Technical Brief: IPAC Recommendations for Use of Personal

IPAC Recommendations for Use of PPE for Care of Individuals with Suspect or Confirmed COVID‑19 1

TECHNICAL BRIEF

IPAC Recommendations for Use of Personal

Protective Equipment for Care of Individuals

with Suspect or Confirmed COVID‑19

Edition: November 2023

Overview

The recommendations in this technical brief incorporate evidence to date on modes of transmission,

effectiveness of personal protective equipment (PPE) in healthcare workers (HCWs) and the

undetermined impact of the emergence of variants and their lineages. Recommendations will be

updated as needed based on emerging information.

Key Findings

• HCWs are at risk of infection from both occupational and community exposures. Therefore,

protection of HCWs from COVID-19 requires both the application of the hierarchy of controls for

infection prevention and control (IPAC) in healthcare settings and public health measures aimed at

reducing COVID-19 transmission in the community setting, particularly vaccination.

• The selection and use of appropriate PPE in the healthcare setting is important given the risk

associated with healthcare interactions. The body of existing evidence comparing N95 respirators

(or equivalent) to medical masks (surgical/procedure) has substantial limitations related to high risk

of bias and unmeasured confounding. There is one Randomized Control Trial (RCT) that found

medical masks to be non-inferior to N95 respirators (based on a pre-specified margin of 2) at

preventing RT-PCR confirmed symptomatic COVID-19 infection when providing care to patients with

suspect or confirmed SARS-CoV-2. The remaining evidence is mixed with some large observational

studies supporting a protective effect of N95 respirator use over medical masks when caring for

patients with suspect or confirmed COVID-19 based on studies conducted prior to September 2021.

• The recommended PPE when providing direct care for patients with suspect or confirmed COVID-19

includes a well-fitted medical mask (surgical/procedure) or a fit-tested, seal-checked N95 respirator

(or equivalent), eye protection, gown, and gloves.

• There are estimates of significant increased transmissibility and decreased vaccine effectiveness of

the primary series of COVID-19 vaccine against some COVID-19 variants. Uptake of all eligible

boosters has demonstrated improved vaccine effectiveness against severity of illness with some

known COVID-19 variants and may be of benefit for emerging and future COVID-19 variants and

subvariants. It is recommended that HCWs remain up to date with recommended vaccines doses

when eligible, with the goal of providing increased protection from COVID-19 and from exposures

in both the community and healthcare setting.

IPAC Recommendations for Use of PPE for Care of Individuals with Suspect or Confirmed COVID‑19 2

Background

Evidence on the routes of transmission for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)

have been summarized elsewhere.

1, 2

SARS-CoV-2 is transmitted most frequently and easily at short range

through exposure to respiratory particles that range in size from large droplets to smaller aerosols that

can be inhaled or deposited on mucous membranes.

Infection can also occur by touching mucous

membranes with soiled hands contaminated with virus.

Evidence also suggests long-range aerosol

transmission can occur, particularly where there is inadequate ventilation and/or highly infectious

individual(s).

• Evidence has suggested the potential for increased transmissibility of some COVID-19 variants and

subvariants.

The mechanisms for increased transmissibility are unclear. There has also been

relatively lower vaccine effectiveness against some variants and subvariants, hence the utmost

need for optimization and adherence to all layers of current IPAC measures including respiratory

protection with a good facial fit.

4,5

• Ontario HCWs have potential risk of occupational exposure, however community exposure has been

a significant risk as well.

The risk of COVID-19 infection for HCWs is influenced by multiple factors

including virus characteristics (i.e. infectious dose), local epidemiology, HCW factors (i.e., immune

status, hand hygiene practices), PPE practices (including choice, fit and appropriate donning and

doffing), patient factors (i.e., vaccination status, ability to mask for source control), interaction

(i.e., close, prolonged contact, procedures associated with higher transmission risk), and

environmental factors (i.e., crowding and ventilation). For the best protection, multiple layered

preventive measures should be used in combination to help reduce the risk of COVID-19 infection.

• Vaccination, including uptake of all recommended and eligible doses, increases vaccine

effectiveness to protect HCWs from community and occupational infection risk.

7,8

HCWs should

follow National Advisory Committee on Immunization (NACI) and/or provincial recommendations

for appropriate booster doses and updated COVID-19 vaccines.

Preamble

The protection of HCWs, as well as other staff, in all settings where health care is provided is critical.

Health care settings include, but are not exclusive to, acute care, pre-hospital care, long-term care,

primary care, ambulatory care clinics, dental care and community care, including home care and other

locations in the community where health care is provided (e.g., school settings, residential care or

correctional facilities). A hierarchy of hazard controls is used in healthcare settings (and other

workplaces) to reduce the risk of infection transmission. This technical brief focuses on

recommendations for PPE, however PPE alone is not sufficient to protect HCWs, particularly in the

context of substantial community transmission, and recommendations must be implemented along with

HCW vaccination and other protective measures within the hierarchy of controls. Recommendations for

IPAC best practices incorporate the science of infection transmission, the effectiveness of measures in

isolation and in combination as layered mitigation measures, as well as the effectiveness and the impact

of implementation fidelity.

The PPE recommendations summarized in the table below are based on the best available evidence and

were adapted from the World Health Organization’s Rational Use of Personal Protective Equipment for

Coronavirus Disease 2019 and Health Protection Scotland’s Standard Infection Control Precautions

Literature Review of AGMPs.

10,11

IPAC Recommendations for Use of PPE for Care of Individuals with Suspect or Confirmed COVID‑19 3

Health care settings should adhere to legislative requirements applicable to their organization/setting.

For the purposes of this document, the individual receiving care will be referred to as a patient

regardless of where the care is being provided.

