【Cochrane简语概要】衣物和设备用于为医护人员预防埃博拉和其他高传染性疾病

医护人员面临感染埃博拉病毒和SARS等疾病的风险。预防感染的一种方法是使用个人防护设备，如防护服、手套、口罩和护目镜，以防止工作人员受到污染。目前还不清楚哪种设备保护效果最好，以及使用后如何最好地将其移除。目前也不清楚令医护人员遵守此设备使用说明的最佳培训方式是什么。

研究背景

我们发现17项研究，涉及1950名受试者，并评价了21种干预。我们将研究分为三类：比较防护服的种类，比较穿上和脱下防护服的方法，以及对医护人员使用防护服进性培训的不同方法。其中12项研究使用荧光标记物或无害病毒来模拟医院发生的情况。有2项研究在实地环境下进行：一项在2003年非典流行期间，另一项在2015年埃博拉疫情期间。三项研究，涉及962名受试者，对比了积极培训与消极培训对防护装备使用的影响。所有研究的偏倚风险要么不清楚，要么有高风险。

各类防护服比较 
尽管穿着防护服，10%到100%的工作人员身上发现了荧光标记。一项研究中提出，透气性好的衣服不会比不透气的衣服造成更多的污染，但是使用者更满意。另一项研究提出，长袍比围裙的污染少。四项研究评价了防护服的变化以使其更容易被脱下。与单独脱下的长袍和手套相比，将手套附在袖口处一起脱下的长袍污染更少。研究发现，将手套和口罩改进为带有可抓握的标签，在脱去防护服时可减少污染。四项研究没有报告足够的资料来得出结论。这个证据的质量很低。

各类脱去防护服的比较

一项研究发现，两副手套比只有一副手套的污染少。另一项使用两副手套的研究表明，使用含酒精的洗手液清洗手套内部，不会比使用次氯酸盐溶液的污染少。另一项研究提出，遵循美国疾病控制与预防中心（CDC）对脱围裙或长袍的指导，可减少污染。一项研究发现，那些被告知如何正确脱下防护服的人比那些没有被告知的人受到的污染更少。一项研究没有报告足够的资料，无法得出结论。此证据的质量也很低。

积极培训

与消极培训相比，积极培训（包括计算机模拟）在指导医护人员使用何种防护，如何移除防护方面的错误更少。一项研究表明，在如何穿戴防护服的测试中，观看视频的受试者的得分要高于观看如何正确穿戴防护服的传统讲座的受试者。

（图片来源于网络）

证据的质量

由于研究的局限性、间接性和受试者人数少，我们评价证据的质量为非常低。

我们还需要研究什么？

没有关于护目镜或面罩影响的研究。研究人员需要就模拟暴露的最佳方式达成一致。然后，需要对至少60名受试者进行更多的模拟研究，最好使用无害的病毒，以找出哪种类型和组合最具保护作用。在使用后脱下防护服的最佳方式也不清楚。我们还需要研究找出哪种培训在长期内效果最好。接触高度传染性疾病的医护人员应登记防护设备，并留意其感染风险。我们十分希望非政府组织开展更多的研究，登记和记录他们的工作人员使用的个人防护装备的类型。

结论: 

我们发现了非常低质量的证据，表明更透气的PPE可能不会导致更多的污染，但可能有更高的用户满意度。对PPE的更改（例如增加抓片）可能会减少污染。双层手套，遵循CDC的脱设备指导和在脱设备时的口头指示可以减少污染，提高依从性。PPE使用中的面对面培训比基于视频或文件夹的培训更能减少错误。由于资料来自具有高偏倚风险的单一的小型研究，因此我们无法确定影响的估计。

我们仍然需要随机对照试验，来找出哪种培训在长期内效果最好。我们需要对几十名受试者进行更好的模拟研究，以找出哪种PPE保护性最好，以及去除PPE的最安全方式是什么。迫切需要就模拟暴露和评价结局的最佳方式达成共识。接触高度传染性疾病的医护人员应登记使用个人防护设备，并对其在实地感染的风险进行前瞻性跟踪。

译者：朱思佳，审校：刘雪寒、鲁春丽；编辑排版：刘美迪、张晓雯，北京中医药大学循证医学中心

相关文章链接

【Cochrane Plain Language Summary】

Protective clothes and equipment for healthcare workers to prevent them catching coronavirus and other highly infectious diseases

