Personal Protective Equipment in the School Setting

Personal protective equipment (PPE) includes a surgical mask, N95 respirator, eye protection, disposable gloves, and a gown (disposable or cloth). Whether PPE should be worn by school health personnel and the type of PPE worn should be based on several factors, including:

• The type of service being provided
• The anticipated risk of exposure to infectious body fluids
• The assessment of risk for infectious / communicable disease

Examples of appropriate use of PPE for adherence to Standard Precautions include: use of masks with possible droplet or airborne transmission through respirations, coughing or sneezing; use of gloves in situations involving possible contact with blood or body fluids, mucous membranes, non-intact skin or potentially infectious material; use of a gown to protect skin and clothing during procedures or activities where contact with blood or body fluids is anticipated; use of mouth, nose and eye protection during procedures that are likely to generate splashes or sprays of blood or other body fluids.

PPE should be removed and properly disposed after use and handwashing should be completed before interacting or working with another student.

Resources:

• COVID-19 Reference Personal Protective Equipment (PPE)
• CDC Types of Masks and Respirators

N95 respirators

An N95 respirator is a protective device designed to achieve a tight facial fit and efficient filtration of airborne particles. The N95 designation means that when subjected to careful testing, the respirator blocks at least 95 percent of small (0.3 micron) test particles. A standard N95 respirator could be worn to control COVID-19 exposure when performing procedures that are likely to generate a higher level of potentially infectious aerosol particles than from coughing, sneezing, talking, or breathing (also known as aerosol generating procedures, or AGP). Open suction of a tracheostomy, where the caregiver is working on an open tracheostomy, is an example of an AGP.

Some respirators are designed and tested to meet international standards. The most widely available respirators that meet an international standard are KN95 respirators.  CDC Types of Masks and Respirators provides additional information to consider if purchasing or using KN95 respirators.

Surgical masks

Medical-grade face masks (surgical masks) are FDA-regulated masks that are fluid resistant and provide the wearer protection against large droplets, splashes, or sprays of bodily or other hazardous fluids. These should be worn by school health staff who are assessing students or staff for respiratory symptoms and providing health care procedures (e.g., nebulization treatments, assisting student use of a peak flow meter, oral or nasal suctioning, etc.). Tracheostomies that are set up with a closed or in-line suction system are not considered aerosol-generating procedures (AGPs), as the entire suctioning process is contained in a closed system and therefore do not require an N95.

Eye protection (face shields)

Eye protection should be worn if there is a reasonable chance that a splash or spray of blood or body fluids may occur to the eyes, mouth, or nose. Eye protection should be removed and cleaned if it becomes visibly dirty or difficult to see through. Examples of services in which eye protection may be warranted include feeding, suctioning, and assisting with medications that are difficult to swallow, and when working with students who have known to exhibit such behaviors as spitting or biting.

Gloves (nonlatex)

Gloves should be worn when there is reasonable expectation that the service provider may encounter blood, body fluids, nonintact skin, mucous membranes, and contaminated items. Hand washing should be performed before and after the use of gloves. Examples of services for which gloves are recommended include toileting or diapering; feeding or providing oral care; assisting with personal hygiene, such as brushing teeth or wiping away secretions; and assisting with medications or other nursing treatments. Gloves should be removed and changed before contacting clean spaces (e.g., medication cabinets) and medical equipment.

Gowns (disposable, smock, other clothes, or coverings)

Gowns or other coverings are recommended when there is a reasonable expectation that saliva or other body fluids may come into contact with an employee's clothing. Reuse of disposable gowns is discouraged due to the high likelihood of contamination when removing and putting on a used gown. Cloth coverings can be used between multiple students if the gowns are not visibly dirty and should be hung and stored in a location that is dry and away to reduce risk for the cross spread of infection. Cloth coverings should be washed at least daily, or more often if visibly dirty. Staff could consider wearing a gown when assisting students with personal care (e.g., feeding, toileting, assisting with hygiene, or transferring).

Staff training and education

Space should be designated for putting on (donning) and removing (doffing) protective equipment. Learning to correctly don and doff protective equipment is important to prevent self-contamination when using PPE. School health personnel using PPE should receive initial training with return demonstration, and thereafter at least annually to ensure optimal benefit from PPE use. School districts should consider having a designated staff member (such as the school nurse) who can help staff as needed during the school day. Schools should consider placing signs, as appropriate, as a visual cue to guide staff on proper use and disposal of PPE.

Resource

• CDC: Sequence for Putting on Personal Protective Equipment (PPE) (PDF)

Recommendations for optimizing, disposing, and cleaning PPE

Used disposable PPE (gloves, gowns, or masks) may be put in a designated lined trash receptacle and removed in the same way as other school garbage.

Eye protection (face shields) should be cleaned and disinfected when visibly dirty, or at least daily, following manufacturer's direction or using the CDC guidance below.

• While wearing gloves, carefully wipe the inside, followed by the outside of the face shield. Use a clean cloth soaked with neutral detergent solution or a cleaning wipe.
• Carefully wipe the outside of the face shield using a wipe or clean cloth saturated with EPA-registered hospital disinfectant solution.
• Wipe the outside of face shield with clean water or alcohol to remove residue.
• Dry fully (air dry or use clean absorbent towels).
• Remove gloves and wash hands.

Gloves should be changed after providing care to each student, when ripped or torn, when dirty or contaminated, and when moving from a dirty to a clean procedure (i.e., cleaning up vomit, then preparing medicine).

Considerations when using an N95 respirator

General considerations during extended use and reuse of PPE-

• Extended use refers to wearing the same item of PPE for multiple patient encounters without removing the PPE between patients.
• Reuse refers to using the same item of PPE for multiple patient encounters with removal and storage of the item between patients.
• Staff should perform diligent hand washing before and after putting on, removing, or adjusting any piece of PPE intended for extended use or reuse.
• Staff should take extreme care not to inadvertently touch any piece of PPE worn on the head (N95, face mask, or eye protection) to avoid contamination.
• Any piece of PPE that is typically disposable but is being used for extended use or reuse should be restricted for use by one person and not be shared between staff.
• Any piece of PPE being used for extended use or reuse should be inspected prior to use for visible signs of soiling or damage and discarded if needed.
• Any piece of PPE that no longer fastens securely should be discarded.
• N95 respirators, face masks, and eye protection should be carefully stored between uses in a clean, breathable storage container, such as a labeled paper bag or cardboard box. Plastic bags are not recommended.
• Staff should leave the care area before removing their PPE.
• Recommendations for limited reuse of N95 respirators:
  • Wear gloves when performing a seal check on a previously used respirator and discard gloves afterward.
  • When removing an N95, wash hands and remove the respirator by the straps without touching the inside.
  • Contact the respirator manufacturer for recommendations on the maximum number of reuses for that N95 model. If no manufacturer guidance is available, data suggest no more than five reuses per device.

During both extended use and reuse of N95s, remove the mask if it becomes dirty, wet, damaged, or hard to breathe through.

Resources

• Public Health Respiratory Protection Program Template
• CDC: Filtering out Confusion: Frequently Asked Questions about Respiratory Protection
• CDC: Proper N95 Respirator Use for Respiratory Protection Preparedness
• CDC: Difference Between Respirators and Surgical Masks
• CDC: Types of Masks and Respirators
• OSHA Standard 1910.134 Respiratory protection
• CDC: NIOSH-approved N95 Particulate Filtering Facepiece Respirators