Recommended Risk Assessments

Organizational Risk Assessment

A recommended practice is to conduct an Organizational Risk Assessment (ORA). An ORA is a systematic

approach to identifying areas of infection risk and assessing the efficacy of control measures that are in

place to mitigate the transmission of infections in the health care setting. The ORA is central to any

health care organization’s preparation and planning to protect HCWs. Organizations have a

responsibility to provide education and training to HCWs regarding the organization’s ORA and any

identified gaps and provide guidance around the organizational factors that may affect the selection and

use of PPE such as local epidemiology, patient population, and assessment of ventilation in the setting.

Organizations also have a responsibility for engagement of the Joint Health and Safety Committees or

Health and Safety representatives, as appropriate.

An ORA of the most important control measure, elimination, would include vaccination status of HCWs

in the organization and supports for HCWs to stay home when sick. Facilitues

Engineering control measures include care and maintenance of heating ventilation air conditioning

(HVAC) systems, physical barriers for screening and access to point of care alcohol-based hand rub

(ABHR) administrative controls, such as policies and procedures regarding screening, use of private and

airborne infection isolation rooms, monitoring the local epidemiology (including implications of

newemerging variants) and appropriate selection and use of PPE including the use of a point-of-care risk

assessment (PCRA).

An organizational awareness of ventilation / air exchanges in areas in the organization, to identify rooms

that do not meet the minimum CSA Group standard can prioritize areas to limit occupancy and facilitate

placement of individuals with suspect or confirmed COVID-19. Application of the hierarchy of controls

can help to mitigate the risk of transmission when upgrades are not possible or are in process

(for example, elimination – not using the room; substitution – only using for screen negative patients;

engineering – optimizing ventilation, only using the room for patients able to mask; administration –

limiting occupancy, using rooms for only short visits; PPE – use of N95 respirators or equivalent).

Point of Care Risk Assessment (PCRA)

Performing a risk assessment is the first step in Routine Practices,

which are to be used with all

patients, for all care and for all interactions. A point of care risk assessment (PCRA) also includes

assessing the exposure risk specific to the care intervention being performed and duration of the

activity. Education and training is to be provided to the HCW on how to effectively perform a risk

assessment, including information on the efficacy of control measures identified in the organizational

risk assessment that would be pertinent to the point-of-care risk assessment. Risk assessments are

dynamic and should be completed by the HCW before each patient interaction or task to determine

whether there is risk of being exposed to an infection and for selection of the correct PPE required to

protect the health worker and other staff in their interaction with the patient and patient environment.

IPAC Recommendations for Use of PPE for Care of Individuals with Suspect or Confirmed COVID‑19 4

Examples of risk factors that may increase transmission and infection risk to the HCW include:

• HCW: Not up-to-date on recommended COVID-19 vaccination

• Patient: Unable to mask for source control

• Interaction: Prolonged, close contact, performing a high-risk procedure (see below)

Application of the Hierarchy of Hazard Controls

According to the National Institute for Occupational Safety and Health (NIOSH), the fundamental

framework for protecting workers is through the application of the hierarchy of hazard controls.

The levels of control range from the highest levels considered most effective at reducing the risk of

exposure (i.e., elimination and substitution) to the lowest or last level of control between the worker

and the hazard (i.e., PPE).

The application of the hierarchy of hazard controls is a recognized approach to containment or

mitigation of hazards and is fundamental to an occupational health and safety (OHS) framework.

An understanding of the strengths and limitations of each of the controls enables health care

organizations to determine how the healthcare environment (e.g., infrastructure, equipment, processes

and practices) increases or decreases a HCW’s risk of infection from exposure to a pathogen within the

healthcare setting.

Collaboration between IPAC, OHS and healthcare building engineers supports the comprehensive

evaluation and implementation of measures to reduce the risk of HCWs’ exposure to pathogens.

The hierarchy of controls is intended to compliment other public health measures such as physical

distancing, hand hygiene and respiratory etiquette.

Elimination and Substitution

Elimination and substitution are considered to be the most effective measures in the hierarchy of controls,

but are not often feasible or possible to implement fully as it relates to infection control in health care

settings. COVID-19 vaccines are available in Canada and high vaccination coverage (including additional

doses as recommended) is an integral component of protecting HCWs from severe disease, reducing the

spread of SARS-CoV-2 in the population, and reducing the likelihood of infected patients in health care

settings.

15,16

Vaccination will be less effective as an elimination strategy with emerging variants and

sub-variants capable of immune escape.

4,5

Additionally, consideration for virtual clinical visits instead

of in-person visits where appropriate can reduce overall COVID-19 burden within the clinical setting.

Engineering and Systems Control Measures

Engineering controls reduce or eliminate exposure by isolating the hazard from the individual and/or by

physically directing actions to reduce the opportunity for human error.

Examples include ventilation (e.g., airborne infection isolation room [AIIR], reducing structural barriers

to airflow, optimizing fresh air changes in the HVAC system), full-length physical barriers between the

patient and the HCWs at reception and triage, point-of-care sharps containers and easily access to

ABHR. Other examples include single occupancy room design and ante-chambers for donning and

doffing PPE that require additional training (see Administrative Control Measures) to prevent these

areas from becoming contaminated with soiled PPE.

IPAC Recommendations for Use of PPE for Care of Individuals with Suspect or Confirmed COVID‑19 5

Administrative Control Measures

Administrative controls are measures to reduce the risk of transmission of infections to HCWs and

patients through the implementation of policies, procedures, training and education.

Effective administrative control measures to prevent the transmission of infection require the support of

leadership in the health care organization, and occur in consultation with HCWs and management

through the Joint Health and Safety Committee or Health and Safety representative to provide the

necessary organizational procedures, resources, education and training to effectively apply the controls

and the commitment of HCWs and other users to comply with their application.

Examples of administrative controls include HCW vaccination policy, sick leave policy,electronic alert

system and infectious disease flags for early detection, placement and additional precautions for

patients with infectious syndromes. Active screening, passive screening (signage), restricted visitor

policies, restricting entrances, cohorting of staff and patients and, audits of practice.