Background

Healthcare workers treating patients with infections such as coronavirus (COVID-19) are at risk of infection themselves. Healthcare workers use personal protective equipment (PPE) to shield themselves from droplets from coughs, sneezes or other body fluids from infected patients and contaminated surfaces that might infect them. PPE may include aprons, gowns or coveralls (a one-piece suit), gloves, masks and breathing equipment (respirators), and goggles. PPE must be put on correctly; it may be uncomfortable to wear, and healthcare workers may contaminate themselves when they remove it. Some PPE has been adapted, for example, by adding tabs to grab to make it easier to remove. Guidance on the correct procedure for putting on and removing PPE is available from organisations such as the Centers for Disease Control and Prevention (CDC) in the USA.

This is the 2020 update of a review first published in 2016 and previously updated in 2019.

What did we want to find out?

We wanted to know:

what type of PPE or combination of PPE gives healthcare workers the best protection;

whether modifying PPE for easier removal is effective;

whether following guidance on removing PPE reduced contamination;

whether training reduced contamination.

What did we find?

We found 24 relevant studies with 2278 participants that evaluated types of PPE, modified PPE, procedures for putting on and removing PPE, and types of training. Eighteen of the studies did not assess healthcare workers who were treating infected patients but simulated the effect of exposure to infection using fluorescent markers or harmless viruses or bacteria. Most of the studies were small, and only one or two studies addressed each of our questions.

Types of PPE

Covering more of the body leads to better protection. However, as this is usually associated with increased difficulty in putting on and removing PPE, and the PPE is less comfortable, it may lead to more contamination. Coveralls are the most difficult PPE to remove but may offer the best protection, followed by long gowns, gowns and aprons. Respirators worn with coveralls may protect better than a mask worn with a gown, but are more difficult to put on. More breathable types of PPE may lead to similar levels of contamination but be more comfortable. Contamination was common in half the studies despite improved PPE.

Modified PPE

Gowns that have gloves attached at the cuff, so that gloves and gown are removed together and cover the wrist area, and gowns that are modified to fit tightly at the neck may reduce contamination. Also, adding tabs to gloves and face masks may lead to less contamination. However, one study did not find fewer errors in putting on or removing modified gowns.

Guidance on PPE use

Following CDC guidance for apron or gown removal, or any instructions for removing PPE compared to an individual’s own preferences may reduce self-contamination. Removing gown and gloves in one step, using two pairs of gloves, and cleaning gloves with bleach or disinfectant (but not alcohol) may also reduce contamination.

User training

Face-to-face training, computer simulation and video training led to fewer errors in PPE removal than training delivered as written material only or a traditional lecture.

Certainty of the evidence

Our certainty (confidence) in the evidence is limited because the studies simulated infection (i.e. it was not real), and they had a small number of participants.

What do we still need to find out?

There were no studies that investigated goggles or face shields. We are unclear about the best way to remove PPE after use and the best type of training in the long term.

Hospitals need to organise more studies, and researchers need to agree on the best way to simulate exposure to a virus.

In future, simulation studies need to have at least 60 participants each, and use exposure to a harmless virus to assess which type and combination of PPE is most protective.

It would be helpful if hospitals could register and record the type of PPE used by their workers to provide urgently needed, real-life information.

Search date

This review includes evidence published up to 20 March 2020.

Authors' conclusions:

We found low- to very low-certainty evidence that covering more parts of the body leads to better protection but usually comes at the cost of more difficult donning or doffing and less user comfort, and may therefore even lead to more contamination. More breathable types of PPE may lead to similar contamination but may have greater user satisfaction. Modifications to PPE design, such as tabs to grab, may decrease the risk of contamination. For donning and doffing procedures, following CDC doffing guidance, a one-step glove and gown removal, double-gloving, spoken instructions during doffing, and using glove disinfection may reduce contamination and increase compliance. Face-to-face training in PPE use may reduce errors more than folder-based training.

We still need RCTs of training with long-term follow-up. We need simulation studies with more participants to find out which combinations of PPE and which doffing procedure protects best. Consensus on simulation of exposure and assessment of outcome is urgently needed. We also need more real-life evidence. Therefore, the use of PPE of HCW exposed to highly infectious diseases should be registered and the HCW should be prospectively followed for their risk of infection.

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