Standard Infection
Control Precautions
Literature review.
Footwear
Personal Protective Equipment(PPE) Footwear
Publication date: 5 August 2021

Key information
Document title:

Standard infection control precautions literature review.
Personal Protective Equipment (PPE) – Footwear

Date published/issued:

5 August 2021

Date effective from:5 August 2021

Version/issue number:

3.0

Document type:

Literature review

Document status:

Final

Contact
ARHAI Scotland Infection Control team:
Telephone: 0141 300 1175
Email: nss.hpsinfectioncontrol@nhs.scot

1Document information
Purpose:To inform the Standard Infection Control Precaution (SICPs) andTransmission Based Precautions (TBPs) sections on footwear within the
National Infection Prevention and Control Manual in order to facilitate theprevention and control of healthcare associated infections in NHSScotland
health and care settings.

Target audience:

All health and care staff involved in the prevention and control of infectionin Scotland.

Circulation list:

Infection Control Managers, Infection Prevention and Control Teams,
Public Health Teams.

Description:

This literature review examines the available professional literature on theuse of footwear as Personal Protective Equipment (PPE) for standard
infection control purposes in health and care settings.

Update/review schedule: Updated as new evidence emerges with changes made torecommendations as required.
Review will be formally updated every 3 years with next review in
2024.
Cross reference: National Infection Prevention and Control Manual

Update level:

Practice – No significant change to practiceResearch – No significant change to research2Version History
This literature review will be updated as new evidence emerges
Version

Date

Summary of changes

Changesmarked3.0

August 2021

This literature review has been updated
using two-person systematic review
methodology. Five additional researchquestions were added and two existing
research questions were modified.

2.0

August 2015

Updated after review of current literature

1.0

January 2012

Defined as final

Approvals
VersionDate Approved

Name

3.0

July 2021

Steering (Expert Advisory) Group for
SICPs and TBPs

2.0

August 2015

Steering (Expert Advisory) Group for
SICPs and TBPs

1.0

January 2012

Steering (Expert Advisory) Group for
SICPs and TBPs

Linked Documentation
Document title

Document Filepath

National Infection Prevention
and Control Manual

National Infection Prevention and Control Manual
http://www.nipcm.hps.scot.nhs.uk/

3

Contents:
1. Objectives.................................................................................................................................... 5
2. Methodology ............................................................................................................................... 6
3. Discussion................................................................................................................................... 6
3.1 Implications for practice ...................................................................................................... 6
3.2 Implications for Research ................................................................................................. 11
4. Recommendations ................................................................................................................... 12
References ...................................................................................................................................... 16
Appendix 1 Specific standards relating to the quality and performance of footwear ........ 18
Appendix 2 Grading of Recommendations................................................................................ 21

4

1. Objectives
The aim of this review is to examine the extant professional literature regarding the use of
footwear as Personal Protective Equipment (PPE) for standard infection control purposes inhealth and care settings.
The specific objectives of the review are to determine:• Are there any legislative requirements for the use of footwear as PPE for infection control
purposes?
• What types of footwear are suitable for health and other care settings?
• When should overshoes be used?
• When/Where should dedicated footwear be used?
• How should dedicated footwear be donned?
• How should dedicated footwear be doffed?
• When should footwear be cleaned?
• How should footwear be cleaned?
• How should dedicated footwear be stored?
• How/when should footwear be disposed of?
N.B. This review did not assess the use of footwear in certain health and care settings where
there may be a health and safety requirement for wearing specialist footwear, for example ineither estates or kitchen environments. Additionally, this review did not assess the use of
footwear as PPE for high consequence infectious diseases (HCIDs). The literature review thatexamines the extant professional literature regarding PPE for HCIDs is available.

52. Methodology
This targeted literature review was produced using a defined methodology as described in the
National Infection Prevention and Control Manual: Development Process.