Personal Protective Equipment (PPE)

The PPE tier refers to the availability, support and appropriate use of protective gear to minimize

exposure and prevent transmission. As the last tier in the hierarchy of hazard controls, PPE should not

be relied on as a stand-alone primary prevention program. Examples of PPE include gloves, gowns,

respiratory protection, including medical or surgical/procedure masks (ASTM level 1-3) and N95

respirators and eye protection (including some types of safety glasses, face shields, goggles).

17,18

A systematic review on the protective effects of eye protection on transmission of SARS-CoV-2 identified

5 observational studies which demonstrated an overall protective effect, however all of the studies were

at high risk of bias and the certainty of the evidence was very low.

Wearing a surgical/procedure mask (henceforth referred to as a medical mask) has been shown to be

effective in preventing transmission of acute respiratory infections such as influenza.

20,21

A number of

studies have attempted to provide further insight into the use of medical masks and N95 respirators for

protection against respiratory viruses including SARS-CoV-2; summaries are included below.

There is one published randomized control trial (clinicaltrials.gov NCT04296643) which examined

whether the effectiveness of medical masks was non-inferior to fit-tested N95 respirators worn by

health care workers (HCWs) for the prevention of reverse transcriptase polymerase chain reaction

(RT-PCR)-confirmed symptomatic Coronavirus Disease 2019 (COVID19) infection in HCWs providing

routine care to patients with suspect or confirmed COVID-19.

The study design was a randomized, non-

inferiority trial conducted from May 4, 2020 to March 29, 2022 in Canada, Israel, Pakistan and Egypt.

HCWs were randomly assigned to wear medical masks (n=497) or N95 respirators (n=507) when

providing routine care to patients with suspect or confirmed COVID-19 for 10 weeks (or up to 2 weeks

following receipt of an mRNA vaccine). The authors used a pre-specified relative effect size (hazard ratio

[HR]) margin of within 2, and found medical masks to be non-inferior to N95 respirators based on this

pre-specified margin. While the results indicated non-inferiority, the margin was wide, meaning the

results should be interpreted as ruling out a doubling in hazard of confirmed symptomatic COVID-19 for

those wearing medical masks compared to N95 respirators. A hazard reduction of less than 2 but greater

than 1 could not be determined based on this study’s design.

Results of systematic reviews and meta-analyses prior to this RCT show no significant difference

between N95 respirators and medical masks when used by HCWs to prevent transmission of acute

respiratory infections from patients.

24,25

IPAC Recommendations for Use of PPE for Care of Individuals with Suspect or Confirmed COVID‑19 6

An early systematic review and meta-analysis of mask effectiveness for prevention of SARS-CoV-2

infection identified a significant protective effect of mask use in HCWs (adjusted OR 0.18; 95% CI 0.09-

0.34), but did not compare different types of masks.

A subsequent systematic review did not directly

compare N95 respirators and medical masks, but analysis showed an overall protective effect in the use

of N95 respirators and medical masks. Sub-analysis of mask type showed a strong protective effect in

the use of N95 respirators and a statistically significant protective effect using medical masks, but with

lower confidence of the latter due to a low sample size.

A systematic review of 12 studies published to

June 2021 compared medical mask use to N95 respirators or equivalent among HCWs, and found an

overall similar infection rate between the two groups (9.46% and 8.96%, respectively). Notably, many of

the included studies were at high risk of bias and used variable measures to determine infection rate

and source of acquisition (i.e. community or nosocomial) among infected HCWs.

An observational cohort study from Switzerland analyzed self-reported mask use in context of

cumulative SARS-CoV2 exposure among nearly 3,000 HCWs between September 2020 and September

2021, and found HCW SARS-CoV-2 positivity at 21% with respirators and 35% with medical masks

(OR, 0.49; 95% CI, 0.39-0.61).

Household exposure was associated with the greatest risk of infection

in multivariable analysis (OR 7.79; 95%CI 5.98-10.15); respirator use (OR 0.56; 95%CI 0.43-0.74) and

vaccination (OR 0.55; 95%CI 0.41-0.74) associated with the lowest risk of infection. While less than 10%

of overall participants consistently wore a mask outside of the healthcare setting, there were no data on

community and nosocomial sources of acquisition among infected HCWs.

Additional observational studies in jurisdictions that have recommended medical masks for routine care

of suspect or confirmed patients with COVID-19 have reported on the general effectiveness of these

policies by demonstrating low nosocomial infection rates compared to community exposures.

30-32

However, all of these studies were done during times of earlier variants of SARS-CoV-2.

There is further mixed evidence on the relative effectiveness of N95 respirators (or equivalent)

compared to medical masks for SARS-CoV-2. Two survey studies comparing infection rates among HCWs

who reported respirator use demonstrated significantly higher seropositivity for SARS-CoV-2 compared

to those reporting medical mask use.

33,34

However, in the survey study from France there was an

increased odds of seropositivity if HCWs reported universal respirator use (i.e., for care of non-COVID-19

patients) compared to those who wore medical masks.

In a case-control study of HCWs in Colombia

there was a significant increased infection risk by RT-PCR among those who did not use a respirator.35

In a cohort study from Switzerland of over 3000 HCWs, 22% preferentially used respirators and was

associated with non-statistically significant risk reductions in COVID-19 compared to medical masks

(adjusted HR 0.8; 95%CI 0.6-1.0, p=0.052 and 0.7; 95%CI 0.5-1.0, p=0.053 for PCR-confirmed SARS-CoV-2

and seroconversion, respectively).

In an ecological study from England that compared COVID-19

outbreaks among orthopedic surgery wards based on respirator policies, fewer outbreaks were reported

on units that recommended use of respirators when caring for symptomatic patients (11/13 of medical

mask units vs 3/6 respirator units), although this difference was not statistically significant.

A prospective cohort study assessed SARS-CoV-2 seroconversion rates in the context of mask policies

based on medical masks or FFP-2 respirators. It found that differences in mask policy did not affect the

seroconversion rate and that the most important risk factors for seroconversion were exposure to

infected co-workers and household contacts.

In a small case-control study, there was no significant association with respirator use and infection.

