Medical gloves in the era of coronavirus disease 2019 pandemic
Medical gloves in the era of coronavirus disease 2019 pandemic
Medical gloves in the era of coronavirus disease 2019 pandemic
The current coronavirus 2019 disease (COVID-19) pandemic has greatly changed our perspective of the risk for infection from contact, and the use of personal protective devices (PPDs) usually reserved for health care workers (HCWs) has spread to the general population, sometimes indiscriminately. As a result, medical glove stock has been depleted, but most of all medical gloves have become a source of medical concern., , , 
The World Health Organization (WHO) has warned about the limited protective efficacy of gloves. There is high risk for infection spread with their incorrect use that could instead favor the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Regular use of gloves for daily activities may lead to a false sense of protection and to an increased risk for self-contamination. This would involve the involuntary touching of the face or the spreading of fomites to desks, phones, and computers keyboards. A study has found that viruses can survive on gloves for 2 to 4 hours.5
Hand-to-face contact has a substantial role in upper respiratory tract infections,6 , 7 although COVID-19’s main way of transmission remains symptomatic person-to-person through respiratory droplets., , ,  The Centers for Disease Control and Prevention (CDC) and the European Center for Disease Prevention and Control (ECDC) have recently provided guidance to regulate the use of gloves both in the health care setting and in the community.2 , 4 In the context of the COVID-19 pandemic (Table 1 ), gloves are recommended when caring for confirmed or suspected COVID-19 patients, especially when there is the risk of contact with body fluids (eg, blood, wound care, aerosol-generating procedures).
Hand protection with gloves is essential in any medical procedure, because skin cleaning/disinfection alone does not remove all pathogens, especially when the contamination is considerably high. Nonsterile disposable gloves should be prioritized, and ECDC alerts that no direct evidence documents an increased protection against COVID-19 through glove use, compared with proper hand hygiene alone. Meticulous hand hygiene with water and soap or by alcohol-based hand rub solutions is not avoided by the use of gloves.
There are many different types of gloves, depending on the level of protection, tactility, risk of allergy, or cost (Table 2 ). Although biohazard risk requires frequent glove changing, the extended use of gloves, decontamination with hand disinfectants, and reuse are frequent.8 All of this should be avoided, because effects of hand sanitizers are tested on the skin, whereas application on gloved hands affects gloves’ mechanical properties. In a recent investigation,9 the application of 70% ethanol or 63% isopropanol commercial disinfectants reduced the tensile strength of latex and nitrile gloves, with a higher impact on nitrile gloves. Elongation did not change much with latex gloves, but nitrile gloves were affected. There are additional concerns about permeability, as alcohol can permeate any type of glove after 10 minutes. Some types of disposable gloves are permeated at 2 minutes, and repeated exposure to disinfectants can increase the permeability of the gloves. Alcohol is inactivated in the presence of organic matter, which can easily remain on used gloves, thus potentially driving the viral transmission.
Extended length gloves are not necessary when providing care to suspected or confirmed COVID-19 patients. They are not specifically recommended, except for activities with increased risk, such as submerging hands into a solution. For standard procedures, it is sufficient to cover the cuff (wrist) of the gown while donning., , , 
Another common measure that is no longer recommended is “double gloving,” except for surgical procedures that carry a high risk of disrupting the integrity of the glove. Double gloving seems to increase the incidence of dermatologic side effects, from irritation and overhydration to induction of latex allergy. The increase of skin damage as the consequence of overzealous PPD use and hand hygiene is an emergent consequence of the COVID-19 handling., , 
About 74.5% of front-line COVID-19 HCWs developed hand dermatitis in the Chinese experience.13 A questionnaire-based study suggested that 88.5% of skin reactions on the hands are associated with the use of latex gloves.14 Three types of adverse events might occur: latex allergy, talcum powder reactions, and irritant dermatitis. Excluding latex allergy and powder within the gloves, the problem of excessive dryness and pruritus, associated with irritant dermatitis, may be aggravated by occlusion, leading to sweating and/or overhydration. This then may increase the permeability to sanitizers or detergents, creating a vicious cycle, plus aggravation of hand dermatitis.12
A peculiar pattern of hand dermatitis has been recognized, characterized by erythema and fine scaling on the palms and web spaces.15 This may be attributed to the depletion of surface lipids, resulting in deeper penetration of detergents, and progressive damage of skin layers is a major pathogenetic mechanism. Irritant contact dermatitis is more commonly found with iodophors, chlorhexidine, chloroxylenol, triclosan, and alcohol-based products, whereas allergic contact dermatitis develops due to quaternary ammonium compounds, iodine or iodophors, chlorhexidine, triclosan, chloroxylenol, and alcohol sensitization.
To date, there have been no verified reports of COVID-19 infection as direct consequence of skin damage. Angiotensin-converting enzyme 2 (ACE2), which is the main cell receptor for SARS-CoV-2 entry, can be expressed in the basal layer of the epidermis, hair follicles, and eccrine glands, as well as on skin blood vessels.16
Basic skincare measures should be taken to avoid the risk of SARS-CoV-2 entry through the skin., , , , ,  Careful hand skin drying and hypoallergenic hand cream/emollients may be employed to prevent trapping sanitizers in the web spaces. Emollients may also be applied at other times to correct any residual dryness and scaling, or with the occurrence of hand dermatitis, topical corticosteroids are indicated.
A final consideration is the generation of massive amount of medical waste, caused in part by the extensive use of PPDs.17 HCWs, together with the general population, are using more gloves than ever before, whereas it should be limited to very essential preventive measures.
