an unprecedented outbreak of ebola virus disease ( evd ) is occurring in west africa .
in addition to the morbidity and mortality effects on the population at large , there is a significant impact on healthcare providers in the region .
although many healthcare worker exposures may occur prior to evd being suspected and appropriate isolation implemented , exposures can occur in spite of isolation procedures and ppe use .
although there is anecdotal evidence regarding the efficacy of ppe , a review of literature reveals few controlled studies of ppe ensembles relevant to evd .
field studies of ppe in the setting of evd are difficult because of ethical and safety concerns .
it is thought a high level of training is required to safely don , use , and doff ppe .
introducing a new ppe ensemble into the field could increase exposure risk of participants who are already well - trained on a current ppe ensemble . there may be some hesitancy among participants to try an  unproven  ppe set .
finally , in a high disease prevalence area , with a relatively small number of  events ,  a very large study population would be required to account for the possibility of evd acquisition from non - work exposures or activities ( i.e. non - medical contacts within the community ) .
the possibility that exposures can occur in spite of ppe utilization is evident from recent disease acquisition by two healthcare workers in the united states .
these regulatory standards are material standards so that testing of individual components ( gloves , gown , etc . ) result in a rating for the tested component .
some ppe ensemble testing has been performed , so called  man - in - suit - testing ( mist )  ) but this has primarily focused on radiation , thermal or chemical exposures where exposure risk is dose - dependent , or in aerosol scenarios .
zamora et al . compared two personal protective systems ( ensembles ) for biological exposures in 2006 and found significant differences in contamination rates . in 2010
the institute of medicine released a report regarding certification of personal protective technologies , noting that additional testing of ppe ensembles should be performed .
given the large number and variations of individual ppe components , it would not be feasible to test all potential combinations of ppe commercially available .
additionally , the recent surge in ppe purchasing in response to evd has caused significant shortages of some ppe components and manufacturers with a history of field use .
some healthcare facilities have had to develop ppe protocols based on the best use of locally available components ( author , personal communication ) .
ideally , a ppe ensemble would be evaluated at the local level by the staff anticipated to wear the equipment .
doffing or removal of ppe after a patient encounter may be a particularly high risk activity .
appropriate testing of ppe ensembles should include mist type testing to confirm product efficacy in real world scenarios .
fluorescent agents have been used in training for hand - washing ,   and environmental decontamination , as well as ppe ensembles , .
non - toxic and mixed with an appropriate carrier , these agents can potentially mimic the natural contamination which occurs with an infectious agent spread by contact route .
the purpose of our study was to compare two ppe ensembles used by volunteers with minimal prior training , and to evaluate the feasibility of fluorescent markers as an assessment tool for ppe effectiveness .
eight healthcare providers ( six registered nurses and two physicians ) volunteered for this preliminary study .
the study protocol was approved by the texas tech university health science center institutional review board .
the participants were randomized to one of two ppe ensembles that meet current ( as of 10/20/14 ) cdc recommendations for ppe .
one ppe ensemble ( standard ) utilized commercial components that meet current cdc recommendations . the other ppe ensemble ( alternate ) was composed of components already available at local hospitals or retail stores .
1 ) included a neck - to - ankle coverall with overlying water impermeable surgical gown , knee - length impermeable leggings , and stryker hood ( stryker , kalamazoo , mi , usa ) .
2 ) ensemble included two plastic gowns ( worn over the front and back of the torso ) , rain - suit pants , a rain - suit hood cut from a rain jacket , ankle length shoe covers , and a plastic  spark - shield  commonly used for metal working to cover the face . both ppe ensembles utilized double gloving , with the outermost glove a forearm length surgical glove and n-95 masks .
when complete , both ppe ensembles met the cdc recommendations for ppe and no skin was exposed in either group .
subjects were then randomized to standard or high volume exposures ( hve ) to simulate fluid splash .
subjects randomized to standard exposure came into contact with a training mannequin contaminated with fluorescent agents to simulate bodily fluids .
subjects randomized to hve had standard exposure , but then also had an additional 100  ml of fluorescent agent splashed onto the front torso of their garment .
the fluorescent agents used included fluorescent powder ( glogerm glogerm co , moab , ut , usa ) , liquid clothes detergent with bleach alternative ( tide proctor & gamble inc .
, providence , ri , usa ) , and dissolvable fluorescent tablets ( bright dyes orange dye kingscote chemicals , miamisburg , oh , usa ) . a base mixture of 500  ml of liquid detergent , 500  ml of water and three fluorescent tablets was used to create body fluids .
the base mixture was combined with oatmeal , chocolate powder and crushed cereal to simulate different bodily fluids .
the testing area was divided into four areas , a ppe donning area ( staging area ) , patient encounter room , ppe doffing area , and a separate dark room for black light photography .