In a cross-sectional survey study of emergency departments (ED) in the Netherlands, 13/45 (29%) had

policies for respirator use (and eye protection) for all contacts with suspect or confirmed COVID-19

patients, and there was no difference in ED staff infections in these units compared to EDs that

IPAC Recommendations for Use of PPE for Care of Individuals with Suspect or Confirmed COVID‑19 7

recommended medical masks for the care of patients with suspect or confirmed COVID-19.

In a large

retrospective cohort study from the United States of HCWs providing non-AGMP routine care of patients

with COVID-19, there was no association in PCR-positive SARS-CoV-2 status between medical mask and

respirator use.

The body of existing evidence is mixed regarding a protective effect of respirator use compared to

medical masks and has substantial limitations related to high risk for bias and unmeasured confounding.

The degree of protection for HCWs from other infection prevention measures (i.e., up-to-date

vaccination status) is important to protect against exposures from community sources and in other

occupational settings (i.e., staff eating areas, unrecognized patient or staff cases). A strong

recommendation in favor of the use of a medical mask versus a respirator cannot be made based on

existing evidence and further research is required. For routine care, of a patient with suspect or

confirmed COVID-19, mask choice is best decided by PCRA.

Patient Accommodation

Patients with suspect or confirmed COVID‑19 should be cared for in single rooms, whenever possible.

The use of an AIIR is the recommended when performing an AGMP (see below). If an AIIR is not

available, a single room with the door closed should be used for the procedure. In one study the

universal use of AIIR for care of patients with suspect or confirmed COVID-19 did not reduce HCW

infection rates.

There is no evidence to suggest that a fallow time is required after a patient with

suspect or confirmed COVID-19 leaves the room or following a high risk procedure (i.e., AGMP). The

evidence and recommendations supporting fallow times prior to re-entering a room (after an infectious

source leaves) stem from Tuberculosis (TB) literature, and are not reflective of, nor translatable to

respiratory viruses such as SARS-CoV-2. Therefore, there are no recommendations on the use of fallow

time for SARS-CoV-2 in any setting.

Procedures with Increased Transmission Risk

The procedures that are listed as aerosol-generating medical procedures (AGMPs) are those

procedures/encounters that have epidemiological data that indicate they may significantly increase

risk of infection to HCWs within close range of the procedure and thus fit-tested N95 respirators

(or equivalent) may provide a higher level of protection, but a well-fitted medical mask

(surgical/procedure) is recommended as a minimum level of respiratory protective equipment, in

addition to eye protection.

The presence of aerosols is not sufficient to consider a procedure/encounter as having increased risk of

transmission. However, it is acknowledged that other procedures may have high-risk features similar to

an AGMP, including close, prolonged contact with the airway). The risk associated with these procedures

will depend on other factors such the likelihood of infectious SARS-CoV-2 virus, community infection

rates, duration of procedure, presence of symptoms of SARS-CoV-2 and the distance from the patient.

While these procedures share similar high-risk features to AGMPs, they currently lack clear evidence on

differences inrisk to HCWs who use a medical mask versus an N95 respirator based on their PCRA.

The collection of a nasopharyngeal swab or throat swab is not considered a procedure with increased

risk of transmission.

IPAC Recommendations for Use of PPE for Care of Individuals with Suspect or Confirmed COVID‑19 8

Table 1: Procedures Considered AGMPs

Procedures Considered AGMPs

• Intubation, extubation and related procedures e.g., manual ventilation and open deep suctioning

• Tracheotomy/tracheostomy procedures (insertion/open suctioning/removal)

• Bronchoscopy

• Surgery using high speed devices in the respiratory tract

• Some dental procedures (e.g., high-speed drilling and ultrasonic scalers)

• Non-invasive ventilation (NIV) e.g., Bi-level Positive Airway Pressure (BiPAP) and Continuous

Positive Airway Pressure ventilation (CPAP)

• High-Frequency Oscillating Ventilation (HFOV)

• Induction of sputum with nebulized saline

• High flow nasal oxygen (high flow therapy via nasal cannula)

Summary of PPE Recommendations

This guidance is intended to inform recommended and other appropriate PPE for the care of patients

with suspect or confirmed COVID-19. In light of evidence of COVID-19 variants having varying relative

transmissibility,

varying mechanisms and variables for increased transmissibility and potential reduced

vaccine effectiveness, the recommended PPE for direct care of patients with suspect or confirmed

COVID-19, includes a well fitted medical mask (surgical/procedure) or a fit-tested, seal-checked N95

respirator (or equivalent), eye protection, gown and gloves.

Selection of appropriate PPE should include point-of-care risk assessment, fit, and tolerability of the

mask and equipment. HCWs should follow their local organizational guidance.

Note:

For every patient and/or patient environment encounter, perform a point-of-care risk

assessment and apply the

Four Moments for Hand Hygiene.

iversal masking with well-fitted medical masks for source control

(i.e., to protect others from

the mask wearer) and routine use of eye protection for all clinical encounters are additional

IPAC practices that have been implemented during the course of the

pandemic and can be

considered based on varying periods of transmission risk as outlined in the PHO

’s Interim IPAC

Measures Based on Respiratory Virus Transmission Risk in Health Care S

ettings.

IPAC Recommendations for Use of PPE for Care of Individuals with Suspect or Confirmed COVID‑19 9

Health Care Settings – Inpatient Settings

Table 2: Health Care Settings – Inpatient Settings

Setting Individual Activity Recommended PPE

Patient room Health care workers

Providing direct care to patients

with suspect or confirmed COVID‑19

• Medical mask* or N95 respirator

(fit-tested, seal-checked)

• Isolation gown

• Gloves

• Eye protection

Patient room Health care workers

Medical procedures with increased

transmission risk (e.g., AGMP)

performed on patients with suspect

or confirmed COVID‑19

• N95 respirator (fit-tested, seal-checked)

or medical mask*

• Isolation gown

• Gloves

• Eye protection

Patient room

Environmental service

workers

Entering and cleaning in the room of

patients with suspect or confirmed

COVID‑19

• Medical mask* or N95 respirator

(fit-tested, seal-checked)

• Isolation gown

• Gloves

• Eye protection

Patient room Visitors

Entering the room of a patient with

suspect or confirmed COVID‑19

• Medical mask*

• Isolation gown

• Gloves

• Eye protection

Patient Room

Transient activities

(e.g., Food service

delivery, laundry

pick-up/drop-off)

Entering the room of a patient with

suspect or confirmed COVID‑19

• Medical mask*

• Isolation gown

• Gloves

• Eye protection

IPAC Recommendations for Use of PPE for Care of Individuals with Suspect or Confirmed COVID‑19 10

Setting Individual Activity Recommended PPE

Triage Health care workers

Preliminary screening not involving

direct contact

• If able to maintain spatial distance of at least

2 m or separation by physical barrier, use

Routine Practices.