Medical gloves remain an essential part of the infection-control strategy; however, caring for patients with COVID-19 has pointed out the need for more accuracy and respect of novel guidance. Prolonged use of gloves, outside of direct patient contact, might be self-defeating rather than protective. Hand dermatitis is an emerging concern. At this time, the U.S. Food and Drug Administration has not cleared, approved, or authorized any medical gloves for specific protection against the virus that causes COVID-19 or prevention of COVID-19 infection.
Broadly speaking, there are 2 types of medical gloves: examination gloves, which are ambidextrous, usually nonsterile, and come in a small range of sizes, are used for nonsterile and less dextrous tasks and also for most dental work; surgical gloves are sterile, come individually packaged in handed pairs, and are usually available in half-inch intervals of hand girth. They are used in the operating theater for a variety of dextrous tasks, ranging from microsurgery on the eye or ear to bone setting or hip replacement.
Because the majority of clinical work is not perceived to be as dextrous as surgery, less emphasis is placed on the performance of examination gloves. Until recently, both examination and surgical gloves were generally made from natural rubber latex (commonly referred to as “latex”), although alternatives were available for known cases of latex allergy. However, the lack of regulation of manufacturing processes in the early years of mass production meant that gloves often contained a high level of allergenic proteins, which led to a steady increase in the number of cases of latex allergy reported.1
Current guidelines from the National Health Service and the Royal College of Physicians2 in the United Kingdom state that “the evidence does not … support a need to ban latex completely from the workplace.” They note that nonlatex surgical gloves “have higher failure rates in use and lower user satisfaction than latex gloves.” Instead, they advocate the use of nonpowdered, low-protein latex gloves, except for employees with latex allergy, latex sensitization, or latex-induced asthma, where nonlatex alternatives are recommended. However, most primary care health care groups and hospitals in the United Kingdom have replaced latex in nonsurgical situations with less flexible alternatives3 such as nitrile to remove the risk of latex allergy in patients and practitioners.
Similarly, the American College of Allergy, Asthma, and Immunology4 recommends that “a facility-wide review of glove usage should be undertaken to determine the appropriateness of use … and thereby prevent the unnecessary use of latex gloves” and advocates nonpowdered, low-protein gloves as standard in a health care facility but also states that “hospitals need to evaluate manufacturer information on nonlatex gloves in areas of durability, barrier protection, and cost” because “latex is still considered superior with respect to barrier characteristics against transmissible diseases.” Surgeons have generally resisted moves to replace surgical gloves in the same way because of the perceived reduction in manual performance when using nonlatex alternatives.
With respect to the glove design process, there is little or no evidence that gloves are evaluated in terms of their effects on users’ manual performance. All the currently available standards5, 6 focus on the barrier integrity of the gloves by defining tensile strength, freedom from holes, and tear resistance. Similarly, much of the research on medical gloves has concerned barrier integrity7, 8 and adherence of practitioners to handwashing and glove handling guidelines.9, 10 Clearly, because the primary role of the gloves is to prevent the spread of infection, it is important that the design brief takes these things into consideration, but achieving good barrier integrity is not necessarily incompatible with achieving the best performance.
Glove performance also has an effect on safety, particularly in a surgical environment. Surgeons using plastic gloves with less-than-optimal frictional properties, for example, may be more likely to drop instruments, to slip when performing delicate procedures, or to increase their stress levels when attempting to compensate. Similarly, practitioners who cannot feel a pulse through gloves when taking blood will be more likely to remove the gloves and increase their risk of infection. A 1994 survey of health care workers11 found that a “perceived interference with technical skills” was a common obstacle to compliance with universal precautions. There is also a subjective element to the performance that must be considered, which is that practitioners’ comfort and confidence in their gloves may affect their concentration levels and therefore their ability to perform surgery over extended periods of time.
It is vital that the glove design process includes an assessment of their effect on manual performance to ensure that practitioners can operate safely and efficiently. The first step in this process is to determine the key aspects of manual performance in medical practice and where current gloves have a significant adverse effect. The second is to design tests that are useful predictors of clinical performance. It is therefore necessary to identify the tasks that are most challenging and on which gloves are thought to have the greatest impact so that the tests can be designed to simulate relevant manual skills.
To achieve this, semistructured interviews with medical practitioners were carried out. As well as gathering information on the participants’ roles, disciplines, and glove use, a series of open-ended questions were used to identify tasks believed by users to require the most dexterity and tactility, and those most affected by glove performance, as well as any other issues related to HDPE gloves that might aid the study. The interviews took place within Sheffield Teaching Hospitals NHS Foundation Trust (STH) and received ethical approval from the research ethics committees of STH and The University of Sheffield, UK.
Focus groups were considered as a means of gathering data fairly quickly and stimulating discussion. However, the limited availability, particularly of senior staff, made this a difficult approach. Furthermore, it has been shown12 that, when recruitment, transcription, and analysis are included, focus groups can be much more time-consuming than individual interviews. Although focus groups are generally accepted to produce a wider range of responses, this is not always the case and depends on the nature of the questions.12, 13 In this study, many of the questions were of a technical nature and specific to the individual’s specialty. There was also a concern that participants’ opinions on specific gloves would be influenced by those of their colleagues.
Interviews were therefore conducted on a one-to-one basis to increase flexibility and enable senior staff to participate at their own convenience, often between operations or appointments. The questions were designed to be sufficiently open-ended so that the participant was not led down one particular line of thought but also included prompts where information was not forthcoming. With a wide enough selection of participants, it was hoped that a consensus would be formed in at least some of the areas, which would enable judgments to be made on the most productive direction for future research.