In a reported cluster of cases of SARS among Canadian health care workers,1 infections occurred despite apparent compliance with recommended infection control precautions. In the report it was noted that contact with a patient or with a contaminated environment might have led to health care workers infecting themselves as they removed their personal protective equipment (PPE). Many health care workers apparently lacked a clear understanding of how best to remove PPE without contaminating themselves. However, the correct order of removal as presented in the report was extremely condensed (gloves first, followed by mask and goggles).1
In fact, little information about the appropriate sequence of removing PPE is available, and what is available often contains contrasting recommendations (Table 1).2,3,4,5,6 Moreover, for several of these sets of recommendations, hands potentially contaminated through contact with patients' droplets and secretions present on the PPE could contact the nose, mouth or eyes while the health care worker is removing his or her mask and eye protection.
Table 1.
Careful hand hygiene plays a pivotal role in reducing the risk of transmission of SARS. Accordingly, the National Institute for Infectious Diseases in Italy has developed a procedure whereby the health care worker removes most PPE while wearing mask and eye protection and carefully decontaminates the hands before removing protection of the mucous membranes of the face. This procedure must be carried out in the health care worker's change area, outside the patient's isolation room.
Vincenzo Puro Emanuele Nicastri National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani Rome, Italy