal check
    • Only reuse for up to five donnings (unless the manufacturers label recommendation explicitly states another number)
    • Follow recommended inspection procedures
    • Discard any respirator that is obviously damaged or becomes difficult to breathe through
    • Pack or store respirators between uses so that they do not become damaged or deformed.

    Q9. What if N95 respirators are not available at all?
    A9. 
     If no respirators are left these strategies should be considered:

    Administrative Controls
    • Postpone elective and non-emergency procedures until seeing the animal in person does not expose the veterinary staff to known or suspected COVD-19 patients prior to release from quarantine.
    • Consider taking extra precautions regarding veterinarians and staff who are themselves at higher risk for severe illness from COVID-19. According to the CDC, this may include older adults and those with chronic medical conditions.  
    Engineering Controls
    •  Use a patient isolation room that limits the exposure of other personnel and patients for risk-reduction.
    Personal Protective Equipment and Respiratory Protection
    • Use masks not evaluated or approved by NIOSH or homemade masks as a last resort.
    Reusable facemask shield, goggles
    • Protective eyewear, such as goggles, may be reused if the user follows decontamination methods in the product labeling. 
    • A reusable face shield that can be decontaminated may be an acceptable method of protecting against droplet transmission.

       
      Employers have the obligation to provide their workers with PPE needed to keep them safe while performing their jobs. The type of PPE required will be based on the risk of being infected while working and job tasks that lead to exposure. In addition, the OSH Act’s General Duty Clause, Section 5(a)(1), requires employers to provide their employees with a workplace free from recognized hazards likely to cause death or serious physical harm.

      Agency COVID-19 websites:

      Association COVID-19 sites:

      The use of PPE in veterinary medicine for protection of the wearer (e.g., infectious disease) is much less common than the use of PPE to protect the patient (e.g., surgery). Some interpretation of FDA’s guidance is needed for most veterinary practices.

        

      This content is not intended or offered, nor should it be taken, as legal or other professional advice. The content on this webpage is subject to frequent updates and revisions. Please make sure you check back regularly and confirm all information with the relevant jurisdiction. The AVMA provides this content for informational purposes only and not as a substitute for appropriate professional advice based on specific circumstances. You should always consult with your own professional advisors (e.g. attorney, accountant, insurance carrier). AVMA provides the content on this webpage “as is” with no representations or warranties. Any links to third party websites or content implies no endorsement or affiliation.”