Ministry of Health and Family Welfare Novel Coronavirus Disease 2019 (COVID-19): Guidelines
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 |