3. Discussion
3.1 Implications for practice
Are there any legislative requirements for the use of footwear as PPE for infection
control purposes?
There are no specific legislative requirements regarding the use of footwear as PPE for
standard infection control purposes, although the use of PPE in health and care settings iscovered by the Health and Safety at Work etc. Act (1974),1 Control of Substances Hazardous to
Health 2002 Regulations (as amended),2 and the Personal Protective Equipment at Work
Regulations 1992 (as amended).3
The Health and Safety at Work etc. Act is the generic health and safety legislation for the UK
and broadly covers the use of PPE and risk, but is not healthcare specific. Control of
Substances Hazardous to Health (COSHH) is more specific and provides details in relation tohazardous materials and the use of PPE, and can almost be viewed as a detailed schedule ofthe Health and Safety at Work etc. Act, which would include pathogens in health and caresettings and the use of appropriate PPE. For example, the use of gloves to protect against
blood borne viruses during venepuncture.2 If an activity does not involve or is perceived not to
involve contact with a hazardous material, then the Personal Protective Equipment at Work
Regulations 1992 provide general guidance on the use of PPE;3 in health and care settings this
could be the use of gloves to protect against glass fragments when cleaning up broken glass.
However, if the glass contained a laboratory sample then the activity would be covered by
COSHH.1
UK legislation outlines responsibilities of the employer and employee. Employers are obligatedto provide appropriate PPE for their employees when hazards within the workplace cannot beotherwise controlled.1-3 Employers are also responsible for ensuring that PPE is suitable for thetask undertaken, fits correctly and complies with PPE Regulations 2002.3 Furthermore, the PPE
6

provided should provide the maximum protection possible with minimum discomfort. If multiple
items of PPE are worn together, the employer must ensure that they are compatible with eachother and that the level of protection they offer is not reduced.2, 3
It was previously a requirement that PPE was CE marked.4 Given the UK’s exit from the EU,from 1st January 2021 PPE must now be UKCA marked.5 Where conformity assessments were
performed by a UK conformity assessment body prior to 1st January 2021, PPE that is CE
marked may still be used until 31st December 2021.5 If conformity assessments were performedby an EU notified body, manufacturers must continue to use CE marking for PPE products
placed on the GB market. Again, CE-marked products can only be placed on the UK market
until 31st December 2021.5
Legislation outlines that employers must provide sufficient instruction on the correct use of
PPE.2, 3 Employees are then responsible for ensuring that they comply with these instructions
and use PPE that is suitable for the task being undertaken.2, 3 Employers are responsible for
ensuring that PPE is regularly checked and repaired or replaced before further use if damaged.
Employees are responsible for ensuring that PPE is well-maintained and kept in a clean
condition.2, 3
PPE Regulations 2002, associated with the PPE (Enforcement Regulations) 2018 and theRegulation (EU) 2016/425, outline that PPE available on the market must be supplied withinformation on, “storage, use, maintenance, servicing, cleaning and disinfecting; the level ofprotection provided by the PPE; suitable PPE accessories and appropriate spare parts;
limitations on use and the obsolescence period [expiry date] for the PPE or certain of its
components”.3
Specific standards relating to footwear in health and care settings is outlined in Appendix 1.

What types of footwear are suitable for health and care settings?
There is very limited evidence on this topic. Overall, there is consensus that the footwear types
worn by healthcare personnel should be driven by health and safety requirements, i.e.
minimising the risk of trips and falls, as well as risk of contamination from blood and other bodily
fluids.6, 7 Suitable footwear should therefore be closed toe with low heels and non-skid soles.6
This is further supported by the Scottish Government National Uniform Dress Code andLaundering Policy, which states that staff should wear soft-soled, closed toe shoes.8

