The Increasing Visibility of the Threat of Health Care Worker Self-contamination

The vulnerability of health care workers to acquisition and propagation of infectious agents has received global attention because of recent outbreaks of highly communicable and fatal diseases, including Ebola virus disease and severe acute respiratory syndrome. The emergence of these high-profile pathogens has prompted calls for better personal protective equipment (PPE), specifically, masks, gowns, and gloves, to protect health care workers and patients.

In this issue of JAMA Internal Medicine, Tomas and colleagues¹ provide a timely addition to the existing literature on the limitations of our current PPE. In a series of related studies that use previously described methods² to simulate contaminated PPE, the investigators convincingly document a high frequency of health care worker self-contamination when using PPE. The bulk of their data come from 435 simulations of donning and/or doffing of gowns and gloves contaminated with a fluorescent lotion: 234 were soiled glove simulations, and 201 were soiled gown simulations. Almost half (46.0%) of these simulations resulted in health care worker self-contamination of skin or clothing. Specific sites of contamination varied but most commonly involved the hands during glove removal and the neck during gown removal. Furthermore, 39.5% of participants were observed to be using improper technique by 2 independent observers who compared participants’ techniques with the Centers for Disease Control and Prevention (CDC) procedure³ for donning and/or doffing PPE. The probability of self-contamination was much greater when using improper technique (70.3% vs 30.0%). In a separate experiment, the investigators document that fluorescent lotion contamination is a reliable predictor of microbe contamination by mixing bacteriophage MS2 to the solution and performing additional simulations; contamination with the lotion vs MS2 was not statistically different.¹