• If unable to maintain spatial distance of at

least 2 m or separation by physical barrier

wear a medical mask.*

Triage

Patient with suspect or

confirmed COVID‑19

Any

• Maintain spatial distance of at least 2 m

or separation by physical barrier

• Provide patient and accompanying caregivers

with medical mask* if tolerated and not

contraindicated. Patient to perform

hand hygiene.

Administrative areas

All staff, including

health care workers

Administrative tasks that do not

involve contact with patients

• Routine Practices

*A non-fit tested N95respirator (or equivalent) is considered an alternative to a medical mask.

IPAC Recommendations for Use of PPE for Care of Individuals with Suspect or Confirmed COVID‑19 11

Health Care Settings – Ambulatory and Outpatient Settings/Clinics

Table 3: Health Care Settings – Ambulatory and Outpatient Settings/Clinics

Setting Individual Activity Recommended PPE

Consultation or exam

room/area

Health care workers

Providing direct care to patients

with suspect or confirmed

COVID‑19

• Medical mask* or N95 respirator

(fit-tested, seal-checked)

• Isolation gown

• Gloves

• Eye protection

Consultation or exam

room/area

Patients with suspect or

confirmed COVID‑19

Any

• Provide medical mask* to patient and

accompanying caregivers if tolerated and

not contraindicated.

• Perform hand hygiene

Consultation or exam

room/area

Environmental service

Workers

After and between consultations

with patients with suspect or

confirmed COVID‑19

• Medical mask*

• Isolation gown

• Gloves

• Eye protection

Waiting room

Patient with suspect or

confirmed COVID‑19

Any

• Provide medical mask* to patient and

accompanying care giver if tolerated and

not contraindicated.

• Immediately move the patient to a single

patient room or separate area away from

others; if this is not feasible, ensure spatial

distance of at least 2 m from other patients.

Administrative areas

All staff, including health

care workers

Administrative tasks that do not

involve contact with patients

• Routine Practices

IPAC Recommendations for Use of PPE for Care of Individuals with Suspect or Confirmed COVID‑19 12

Setting Individual Activity Recommended PPE

Triage/Reception Health care workers

Preliminary screening not

involving direct contact

• If able to maintain spatial distance of at

least 2 m or separation by physical barrier

use Routine Practices

• If unable to maintain spatial distance of at

least 2 m or separation by physical barrier

wear a medical mask.*

Triage/Reception

Patients with suspect or

confirmed COVID‑19

Any

• Maintain spatial distance of at least 2 m or

separation by physical barrier.

• Provide medical mask* to patient and

accompanying caregiver if tolerated and not

contraindicated.

*A non-fit tested N95 respirator (or equivalent) is considered an alternative to a medical mask.

IPAC Recommendations for Use of PPE for Care of Individuals with Suspect or Confirmed COVID‑19 13

Other Settings

Table 4: Other Settings

Setting Individual Activity Recommended PPE

Home Care Health care workers

Providing direct care to clients/patients

with suspect or confirmed COVID‑19

• Medical mask * or N95 respirator

(fit-tested, seal-checked)

• Isolation gown

• Gloves

• Eye protection

Home Care Health care workers

Medical procedures with increased

transmission risk (e.g., AGMP)

performed on clients/patients with

suspect or confirmed COVID‑19

• N95 respirator (fit-tested, seal-checked)

or medical mask.*

• Isolation gown

• Gloves

• Eye protection

Long-term care

home/retirement home

Health care workers

Providing direct care to residents with

suspect or confirmed COVID‑19

• Medical mask* or N95 respirator

(fit-tested, seal-checked)

• Isolation gown

• Gloves

• Eye protection

Long-term care

home/retirement home

Health care workers

Performing medical procedures with

increased transmission risk (e.g.,

AGMP,CPAP and/or open suctioning) on

residents with suspect or confirmed

COVID‑19

• N95 respirator (fit-tested, seal-checked)

or medical mask.*

• Isolation gown

• Gloves

• Eye protection

IPAC Recommendations for Use of PPE for Care of Individuals with Suspect or Confirmed COVID‑19 14

Setting Individual Activity Recommended PPE

Long-term care

home/retirement home

Environmental

service workers

Entering and cleaning in the room of

residents with suspect or confirmed

COVID‑19

• Medical mask* or N95 respirator (fit-

tested, seal-checked)

• Isolation gown

• Gloves

• Eye protection

Long-term care

home/retirement home

Administrative areas

Administrative tasks that do not involve

contact with resident with suspect or

confirmed COVID‑19

• Routine Practices

Long-term care

home/retirement home

Visitors

Entering the room of a resident with

suspect or confirmed COVID‑19

• Medical mask*

• Isolation gown

• Gloves

• Eye protection

*A non-fit tested N95 respirator(or equivalent) is considered an alternative to a medical mask.