7

Expert opinion guidelines recently developed for the use of PPE during the COVID-19 pandemic
advises that footwear should be anti-static, resistant to penetration and washable.9 Guidelines
developed by the World Health Organisation (WHO) on infection, prevention and control (IPC)
measures for epidemic and pandemic-prone acute respiratory infections state that resistantclosed-toe shoes be worn for heavy-duty tasks, such as environmental cleaning.10
The majority of the literature identified was in relation to footwear in operating theatre settings,
and was restricted to professional opinion. Footwear worn in theatre settings should be
comfortable, well-fitting, anti-static, easily cleaned, and have impervious soles with good
traction.7, 11, 12 In some instances, boots or clogs are recommended for use in theatre settings 7,
12

if, for example, gross contamination is anticipated.7

When should overshoes be used?
The evidence-base for this topic is very limited, focussing predominantly on the use ofovershoes in theatre settings. The Association of Perioperative Registered Nurses (AORN) andthe American Association of Nurse Anaesthetists (AANA) have recommended that they should
be worn when a high risk of splash contamination is anticipated.7, 13
The remaining guidelines identified for this review advise against their use,11, 14, 15 citing
shortcomings including lack of traction underfoot, potential increased risk of bacterial
contamination on floors, and cross-contamination to hands when overshoes are doffed.15

When/where should dedicated footwear be used?
Again, the evidence base for this research question is very limited.
Expert opinion pieces recommend that dedicated footwear should be used in operating
theatres.7, 14, 15 The Association of Anaesthetists (ANA) state that these should be donned whenentering the theatre.15 Conversely, the Hospital Infection Society Working Party on Infection
Control in Operating Theatres indicate that given the evidence on bacterial contamination on thefloor of theatre corridors, dedicated footwear should be donned in the theatre department.14
Although there is consensus against the use of overshoes, if overshoes are used, it isrecommended that they are removed before leaving the operating theatre.7, 16 AORN’s
8

guidelines on surgical attire also state that dedicated footwear should be worn in support areasof operating theatres i.e. cleaning and storage areas.7

How should dedicated footwear be donned?
Only one piece of evidence relating to the donning of dedicated footwear was identified,developed in the context of anaesthesia care.13 The AANA recommend donning shoes andovershoes prior to donning gloves.13
Evidence on the donning of footwear in non-theatre and other care settings was not identified.

How should dedicated footwear be doffed?
Two expert opinion pieces discussed the doffing of dedicated footwear in theatre settings,
however these focussed only on the doffing of overshoes.7, 13 AORN recommend thatovershoes should be doffed and discarded immediately after use, after which hand hygiene
should be performed.7 Similarly, the AANA state that overshoes should be doffed and disposedof while gloves are donned.13
Evidence relating to non-acute care settings was not identified. The remaining studies that were
examined focussed on the doffing of footwear in the context of HCIDs, which is outside thescope of this literature review.

When should footwear be cleaned?
Two UK-based expert opinion documents that provide recommendations on the cleaning oftheatre footwear were identified in this review.14, 15 There was consensus in therecommendation that theatre footwear should be cleaned after every use to remove bodily fluidand blood splashes.14, 15 The Association of Anaesthetists and Hospital Infection Society
recommend that procedures should be in place to ensure that this occurs at the end of every
session.14 However, this was not specified in the guidelines produced by the ANA.15
There is no evidence on cleaning requirements for footwear in non-theatre or
non-acute care settings.
9

How should footwear be cleaned?
Two pieces of expert guidance discussed methods of cleaning footwear.7, 15 The
recommendations made were relatively broad and relevant only to the cleaning of dedicatedfootwear used in theatre settings. Guidance from the ANA states that NHS trusts are
responsible for ensuring that there is a system available for cleaning theatre footwear.15 Thissystem must be implemented in each theatre suite.15 AORN guidelines state that any PPE
contaminated with blood, bodily fluids or other infectious agents should be cleaned on-site.
Scrub attire i.e. dedicated footwear for theatre settings, must be bagged/containerised at thelocation where it was used, rather than being rinsed or sorted.7
Evidence on the cleaning of footwear in non-theatre settings and other care settings were not
identified.

How should dedicated footwear be stored?
UK Control of Substances Hazardous to Health (2002) legislation states that following use, PPEshould be stored away from uncontaminated clothing and equipment, in a well-defined place.2
Storage spaces for PPE must prevent external damage i.e. from sunlight, humidity or
chemicals; prevent contamination; and reduce the likelihood of losing PPE.3
Evidence on the storage of dedicated footwear in health and other care settings were not
identified.

