Using Personal Protection Equipment during outbreak situations is a vital part of the routines to prevent responders to an outbreak to get infected, as well as to prevent a virus to escape an infected area. This training in Egypt 2008 was provided by the European Union under the Better Training for Safer Food program.

1. PUBLIC HEALTH, OCCUPATIONAL SAFETY AND
PERSONAL PROTECTIVE EQUIPMENT
Harm Kiezebrink

2. MODULE OBJECTIVES
At the conclusion of this module, participants will
be able to:
• Practice basic infection prevention principles;
• Describe the procedures for taking rest breaks,
water and food when at an infected site without
compromising safety;
• Explain safe procedures for putting on and
taking off PPE.

3. What We Will Do in This Module
• Talk about personal protective equipment (PPE)
• Put on PPE
• Talk about protecting people from HPAI
• Take a break wearing PPE, as we should in an
outbreak response
• Remove PPE in a safe manner so we don’t infect
ourselves or carry disease home or to another location

4. Personal Protective Equipment
(PPE)
•
•
•
•
•
•
•
•
•
Coveralls
Shoe Covers
N-95 Respirator
Goggles
Plastic Apron
Gloves
Germicidal Wipes
Alcohol Wipes
Infectious Waste Bag

5. Why Use PPEs?
• You can be infected by HPAI through
your eyes, nose or mouth

6. Why Use PPEs?
• Virus can be carried to farms
• Virus can survive in the environment
• You may not be aware that it is there

7. What is the difference
between a SURGICAL MASK and a
RESPIRATOR?
Surgical mask
Respirator

8. Particulate Respirators
• N-95, N-99 or N-100, dependent on particle size allowed
through the mesh
• Filter out most infectious agents transmissible by air
• Not appropriate for persons with beards

9. Air-Purifying Respirators
•
•
•
•
Half- or full-face
“Gas Mask”
Replaceable HEPA filters for different hazards
Not appropriate for persons with facial hair

10. Air-Purifying Respirators
“Powered” Air-Supplied Respirators (PAPR)
•
•
•
•
Air circulates, helps keep worker cool
Replaceable HEPA filters
Does not require fit testing
Can be used by a person with facial hair

11. Coverall: Big is good, coveralls should be
2 sizes larger than you normally wear

12. Before You Put on the PPE
• Remove your watch and any jewelry
• Remove extra clothing
• Remove all tobacco products
(cigarettes, snuff, etc.)
• It is recommended to leave cell phones
behind.

13. •
•
•
•
•
•
Before You Put on the PPE:
Wash Your Hands!
Wet hands with soap and water
Rub all surfaces
Rub for 20 seconds
Rinse well
Wash forearms and face
Towel or air dry

14. Donning the PPE properly
SEQUENCE
• Coveralls
• Shoe covers
• Respirator
• Goggles
• Pull hood over head
• Apron
• 2 pairs of gloves

15. Take off what you don’t need
(jewelry, extra clothing, cell phones)
Put On Coveralls

16. Put on Shoe Covers

17. Put On Your Respirator

18. Put on Goggles and Pull Up Hood
You may want to remove vent covers so that
goggles don’t steam up. Don’t cover vents with

19. Put On Apron

20. Put on Inner and Outer Gloves

22. You May Also
Want To:
• Tape on a
sample bag to
carry back
samples

23. Ready to Go!
Leave your
biohazard bag
at the
intersection of
the clean and
dirty area

24. Protecting Poultry Workers and Farm Families
• Education
• Personal hygiene
• Prevention

25. Poultry Farm Worker: Education
•
If workers notice severely depressed birds or high mortality:
– Immediately leave the poultry house to prevent exposure
– Contact a supervisor to investigate
• From outside the house if possible
• Determine if problem is mechanical
•
Anyone entering the house should :
–
–
–
–
Wear full PPE
Limit exposure time
Limit contact with dead or dying birds
Limit contact with potentially infective manure

26. Poultry Farm Worker Protection: Hygiene
• Practicing careful personal hygiene when working with
poultry can greatly minimize workers’ risk of disease.
• Hand-washing
– One of the simplest and most effective
– Hands should be lathered with soap
for at least 20 seconds
– An alcohol-based hand rub can be used

27. Poultry Farm Worker Protection: Hygiene
• Clothing
– Wear clean clothes to the farm
– Change into dedicated work clothing, which
never leave the farm
• Coveralls, head cover, and boots.
– Farm should have a changing area
• Decontamination
– Best practice: Shower at the end of the day,
wear personal clothes home
– Good practice: Change out of work clothes
and shower when arrive home.