IPAC Recommendations for Use of PPE for Care of Individuals with Suspect or Confirmed COVID‑19 15

References

Ontario Agency for Health Protection and Promotion (Public Health Ontario). COVID-19

transmission through short and long-range respiratory particles [Internet]. Toronto, ON: Queen’s

Printer for Ontario; 2022 [cited 2023 Oct 5]. Available from:

https://www.publichealthontario.ca/-

/media/Documents/nCoV/phm/2022/01/covid-19-respiratory-transmission-range.pdf?sc_lang=en

Ontario Agency for Health Protection and Promotion (Public Health Ontario). Additional routes of

COVID-19 transmission – what we know so far [Internet]. Toronto, ON: Queen’s Printer for Ontario;

2021 [cited 2023 Oct 5]. Available from:

https://www.publichealthontario.ca/-

/media/documents/ncov/covid-wwksf/2020/12/routes-transmission-covid-19.pdf?sc_lang=en

Ontario Agency for Health Protection and Promotion (Public Health Ontario). SARS-CoV-2 Omicron

variant BA.2 and sub-lineages of BA.2: evidence and risk assessment (up to date as of June 14,

2022) [Internet]. Toronto, ON: Queen's Printer for Ontario; 2022 [cited 2023 Oct 5]. Available from:

https://www.publichealthontario.ca/-/media/Documents/nCoV/voc/covid-19-omicron-risk-

assessment.pdf?sc_lang=en

Ontario Agency for Health Protection and Promotion (Public Health Ontario). COVID-19 variant of

concern Omicron (B.1.1.529): risk assessment, January 26, 2022 [Internet]. Toronto, ON: Queen's

Printer for Ontario; 2022 [cited 2023 Oct 5]. Available from:

https://www.publichealthontario.ca/-

/media/Documents/nCoV/voc/2022/01/covid-19-omicron-b11529-risk-assessment-jan-26.pdf

Ontario Agency for Health Protection and Promotion (Public Health Ontario). COVID-19 Delta: risk

assessment and implications for practice (September 20, 2021 update) [Internet]. Toronto, ON:

Queen's Printer for Ontario; 2021 [cited 2023 Oct 5]. Available from:

https://www.publichealthontario.ca/-/media/documents/ncov/voc/2021/10/covid-19-delta-

variant-risk-assessment-update.pdf?sc_lang=en

Science M, Bolotin S, Silverman M, Nadarajah J, Maguire B, Parekh RS, et al. SARS-CoV-2 antibodies

in Ontario health care workers during and after the first wave of the pandemic: a cohort study.

CMAJ Open. 2021;9(4):E929-39. Available from:

https://doi.org/10.9778/cmajo.20210044

UK Health Security Agency. SARS-CoV-2 variants of concern and variants under investigation in

England: technical briefing 31 [Internet]. London: Crown Copyright; 2021 [cited 2023 Oct 5].

Available from:

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/fil

e/1040076/Technical_Briefing_31.pdf

Arbel R, Hammerman A, Sergienko R, Friger M, Peretz A, Netzer D, et al. BNT162b2 vaccine booster

and mortality due to Covid-19. N Engl J Med. 2021;385(26):2413-20. Available from:

https://doi.org/10.1056/NEJMoa2115624

Public Health Agency of Canada; National Advisory Committee on Immunization; Committee to

Advise on Tropical Medicine and Travel. Canadian immunization guide [Internet]. Evergreen ed.

Ottawa, ON: Government of Canada; 2023 [modified 2023 Sept 18; cited 2023 Oct 5]. Part 4, Active

vaccines COVID-19 vaccine. Available from:

https://www.canada.ca/en/public-

health/services/publications/healthy-living/canadian-immunization-guide-part-4-active-

vaccines/page-26-covid-19-vaccine.html

IPAC Recommendations for Use of PPE for Care of Individuals with Suspect or Confirmed COVID‑19 16

World Health Organization (WHO). Rational use of personal protective equipment for Coronavirus

disease 2019 (COVID‑19) and considerations during severe shortages: interim guidance [Internet].

ed. Geneva: WHO; 2020 [cited 2023 Oct 5]. Available from:

https://apps.who.int/iris/bitstream/handle/10665/338033/WHO-2019-nCoV-IPC_PPE_use-2020.4-

eng.pdf?sequence=1&isAllowed=y

Health Protection Scotland. Aerosol generating procedures (AGPs) [Internet]. Version 1.6. Glasgow:

Public Health Scotland; 2021 [cited 2023 Oct 5]. Available from:

https://hpspubsrepo.blob.core.windows.net/hps-website/nss/2893/documents/1_tbp-lr-agp.pdf

Public Services Health and Safety Association (PSHSA). Infectious disease threats risk assessment

tool for acute care [Internet]. Toronto, ON: PSHSA; 2020 [cited 2023 Oct 5]. Available from:

https://www.pshsa.ca/resources/infectious-disease-threats-risk-assessment-tool-for-acute-care

Ontario Agency for Health Protection and Promotion (Public Health Ontario), Provincial Infectious

Diseases Advisory Committee. Routine practices and additional precautions in all health care

settings. 3

ed. Toronto, ON: Queen’s Printer for Ontario; 2012. Available from:

https://www.publichealthontario.ca/-/media/documents/bp-rpap-healthcare-settings.pdf?la=en

National Institute for Occupational Safety and Health (NIOSH). Hierarchy of controls [Internet].

Atlanta, GA: Centers for Disease Control and Prevention; 2023 [modified 2023 Jan 17; cited 2023

Oct 5]. Available from:

https://www.cdc.gov/niosh/topics/hierarchy/

Ontario Agency for Health Protection and Promotion (Public Health Ontario). COVID-19 real-world

vaccine effectiveness – what we know so far [Internet]. Toronto, ON: Queen’s Printer for Ontario;

2021 [cited 2023 Oct 5].Available from:

https://www.publichealthontario.ca/-

/media/documents/ncov/covid-wwksf/2021/04/wwksf-vaccine-effectiveness.pdf?sc_lang=en

Ontario Agency for Health Protection and Promotion (Public Health Ontario). COVID-19 vaccine

effectiveness over time – what we know so far [Internet]. Toronto, ON: Queen’s Printer for Ontario;