How/when should footwear be disposed of?
Two pieces of expert opinion guidance relating to the disposal of footwear were identified.7, 13
The AANA recommend that shoe covers should be removed and disposed before exiting a carearea.13 AORN guidelines state that any surgical attire (including footwear) should be removed if
possibly contaminated with blood, bodily fluids or other infectious materials.7

10

3.2 Implications for Research
There is a lack of scientific evidence on the use of footwear in health and care settings. Of note,
there was a lack of evidence in the context of non-acute care settings and the evidence
examined focussed predominantly on the use of dedicated footwear in theatre settings.
Furthermore, a number of studies relating to the use of footwear as an element of PPE for
HCIDs were identified. Given the lack of generalisability of such evidence for standard infection
control practices, this evidence base could not be used to form recommendations in this review.
Consensus is needed on the use of shoe covers in health and care settings. Expert opinion wasboth scant and inconsistent; where those against their use cited health and safety concerns,
and the potential for increased risk of cross-contamination during doffing of PPE.
Two observational studies assessed the use of decontaminating mats used to remove
contaminants from shoe soles; however, the studies had limitations that impacted the validity of
their findings.17, 18 Further rigorous research should be performed in this area to assess
whether the use of decontaminating mats for footwear are beneficial and should be incorporated
into standard infection control practices.
Overall, the majority of recommendations proposed regarding the use of footwear in health andcare settings are led by mandatory legislation. It is generally accepted that the use of overshoes
is no longer appropriate and that all other footwear is kept clean and in good condition. The
need for further research in this area should not be considered a priority.

114. Recommendations
This review makes the following recommendations based on an assessment of the extant
professional literature on footwear as PPE for standard infection control purposes in health andcare settings:
Are there any legislative requirements for the use of footwear as PPE for infection
control purposes?
The Health and Safety at Work etc. Act (1974),1 Control of Substances Hazardous to Health2002 Regulations (as amended)2 and Personal Protective Equipment at Work Regulations 1992
(as amended)3 legislate that employers (i.e. NHS Scotland) must provide PPE which affords
adequate protection against the risks associated with the task being undertaken. Employees(i.e. healthcare workers) have a responsibility to comply by ensuring that suitable PPE is worncorrectly for the task being carried out.
(Mandatory)
PPE must fit the wearer and if being worn with other items of PPE, the employer must ensurethat these are compatible with each other and do not reduce the level of protection provided ifworn together.
(Mandatory)
Employers must check PPE regularly and if found to be defective, repair or replace items before
further use.
(Mandatory)
From 1st January 2021, PPE must be UKCA marked. Where conformity assessments were
performed by a UK conformity assessment body prior to 1st January 2021, PPE that is CE
marked may still be used if placed on the market before 31st December 2021.
(Mandatory)Specific standards relating to the quality and performance of footwear are outlined in Appendix
1.
(Mandatory)

12

What types of footwear are suitable for health and other care settings?
Theatre footwear should:•

have closed toes;•

be clean and well maintained;•

be easy to clean;•be impervious•

be non-slip/have good traction;•

comfortable and well-fitting(Grade C recommendation)

Footwear in non-theatre settings should:•

be soft-soled and have closed toes;(Mandatory)•

have low heels(Grade C recommendation)•

be clean and well maintained;(Mandatory)

When should overshoes be used?
Overshoes/shoe covers should not be used in the general health and care environment.
(Grade C recommendation)

When/Where should dedicated footwear be used?
Dedicated footwear should be worn in the theatre environment.
(Grade C recommendation)
13

How should dedicated footwear be donned?
There is insufficient evidence to form a recommendation regarding this research question.

How should dedicated footwear be doffed?
There is insufficient evidence to form a recommendation regarding this research question.