28. Poultry Farm Worker Protection: Prevention
•
Vaccinations
– Workers should have seasonal influenza vaccinations.
– Vaccination does not protect against H5N1 HPAI.
– Vaccination does help prevent dual infection with AI and
seasonal flu.

29. Backyard / Smallholder Poultry Owners: Education
Protecting Children
– Many HPAI H5N1 cases in children
– Require supervision around poultry
– Restrict access to reduce exposure
Education is the key to protecting farm families

30. Backyard / Smallholder Poultry Owners: Hygiene
• Personal hygiene to decrease their risk
of infection
– Hand washing
– Keep poultry outside family living space

31. Backyard / Smallholder Poultry Owners: Prevention
• Biosecurity to protect their birds
– Covered, screened buildings
– Don’t mix species in a pen
– Separate shoes worn in poultry area, so manure is
not carried into the house

32. Live Bird Market Worker Protection: Prevention
• Birds that die in the markets are potential sources of
infection.
• If a worker finds a dead bird it should be:
–
–
–
–
Removed from the cage
Placed into a closed container
Not be eaten
If possible, the bird should be submitted to authorities for
testing
• After the bird has been handled, the worker should
thoroughly wash hands with soap and water.

33. Live Bird Market Worker Protection: Prevention
• Large Numbers of Dead Birds:
– Limit exposure by leaving the market
– Secure the market areas so others can not enter
– Contact their supervisor, the market owner, or
designated first responder
– Monitor their own health
– Consider quarantine or culling all exposed birds

34. When You Take a Break:
– Remove all PPE
– Or remove only
•
•
•
•
•
Gloves (both pairs)
Boot covers
Respirator
Apron
And then get assistance

35. Taking a Break in PPE
• Moving from Red Zone (infected area)
to Orange Zone (transit area)
– Clean gloves with a germicidal wipe
– Remove apron
– Remove outer boot covers, touch only
outside, so you don’t dirty the coveralls
– Remove outer gloves, touch only outside of
first glove, inside of second glove

36. Taking a Break in PPE
• At interface of Orange Zone and Green Zone
(clean area)
– NEVER TOUCH YOUR DIRTY PPE
– Assistant in Green Zone removes hood and
respirator
– Assistant gives you drink with a straw
– Assistant replaces your respirator, goggles and
hood
– Assistant gives you new apron, gloves and boot
cover
– Return to Red Zone (your seat)

37. Case Definition for Suspect Human HPAI
Any individual presenting with an
unexplained lower respiratory tract
infection with:
• Fever (temperature > 38 C)
• Shortness of breath or
• Difficulty breathing

38. Case Definition for Suspect Human HPAI
And one or more of the following exposures in
the 7 days prior to symptom onset:
•
Exposure to poultry or wild birds or their remains or to an
environment contaminated with their feces in an area where
H5N1 infections in animals or humans have been suspected or
confirmed in the last month
•
Close contact with a suspect, probable or confirmed human or
animal case
•
Consumption of raw or undercooked poultry products in an area
where H5N1 infections in animals or humans have been
suspected or confirmed in the last month
•
Handling animal / human samples suspected of containing H5N1

39. Surveillance of Animal Control Workers and
Family Members of HPAI Affected Households
• Daily symptom check of all control workers
• Symptom check of all family members
• Confirm temperatures of any with suspect
symptoms
• Referral for evaluation of any suspected
cases of human HPAI
• Prompt isolation for anyone exhibiting

40. Accidental Exposure of Workers
to HPAI
• Active daily surveillance for symptoms and fever.
• Consider initiating prophylaxis;
– Oseltamivir 75 mg once a day for 10 days
• Refer for further evaluation and treatment if patient
meets case definition of suspect human HPAI.
• Consider quarantine.

