Personal protective equipment

What is personal protective equipment?

Personal protective equipment (PPE) generally consists of wearable items designed to shield users from environmental hazards. These hazards may be physical, chemical, biological, radiological, or nuclear in nature. PPE can be used in a variety of situations and configurations depending on the type of exposure.

A commonly held misconception is that PPE will fully protect users from harm. There will always be an element of risk when working in a hazardous environment. The purpose of properly used PPE is to reduce this risk of harm.

Ames hazmat suit

Occupational Safety Equipment

Who uses personal protective equipment?

PPE is particularly used in the workplace due to exposure to occupational hazards. Occupations that require this hazard protection can include:

• Healthcare workers exposed to bodily fluids and pathogens
• Builders exposed to construction dust and falling objects
• Firefighters exposed to smoke and high temperatures
• Farmers exposed to animal waste or plant pollen.

Certain forms of PPE such as gloves, dust masks, and hearing protection devices may also be used at home.

• Gloves can protect hands from irritants while performing tasks such as washing, gardening, and cooking.
• A dust mask may be used while cleaning or doing woodwork
• Ear muffs may be worn when using a motor mower or chainsaw.

Examples of personal protective equipment

Different types of PPE have been designed to protect specific parts of the body.

Full-body protection

A hazmat suit can provide comprehensive full-body protection.

• A hazmat or decontamination suit can be made with a variety of materials.
• Most hazmat suits include built-in air purifying and circulation systems.
• They are most frequently used in decontamination procedures involving dangerous chemicals, pathogens, chemical waste, and nuclear waste.

Head protection

Helmets and hair coverings are worn on the head.

• A helmet made with a light, strong material such as fibreglass can be used to protect the head from physical trauma.
• A hair covering (eg, hair net) can be used to prevent hair catching in machinery.

Face protection

Face shields, goggles, and masks are used to protect the eyes and face.

A face shield can be used to protect the user from injury or infection.

• A metal shield may prevent welding burns to the eyes and face.
• A clear plastic shield can prevent bio-hazardous fluid from spraying onto the wearer's face.

Goggles prevent foreign bodies or hazardous liquids from entering the wearer's eyes.

• Ordinary spectacles do not have the same protective capabilities and should not be used as a substitute in healthcare [1].
• Special safety goggles can be worn over spectacles.

A mask or a respirator can prevent dust and infectious particles from being inhaled.

• A mask may also trap respiratory droplets produced by coughing or sneezing.
• Masks are available in different filter sizes.
• A mask with the appropriate filter size should be selected based on the size of the hazardous particles involved [2].

Body protection

An apron, gown, or coverall can be used for body protection.

• An apron can be used when there is less risk of hazardous exposure to the limbs, such as for radiation protection of gonads (ovary, testes).
• A gown or a coverall is used when additional limb protection is required.

Hand protection

Gloves made of a wide range of materials can be used as a protective barrier to shield a wearer from hazards.

• Gloves made from latex, nitrile, and vinyl, reduce the transmission of infection.
• Heat-proof gloves made of acrylic prevent thermal burns or welding burns.
• Durable plastic gloves may protect the hands from some harsh chemicals that could cause burns or irritation.
• Kevlar gloves protect from physical trauma such as cutting knives in abattoirs.

Foot protection

Boots made of different materials are used to protect the feet.

• Rubber boots guard against fluid splashes and prevent slips.
• Steel-toe boots prevent traumatic foot injuries.

Green gloves in surgery

Personal protective equipment during minor skin surgery

How to use personal protective equipment effectively

PPE needs to be selected and sized carefully to best reduce exposure to specific hazards [3]. Professional organisations usually have specific guidelines for PPE selection within particular workplace settings.

PPE needs to be put on (donned) and removed (doffed) according to proper protocol [4].

• If PPE is not donned correctly, protection may be incomplete due to improper fit.
• Improper doffing may cause contamination after the exposure.

Studies in healthcare workers have shown that the rate of contamination is reduced if the worker had completed a structured PPE training course [5]. Hence, PPE education sessions are highly recommended for all users. There is also evidence that supervised PPE use can decrease the rate of PPE protocol deviations and improve the quality of protection [6].