, participants worked in pairs to perform a series of clinical tasks to care for the evd  patient .
 participants were asked to clean the contaminated mannequin , change the mannequin gown , place an automated bp cuff , and check and record the temperature . after completing the tasks ,
finally , the de - gowned participants were examined under  black light  for fluorescence indicative of possible contamination .
an led black light panel , ( chauvet led shadow , model dmx-512 led uv , chauvet lighting , sunrise , florida ) was used to illuminate .
one participant in each ppe ensemble arm had evidence of contamination under black light examination ( fig .
the participant contaminated in the standard arm felt the exposure occurred because of a splash under her hood during hve .
the trainer felt she may have inadvertently touched a contaminated portion of her leggings and subsequently touched her neck during ppe removal .
the participant contaminated in the alternate group likely had a gap appear between her front and back gowns while placing a blood pressure cuff .
this event was not noted at occurrence , but was noticed under black light examination .
the contamination in the alternate ppe ensemble arm likely could have been prevented if a larger range of gown sizes was available .
it may be helpful to consider the body habitus of evd responder when selecting ppe .
clinical activities as part of the assessment process , as the contamination likely would not have occurred without the provider manipulating the mannequin to place the blood pressure cuff .
it could be helpful to videotape exercises such as this to better identify the timing of contamination such as that which occurred in the standard arm .
pin - pointing the conditions of contamination may allow the development of new mechanisms for prevention . in preparation for this exercise
, we found it notable that taping gloves circumferentially is routinely shown in the lay press , but current guidelines do not make this recommendation . in our study ,
circumferential taping did not result in contamination , but greatly impaired the ease of ppe removal . on the other hand ,
a single strip of taped placed longitudinally along the sleeve and glove allowed the glove to be removed with the garment as a seamless piece .
current recommendations do not comment on hair or jewelry , perhaps making the assumption that these will be taken care of as a matter of course . for our study
, we did not specifically ask participants to pull back their hair . although we did not note any contamination specific to this ,
long hair , rings and watches adversely affected the ease of ppe placement and removal and may be an additional risk factor for exposure .
it may be useful for future recommendations to include stipulations about such accouterments . in this very small study ,
ppe ensembles made from readily available components ( approximately $ 36 per outfit ) performed as well as the commercial ppe ensemble .
additionally , it must be borne in mind that increased complexity of ppe may be self - defeating , as the complexity of ppe removal may offset gains made by complexity of ppe .
it is difficult to assess the actual effectiveness of fluorescents as a proxy for ev exposure in this study .
it is possible that small volume contamination occurred that was unable to be visualized , and the clinical relevance of such a small exposure is unknown .
how an exposure on intact skin correlates with risk of subsequent evd development remains to be determined .
the florescent mixtures used in this study were intended to mimic the mechanical effects of bodily fluids during a patient interaction . in spite of widespread use
, it is unknown how these mixtures compare with actual bodily fluids considering the unique chemical and biochemical attributes of blood
. the limitations of this type of testing prevent any assumptions of risk of evd development for a healthcare worker in the field .
this type of testing could , however , allow comparison of different ppe ensembles and protocols under the assumption that more fluorescent  exposures  equates to higher risk of evd development .
another use of this system could be to identify ppe ensembles with lower expense and equivalent testing attributes .
finally , fluorescent markers can be used for training and proficiency testing of ppe ensembles for evd preparedness and even determine minimal standards of training repetition to achieve proficiency . as fluorescent agents and black lights are readily available for purchase in retail stores and over the internet , it is feasible for testing and training to be performed at a local level with ppe ensembles available at hand . beyond the current evd outbreak , this concept is applicable to training for other infectious diseases , such as methicillin - resistant staphylococcus aureus or multidrug resistant gram - negative bacteria , spread primarily by direct contact .
the concept could also be used for some pathogens with a significant respiratory mode of transmission , such as pandemic influenza and novel pathogenic corona viruses , which have a recommended contact component of ppe .
 the recent ebola virus disease ( evd ) outbreak has created interest in personal protective equipment ( ppe ) content and usage . ppe testing has historically been done by individual component , rather than as a bundle for contact isolation . 
 fluorescent agents are commonly used in training for infection control techniques . 
 the purpose of our study was to compare 2 ppe bundles and to evaluate the feasibility of fluorescent markers as an assessment tool for ppe effectiveness . 
 eight healthcare providers volunteered for this preliminary study . 
 participants were randomized to 1 of 2 ppe bundles that meet current ( october 20 , 2014 ) cdc recommendations . 
 one ppe bundle utilized commercial evd - recommended components . the other ppe bundle used components already available at local hospitals or retail stores . 
 participants were also randomized to standard or high volume exposures ( hve ) to simulate fluid splash . 
 each participant was assisted in ppe donning and doffing by an experienced trainer . 
 a training mannequin was contaminated with fluorescent agents to simulate bodily fluids . 
 participants were then given clinical tasks to care for the evd  patient . 
  de - gowned participants were examined under  black light  for fluorescence indicative of contamination . 
 one participant in each ppe arm had evidence of contamination . 
 one of the contamination events was suspected during the patient care exercise . 
 the other contamination event was not suspected until black light examination . in spite of a large difference in cost of ppe , the two bundle arms performed similarly . 
 bundle testing using fluorescent markers could help identify optimal ppe systems . 