When should footwear be cleaned?
Employees are responsible for ensuring that PPE is well-maintained and kept in a clean
condition.
(Mandatory)
Dedicated footwear for use in theatre settings should be removed when leaving the theatre work
area and must be subsequently cleaned and decontaminated.
(Mandatory)
Dedicated footwear used in theatre settings should be cleaned between procedures if visibly
contaminated with blood or bodily fluid.
(Grade C recommendation)

How should footwear be cleaned?
Any PPE on the market must be supplied with information on methods for cleaning anddisinfection.
(Mandatory)

How should dedicated footwear be stored?
PPE, including dedicated footwear, should be stored in a designated place.
(Mandatory)
14

Storage spaces for PPE must prevent external damage from sunlight, humidity or chemicals;
prevent contamination, and reduce the likelihood of losing the PPE.
(Mandatory)

How/when should footwear be disposed of?
Footwear found to be defective should be repaired or replaced before further use.
(Mandatory)

15

References
1.

UK Government. Health and Safety at Work etc. Act 1974,https://www.legislation.gov.uk/ukpga/1974/37/contents (1974).

2.

UK Government. The Control of Substances Hazardous to Health (Amendment)
Regulations 2002. 2002. Available online at:https://www.legislation.gov.uk/uksi/2002/2677/contents/made. Accessed 30/04/2021.

3.

UK Government. The Personal Protective Equipment at Work Regulations 1992.
1992. Available online at:https://www.legislation.gov.uk/uksi/1992/2966/contents/made. Accessed 30/04/2021.

4.

UK Government. Personal Protective Equipment (Enforcement) Regulations 2018.
2018. Available online at: https://www.gov.uk/government/publications/personalprotective-equipment-enforcement-regulations-2018. Accessed 30/04/2021.

5.

UK Government. The Product Safety and Metrology etc. (Amendment etc.) (EU Exit)
Regulations 2019. 2019; Available online at:https://www.legislation.gov.uk/ukdsi/2019/9780111180402/contents. Accessed
13/05/2021.

6.

Bearman G, Bryant K, Leekha S, et al. Healthcare personnel attire in non-operatingroom settings. Infection control and hospital epidemiology 2014; 35. 2: 107-121.
10.1086/675066.

7.

Croke L. Guideline for surgical attire. AORN Journal 2019; 109. 6: P8-P10.
https://doi.org/10.1002/aorn.12733.

8.

Scottish Government. National Uniform Policy, Dress Code and Laundering Policy.
DL (2018) 4. 2018. Available online at:https://www.sehd.scot.nhs.uk/dl/DL(2018)04.pdf. Accessed 07/05/2021.

9.

Keeley L. PPE and COVID-19: what you need to know. 2020. Available online at:https://www.afpp.org.uk/news/CSJ_December_2020_PPE_and_COVID19_what_you_need_to. Accessed 07/05/2021.

10.

Organisation WH. Infection prevention and control of epidemic-and pandemic prone
acute respiratory infections in health care. 2014. Available online at:https://www.who.int/publications/i/item/infection-prevention-and-control-of-epidemicand-pandemic-prone-acute-respiratory-infections-in-health-care. Accessed
07/05/2021.
16

11.

Lafrenière R, Bohnen JM, Pasieka J, et al. Infection control in the operating room:
current practices or sacred cows? J Am Coll Surg 2001; 193. 4: 407-416.
10.1016/s1072-7515(01)01035-3.

12.

Saunders S. Practical measures to ensure health and safety in theatres. Nursing
times 2004; 100. 11: 32-35.

13.

American Association of Nurse Anesthetists. Infection Prevention and Control
Guidelines for Anesthesia Care. 2015. Available online at:https://www.aana.com/docs/default-source/practice-aana-com-web-documents(all)/professional-practice-manual/infection-prevention-and-control-guidelines-foranesthesia-care.pdf?sfvrsn=850049b1_4. Accessed 07/05/2021.

14.

Woodhead K, Taylor EW, Bannister G, et al. Behaviours and rituals in the operating
theatre: A Report from the Hospital Infection Society Working Party on Infection
Control in Operating Theatres. Journal of Hospital Infection 2002; 51. 4: 241-255.
https://doi.org/10.1053/jhin.2002.1220.

15.

Association of Anaesthetists. Infection prevention and control 2020. 2020. Available
online at:https://anaesthetists.org/Portals/0/PDFs/Guidelines%20PDFs/Infection_Control_Guideline_FINAL%202020.pdf?ver=2020-01-20-105932-143. Accessed 07/05/2021.