2021 [cited 2023 Oct 5]. Available from:

https://www.publichealthontario.ca/-

/media/documents/ncov/covid-wwksf/2021/11/wwksf-vaccine-effectiveness-over-

time.pdf?sc_lang=en

Health Canada. Personal protective equipment (COVID-19): overview [Internet]. Ottawa, ON:

Government of Canada; 2023 [modified 2023 Feb 22; cited 2023 Oct 5]. Available from:

https://www.canada.ca/en/health-canada/services/drugs-health-products/covid19-

industry/medical-devices/personal-protective-equipment/overview.html

Shah VP, Breeher LE, Hainy CM, Swift MD. Evaluation of healthcare personnel exposures to patients

with SARS-CoV-2 associated with personal protective equipment use. Infect Control Hosp

Epidemiol. 2022;43(6):770-4 . Available from:

https://doi.org/10.1017/ice.2021.219

Byambasuren O, Beller E, Clark J, Collignon P, Glasziou P. The effect of eye protection on SARS-CoV-

2 transmission: a systematic review. Antimicrob Resist Infect Control. 2021;10(1):1-7. Available

from:

https://doi.org/10.1186/s13756-021-01025-3

Loeb M, Dafoe N, Mahony J, John M, Sarabia A, Glavin V, et al. Surgical mask vs N95 respirator for

preventing influenza among health care workers: a randomized trial. JAMA. 2009;302(17):1865-71.

Available from:

https://doi.org/10.1001/jama.2009.1466

Radonovich LJ, Simberkoff MS, Bessesen MT, Brown AC, Cummings DA, Gaydos CA, et al. N95

respirators vs medical masks for preventing influenza among health care personnel: a randomized

clinical trial. JAMA. 2019;322(9):824-33. Available from:

https://doi.org/10.1001/jama.2019.11645

IPAC Recommendations for Use of PPE for Care of Individuals with Suspect or Confirmed COVID‑19 17

Loeb M, Bartholomew A, Hashmi M, Tarhuni W, Hassany M, Youngster I, et al. Medical masks

versus N95 respirators for preventing COVID-19 among health care workers : a randomized trial.

Ann Intern Med. 2022 Dec;175(12):1629-38. Erratum in: Ann Intern Med. 2023 Jun;176(6):884.

Available from:

https://doi.org/10.7326/m22-1966

Ontario Agency for Health Protection and Promotion (Public Health Ontario). Review of “Medical

masks versus N95 respirators for preventing COVID-19 among health care workers: a randomized

trial” [Internet]. Toronto, ON: King’s Printer for Ontario; 2022 [cited 2023 Oct 5]. Available from:

https://www.publichealthontario.ca/media/Documents/nCoV/Research/2022/12/synopsis-

medical-masks-versus-n95.pdf

Alberta Health Services. COVID-19 Scientific Advisory Group rapid evidence report interim update:

masking guidance for healthcare workers [Internet]. Edmonton, AB: Alberta Health Services; 2021

[cited 2023 Oct5]. Available from:

https://www.albertahealthservices.ca/assets/info/ppih/if-ppih-

covid-19-sag-rapid-evidence-report-masking-guidance-healthcare-workers.pdf

Smith JD, MacDougall CC, Johnstone J, Copes RA, Schwartz B, Garber GE. Effectiveness of N95

respirators versus surgical masks in protecting health care workers from acute respiratory infection:

a systematic review and meta-analysis. CMAJ. 2016;188(8):567-74. Available from:

https://doi.org/10.1503/cmaj.150835

Li Y, Liang M, Gao L, Ayaz Ahmed M, Uy JP, Cheng C, et al. Face masks to prevent transmission of

COVID-19: a systematic review and meta-analysis. Am J Infect Control. 2021;49(7):900-6. Available

from:

https://doi.org/10.1016/j.ajic.2020.12.007

Schoberer D, Osmancevic S, Reiter L, Thonhofer N, Hoedl M. Rapid review and meta-analysis of the

effectiveness of personal protective equipment for healthcare workers during the COVID-19

pandemic. Public Health Pract. 2022 Jun 13 [Epub ahead of print]. Available from:

https://doi.org/10.1016/j.puhip.2022.100280

Kunstler B, Newton S, Hill H, Ferguson J, Hore P, Mitchell BG, et al. P2/N95 respirators & surgical

masks to prevent SARS-CoV-2 infection: effectiveness & adverse effects. Infect Dis Health.

2022;27(2):81-95. Available from:

https://doi.org/10.1016%2Fj.idh.2022.01.001

Dörr T, Haller S, Müller MF, Friedl A, Vuichard D, Kahlert CR, et al. Risk of SARS-CoV-2 acquisition in

health care workers according to cumulative patient exposure and preferred mask type. JAMA

Netw Open. 2022;5(8):e2226816. Available from:

https://doi.org/10.1001/jamanetworkopen.2022.26816

Gohil SK, Quan KA, Madey KM, King-Adelsohn S, Tjoa T, Tifrea D, et al. Infection prevention

strategies are highly protective in COVID-19 units while main risks to healthcare professionals come

from coworkers and the community. Antimicrob Resist Infect Control. 2021;10(1):163. Available

from:

https://doi.org/10.1186/s13756-021-01031-5

IPAC Recommendations for Use of PPE for Care of Individuals with Suspect or Confirmed COVID‑19 18

Yassi A, Grant JM, Lockhart K, Barker S, Sprague S, Okpani AI, et al. Infection control, occupational

and public health measures including mRNA-based vaccination against SARS-CoV-2 infections to

protect healthcare workers from variants of concern: a 14-month observational study using

surveillance data. PLoS One. 2021;16(7):e0254920. Available from:

https://doi.org/10.1371/journal.pone.0254920

Schwartz KL, Muller MP, Williams V, Harry R, Booker S, Katz K, et al. Coronavirus disease 2019

(COVID-19) risk among healthcare workers performing nasopharyngeal testing. Infect Control Hosp

Epidemiol. 2021;43(3);395-7. Available from:

https://doi.org/10.1017/ice.2021.354

Sims MD, Maine GN, Childers KL, Podolsky RH, Voss DR, Berkiw-Scenna N, et al. Coronavirus disease