What are the side effects and risks of personal protective equipment?

While PPE is extremely useful, some people may experience an unwanted side effect from PPE use, such as [7]:

• Overheating
• Contact irritant dermatitis
• Allergic contact dermatitis
• Mechanical skin damage eg, friction and occlusion.

Up to 99% of cutaneous side effects caused by occupational PPE are due to gloves, especially in healthcare workers [8]. Non-glove related dermatoses are more common in manufacturing [7].

Overheating

Overheating due to PPE is very common [9]. PPE may cause an increase in body temperature by preventing heat from being lost via sweat evaporation [10]. Heavier forms of PPE may also increase body heat production due to the increased work of carrying the PPE.

Sweat loss and dehydration from overheating can cause heat-related illness, ranging from a mild heat rash (miliaria) to a life-threatening heat stroke [11]. Cooling measures should be undertaken immediately if there are any signs of heat illness [11].

Contact irritant dermatitis

Most contact dermatitis due to PPE is classified as irritant contact dermatitis, where the dermatitis is dose-related rather than due to the development of a hypersensitivity type of immune reaction. Examples of irritant reactions associated with PPE include:

• Hand dermatitis due to sweating inside a glove
• Gloves and other forms of PPE may directly cause irritant contact dermatitis when they rub on the skin
• Rough clothing such as seams or woollen fibres rubbing on sensitive skin
• Chemicals penetrating through leaks in coveralls

Skin hypersensitivity reactions

Type I and type IV hypersensitivity reactions may develop to specific materials or chemicals used to make PPE.

• Type I hypersensitivity typically presents immediately after exposure with acute urticaria or anaphylaxis. Type 1 allergens are identified with a skin prick test and may include latex protein in rubber gloves.
• Type IV hypersensitivity usually presents a few days after exposure as allergic contact dermatitis. Possible allergens are identified with patch testing.

Allergens causing allergic contact dermatitis due to PPE include [8, 12]:

• Rubber accelerators used in latex and non-latex gloves
• Textile dyes in clothing
• Metals in masks and boots
• Formaldehyde and other preservatives found in N95 respirators and other surgical masks.

Once an allergen is identified, contact with it should be avoided where possible.

Mechanical skin damage

Facial ulcers and acne have been reported in those who wear goggles or a mask for a long period of time due to pressure effects. 

An ulcer is an open defect in the skin barrier. Prolonged pressure on the skin from a mask or a pair of goggles can cause a disruption in blood supply and subsequently, the death of overlying skin. This results in the formation of a pressure ulcer.

Acne mechanica is a complication of acne vulgaris. Pressure and friction on existing acne vulgaris can cause micro-abrasions that exacerbate inflammation [13]. The pustules may become deeper and more enlarged with continued pressure [14].

Irritant contact dermatitis occurs when the skin is directly exposed to soap and water, alcohol (in a sanitiser), or a harsh physical or chemical irritant. The irritant damages the skin barrier, enabling other irritants to enter the skin. This leads to local inflammation, pain, and itching.

Damaged skin is also more likely to develop a secondary bacterial infection [14]. Hence, measures should be taken to prevent skin damage such as removing the source of irritation and limiting the number of hours spent in PPE [13–15].

Regular face washing with a gentle cleanser may help with acne mechanica [14]. A lubricant or moisturiser may be applied at pressure areas [13].

Personal protective equipment for healthcare workers in the COVID-19 era

The Center for Disease Control (CDC) recommends the following personal protective equipment for use in high-risk situations:

• gloves
• long-sleeved isolation gown
• respiratory protection at a minimum a N95 fitted respirator. Powered air-purifying respirators should be available for very high risk procedures.
• front and side eye protection such as goggles and/or face shield.

PPE is only protective if used correctly, particularly when donning and doffing the equipment. A buddy system is recommended to monitor the procedure as well as education and frequent practice to reduce the risk of self-contamination. Decontamination of gloves prior to doffing may further reduce the infection risk. PPE is the least effective tool in the CDC Hierarchy of Controls model to minimise the risk of infection for healthcare workers.