16.

Agarwal M, Hamilton-Stewart P and Dixon RA. Contaminated operating room boots:
the potential for infection. American Journal of Infection Control 2002; 30. 3: 179-183.

17.

Marchetti MG, Finzi G, Cugini P, et al. Hospital use of decontaminating mats. Journalof Hospital Infection 2003; 55. 1: 68-72. http://dx.doi.org/10.1016/S01956701%2803%2900218-4.

18.

Dahmardehei M, Alinejad F, Ansari F, et al. Effect of sticky mat usage in control of
nosocomial infection in motahary burn hospital. Iranian Journal of Microbiology 2016;
8. 3: 210-213.

17

Appendix 1 Specific standards relating to the quality and performance offootwearStandard

Title

Description

Publication date

BS EN ISO 20344:2011

Personal protective equipment.
Test methods for footwear.

This standard outlines performance
testing, mechanical testing, thermal
testing, electrical testing, waterresistance tests, water-absorption tests,
oil-resistance tests, and testing
conditions for footwear.

January 2011.

BS EN ISO 13287:2019

Personal protective equipment.
Footwear. Test method for slip
resistance.

This standard outlines slip tests, friction
tests and physical testing for footwear.

November 2019.

BS EN 13921:2007

Personal protective equipment.
Ergonomic principles.

This standard provides guidance on thegeneric ergonomic characteristics related
to personal protective equipment (PPE) –it does not however cover therequirements which relate to specifichazards that PPE may be designed.

September 2007.

18

Standard

Title

Description

Publication date

Statutory Instrument 2018

Consumer Protection Health and
Safety – The Personal Protective
Equipment (Enforcement)
Regulations 2018 and The Product
Safety and The Product Safety andMetrology etc. (Amendment etc.)(EU Exit) Regulations 2019

Statutory instrument No. 390 sets out thestandards for PPE in the UK.
Schedule 35 of Statutory Instrument No.
696 sets out the amendments made to
Statutory Instrument No. 390 due to the
UK’s withdrawal from the EU andrequires that all PPE is UKCA marked.
As it was previously a requirement that
PPE was CE marked, CE marking is stillvalid until 31st December 2021 if items
are assessed by EU recognised NotifiedBodies.
UKCA and CE marking demonstrates
that an item has been manufactured to aparticular standard and passed theappropriate tests for the PPE type andintended use/purpose.

Instrument No. 390: April
2018; Instrument No.
696: March 2019.

Personal protective equipment.
Occupational footwear.

This standard outlines basic andadditional optional requirements foroccupational footwear that is not exposed
to any mechanical risks i.e. impact orcompression.

February 2012.

No. 390 and The Product
Safety and Statutory
Instrument 2019 No. 696

BS EN 20347:201119

Legend:
BS = British Standards produced by the British Standard Institution (www.bsigroup.co.uk)
EN = European Standards (European Norm) produced by the European Committee for Standardisation (www.cen.eu)
ISO = International Standards produced by the International Standards Organization (www.iso.org)
EN standards are gradually being replaced by ISO standards – when these are adopted in the UK they are prefixed with BS (e.g.
BS EN; BS EN; BS EN ISO). This is usually to accommodate UK legislative or technical differences or to allow for the inclusion of a
UK annex or foreword

20

Appendix 2 Grading of Recommendations
Grade

Descriptor

Levels of Evidence

Mandatory‘Recommendations’ that are directives
from government policy, regulations orlegislation

N/A

Category A

Based on high to moderate quality
evidence

SIGN level 1++, 1+, 2++, 2+, AGREEstrongly recommend

Category B

Based on low to moderate quality ofevidence which suggest net clinicalbenefits over harm

SIGN level 2+, 3, 4, AGREE recommend

Category C

Expert opinion, these may be formed by
the NIPC groups when there is no robust
professional or scientific literature
available to inform guidance.

SIGN level 4, or opinion of NIPC group

No recommendation

Insufficient evidence to recommend one
way or another

N/A

21