2019 (COVID-19) seropositivity and asymptomatic rates in healthcare workers are associated with

job function and masking. Clin Infect Dis. 2021;73(Suppl 2):S154-62. Available from:

https://doi.org/10.1093/cid/ciaa1684

Wilson S, Mouet A, Jeanne-Leroyer C, Borgey F, Odinet-Raulin E, Humbert X, et al. Professional

practice for COVID-19 risk reduction among health care workers: a cross-sectional study with

matched case-control comparison. PLoS One. 2022;17(3):e0264232. Available from:

https://doi.org/10.1371/journal.pone.0264232

Rodriguez-Lopez M, Parra B, Vergara E, Rey L, Salcedo M, Arturo G, et al. A case-control study of

factors associated with SARS-CoV-2 inf ection among healthcare workers in Colombia. BMC Infect

Dis. 2021;21(1):878. Available from:

https://doi.org/10.1186/s12879-021-06581-y

Haller S, Güsewell S, Egger T, Scanferla G, Thoma R, Leal-Neto OB, et al. Impact of respirator versus

surgical masks on SARS-CoV-2 acquisition in healthcare workers: a prospective multicentre cohort.

Antimicrob Resist Infect Control. 2022;11(1):27. Available from:

https://doi.org/10.1186/s13756-

022-01070-6

Mastan S, Malik RA, Charalambous CP, Abdulla M, Alonge J, Chelva R, et al. COVID-19 infection is

related to differences in the use of personal protective equipment by orthopaedic specialist

trainees caring for hip fracture patients during the second surge of COVID-19 in the North West of

England. Eur J Orthop Surg Traumatol. 2021;31(5):989-93. Available from:

https://doi.org/10.1007/s00590-021-03006-z

Szajek K, Fleisch F, Hutter S, Risch M, Bechmann T, Luyckx VA, et al; AMICO Study Group. Healthcare

institutions' recommendation regarding the use of FFP-2 masks and SARS-CoV-2 seropositivity

among healthcare workers: a multicenter longitudinal cohort study. Antimicrob Resist Infect

Control. 2022;11(1):6. Available from:

https://doi.org/10.1186%2Fs13756-021-01047-x

Rosser JI, Tayyar R, Giardina R, Kolonoski P, Kenski D, Shen P, et al. Case-control study evaluating

risk factors for SARS-CoV-2 outbreak amongst healthcare personnel at a tertiary care center. Am J

Infect Control. 2021;49(12):1457-63. Available from:

https://doi.org/10.1016/j.ajic.2021.09.004

Schmitz D, Vos M, Stolmeijer R, Lameijer H, Schönberger T, Gaakeer MI, et al. Association between

personal protective equipment and SARS-CoV-2 infection risk in emergency department healthcare

workers. Eur J Emerg Med. 2021;28(3):202-9. Available from:

https://doi.org/10.1097/mej.0000000000000766

Li A, Slezak J, Maldonado AM, Concepcion J, Maier CV, Rieg G. SARS-CoV-2 positivity and mask

utilization among health care workers. JAMA Netw Open. 2021;4(6):e2114325. Available from:

https://doi.org/10.1001/jamanetworkopen.2021.14325

IPAC Recommendations for Use of PPE for Care of Individuals with Suspect or Confirmed COVID‑19 19

Klompas M, Ye S, Vaidya V, Ochoa A, Baker MA, Hopcia K, et al. Association between airborne

infection isolation room utilization rates and healthcare worker COVID-19 infections in two

academic hospitals. Clin Infect Dis. 2022;74(12):2230-3. Available from:

https://doi.org/10.1093/cid/ciab849

Chan VW, Ng HH, Rahman L, Tang A, Tang KP, Mok A, et al. Transmission of severe acute respiratory

syndrome Coronavirus 1 and severe acute respiratory syndrome Coronavirus 2 during aerosol-

generating procedures in critical care: a systematic review and meta-analysis of observational

studies. Crit Care Med. 2021;49(7):1159-68. Available from:

https://doi.org/10.1097/ccm.0000000000004965

Ontario Agency for Health Protection and Promotion (Public Health Ontario), Provincial Infectious

Diseases Advisory Committee. Best practices for hand hygiene in all health care settings. 4

ed.

Toronto, ON: Queen’s Printer for Ontario; 2014. Available from:

https://www.publichealthontario.ca/-/media/documents/B/2014/bp-hand-hygiene.pdf?la=en

Ontario Agency for Health Protection and Promotion (Public Health Ontario). Interim infection

prevention and control measures based on respiratory virus transmission risk in health care settings

[Internet]. Toronto, ON: King’s Printer for Ontario; 2023 [cited 2023 Oct 5]. Available from:

https://www.publichealthontario.ca/-/media/Documents/I/2023/ipac-measures-transmission-risks-

technical-brief.pdf

Citation

Ontario Agency for Health Protection and Promotion (Public health Ontario). IPAC recommendations for

use of personal protective equipment for care of individuals with suspect or confirmed COVID‑19.

ed. Toronto, ON: King’s Printer for Ontario; 2023.

Disclaimer

This document was developed by Public Health Ontario (PHO). PHO provides scientific and technical

advice to Ontario’s government, public health organizations and health care providers. PHO’s work is

guided by the current best available evidence at the time of publication. The application and use of this

document is the responsibility of the user. PHO assumes no liability resulting from any such application

or use. This document may be reproduced without permission for non-commercial purposes only and

provided that appropriate credit is given to PHO. No changes and/or modifications may be made to this

document without express written permission from PHO.

Publication History

Published: 2020

Edition: October 2022

Edition: November 2023

Public Health Ontario

Public Health Ontario is an agency of the Government of Ontario dedicated to protecting and promoting

the health of all Ontarians and reducing inequities in health. Public Health Ontario links public health

practitioners, front-line health workers and researchers to the best scientific intelligence and knowledge

from around the world.

For more information about PHO, visit publichealthontario.ca.