41. Management of Suspect Human HPAI Case
•
•
•
•
Initiate prompt infection control activities with standard and
airborne precautions for all personnel in contact with suspect
patient.
Refer to nearest health facility capable of evaluation of patient.
Maintain strict isolation of patient, either in health facility or in
home:
– 7 days for adults
– 21 days for children
If suspect human case meets case definition, start Oseltamavir
75 mg twice a day immediately pending confirmation of positive
or negative Influenza A H5 test.

42. Proper Order for Doffing the PPE
• Wipe off gloves with germicidal wipes
• Remove:
–
–
–
–
–
–
–
Apron
Shoe covers
Outer gloves
Coveralls
Goggles
Respirator
Inner gloves
• Tie off biohazard bag
• Wash hands with soap and water

43. Removing PPE:
Biohazard Bag Should Be
Opened at The End Of The
Donning Process in
Preparation For Doffing:
Clean Gloves

44. Remove Apron

45. Remove Shoe Covers

46. Remove Outer Gloves
First hand touches
only outside of first
glove, second hand
touches only inside
of second glove

47. Roll down
coveralls
without
touching
outside

48. Remove
goggles by
the strap
that was
covered by
hood, not by
the front
piece!

49. Remove Respirator:
Bottom Strap first!

50. Remove gloves, tie bag, sanitize hands
with alcohol wipe and wash hands

51. Clean Hands, Arms and Face with
Alcohol Wipes and Wash With Soap
and Water, if Possible
• Wet hands with soap and
water
• Rub all surfaces
• Rub for 20 seconds
• Rinse well
• Wash forearms and face
• Towel or air dry

52. Do Not Reuse PPE
• PPE kit contents are designed for single use only
• Do not wash and reuse
• Reuse could result in:
– Self-contamination
– Contaminating someone else
– Contaminating a new location

53. Discard PPE:
• Immediately if it is torn, heavily soiled or
wet
• Immediately after use
• Change respirator if:
– Dirty
– Damaged
– Difficult to breath through

54. Discard PPE After Use!
• Use plastic bags provided
– Be sure to seal the bag and disinfect the
surface of the bag
– Dispose of the bag appropriately by burial
– Burning is not a preferred method of
disposal due to the environmental
implications associated with burning plastic
– Proper disposal is important to prevent
further disease spread and contamination

55. PPE CASE STUDY
•Read the case study assigned to your table
and discuss what you would say in response to
the concerns raised in the cases.
•Choose someone to take notes and someone
to report your thinking to the larger group.

56. Case Study #1
• You have been called to a site to help with the de-population of a
sick flock. When you arrive and go to the designated place to get
your PPE Kit, many other workers are already there putting on
their PPE. As you start to put your equipment on, you hear a
worker say:
•
“I cannot believe all of this stuff! It is so wasteful to use it once and
then throw it away. I think when I’m finished today I’m going to
keep some of the equipment. After all, I am probably going to
need it again.”
•
You notice that a couple of other workers are nodding in
agreement. You know that it is important to dispose of equipment
after it has been used once and want to say something, but you
are not sure how to approach the worker. After all, you do not
know him and you are not from his village (neighborhood).

57. Case Study #2
•
A worker reports for duty, helping to clean up a chicken yard
where an outbreak of highly pathogenic avian influenza is
suspected, but has not yet been confirmed. He has been trained
on the use of PPE, but this is his first time to put on the
equipment. He opens his PPE Kit from USAID and cannot
believe how many things are in it. But instead of being pleased
with the PPE, he sees it as exaggerating the danger of the
situation. You walk up to him and ask him if he needs help
getting into his gear and he tells you,
•
“There is no way I am putting on all of this to clean up a chicken
yard! We do not need all of this. I have on my own boots. I can
cover my face with a scarf or cloth. Let’s get the job done, and
get out of here. All this stuff is just a waste of time. Why is
everyone being so dramatic?”

58. Questions?