1.0 About the HCID Addendum

This addendum contains information on HCID assessment PPE and associated donning and doffing procedures. It has been developed in collaboration with a task and finish group led by ARHAI Scotland. The sectors and networks represented can be found in Appendix 1.

A systematic literature review was undertaken by ARHAI Scotland to support the development of this addendum. 

The HCID assessment PPE ensemble (defined in Section 2.0) has been endorsed by:

• the Health and Safety Executive (HSE)
• Advisory Committee on Dangerous Pathogens (ACDP)
• Antimicrobial Resistance and Healthcare Associated Infection (ARHAI) Scotland
• NHS England
• Public Health Wales
• Public Health Agency Northern Ireland
• UK Health Security Agency (UKHSA)

2.0 Definitions contained within the HCID addendum

According to UK wide consensus (published by UKHSA), a HCID:

• is an acute infectious disease
• typically has high case-fatality rate
• may not have effective prophylaxis or treatment
• is often difficult to recognise and detect rapidly
• has the ability to spread in the community and within healthcare settings
• requires an enhanced individual, population, and system response to ensure it is managed effectively, efficiently, and safely. 

The current list of HCIDs agreed by the UK 4 nations public health agencies, with advisory committee input as required is available.

The two types of UK HCID PPE ensemble used in the UK are:

• The HCID assessment PPE ensemble. This is the agreed unified UK PPE ensemble, which will be discussed in the sections below. It is worn by staff in NHSScotland to assess and provide clinical care to potential cases where HCID (associated with a pathogen of any transmission route) is suspected and may subsequently be confirmed prior to transfer to an HCID treatment centre in NHS England.
• The HCID treatment PPE ensemble. This is the ensemble worn for continued care of confirmed HCID cases within specialist treatment centres. There are currently none of these centres in Scotland.

The PPE ensemble described throughout this guidance is the ‘HCID assessment PPE ensemble’.

The healthcare worker roles described in this addendum are as follows:

• HCID caregiver or caregivers. This refers to the healthcare workers who will deliver direct care to a suspected or confirmed HCID case.
• Buddy. This refers to the healthcare worker who supports the HCID caregiver or givers during donning and doffing. 

3.0 Scope and audience

It is expected that the HCID assessment PPE ensemble described in this addendum will be implemented by all NHSScotland Boards by 25 August 2026.

The HCID assessment PPE ensemble is intended for use when providing direct care for all suspected or confirmed cases of a HCID prior to transfer to a dedicated HCID treatment centre in NHS England.

Healthcare workers outside of HCID clinical pathways should aim to assess any suspected cases virtually for example by video or phone call. If a suspected or confirmed HCID case presents at a primary care facility, they should be isolated in a room away from all other healthcare workers and service users, and contact made with infectious disease services to arrange next steps. 

It is important that NHS boards identify the most appropriate pathway locally, for the admission, care and transfer of a suspected or confirmed HCID case and ensure that staff within this pathway are trained in the use of the HCID assessment PPE ensemble. NHS boards should prepare to manage a suspected case admitted via any route including adult and paediatric EDs, or maternity units. 

This guidance applies to healthcare workers and staff with responsibility for:

• care of an individual with a suspected or confirmed HCID
• the procurement, stock and storage of HCID assessment PPE ensemble and Buddy ensemble
• the fit testing of healthcare workers required to wear respiratory protective equipment (RPE) as part of the HCID assessment PPE ensemble or the Buddy ensemble

4.0 Personal Protective Equipment (PPE) for the care of individuals with suspected or confirmed HCID

4.1 HCID PPE Assessment ensemble and Buddy ensemble

4.1.1 Procurement and storage

4.1.2 Education and training

4.1.3 Components of the HCID assessment PPE ensemble

Table 1: Components of the HCID assessment PPE Ensemble

Table 2: Components of the Buddy PPE Ensemble

4.1.4 Donning (putting on) HCID assessment PPE and Buddy ensemble

4.1.5 Demarcation of zones within HCID care area

Table 3: Zone Descriptors

4.1.6 Removal (doffing) of HCID assessment PPE and Buddy ensemble

Table 4: Activities permitted in each zone and doffing requirements for HCID Assessment PPE and Buddy ensemble

 

4.1 HCID PPE Assessment Ensemble and Buddy ensemble

In general, PPE ensembles should create a complete barrier at a sufficient level to protect against the risk of contamination with and transmission of infectious agents.

The key principle of the HCID assessment PPE ensemble is total body coverage, to minimise exposing skin or mucous membranes, and with filtering of inhaled air by a respirator. This ensemble has been developed to take account of the risk associated with the provision of direct care to a suspected or confirmed HCID case.

The buddy PPE ensemble has been developed to take account of the risks associated with the role of supporting the HCID caregiver to don and doff PPE where hands on assistance is essential.

The correct donning and doffing of the PPE ensembles is essential to ensure the PPE provides adequate protection against the risk of contamination and transmission of infectious agents.

Minimising contamination of PPE whilst in the red zone helps to reduce the consequences of any errors during doffing.  See section 4.1.5 for techniques to avoid contamination.

4.1.1 Procurement and storage

It is important that departments identified for the care of individuals with a suspected or confirmed HCID, including emergency departments and intensive care units, have sufficient stocks of all HCID assessment PPE items described in this addendum.

Responsibility for the maintenance of adequate HCID PPE stock and appropriate storage should be assigned and managed locally to ensure prompt access in the event it is required.

The following points should be considered when procuring and storing HCID PPE items and is based on an estimate of 72 hours being the time taken to arrange transfer to an appropriate HCID treatment centre in NHS England. Some remote and rural boards may wish to hold a larger stock to take account of delivery times.

• A stock of PPE for education and training.
• Calculation of the number of PPE items required to care for an individual with a suspected or confirmed HCID over a period of at least 72 hours. The calculation should also consider the number of HCID caregivers expected to provide care to the suspected or confirmed HCID case and the number of supporting buddies, as well as an estimate of the number of PPE changes required throughout a shift.
• The need for availability of a variety of sizes of PPE to accommodate different healthcare workers.
• The need for respiratory protective equipment (RPE) for which healthcare workers have been fit-tested in advance.
• The need to regularly check stock availability and expiry dates.

Appendix 2 provides a list of the PPE components and specifications for purchasing. PPE products are available via National Procurement or independent suppliers where stated. These products are subject to change as and when national frameworks are awarded and the NDS supply and product code could vary depending on when orders are placed however the specification will remain unchanged.

4.1.2 Education and Training

It is important that NHS boards ensure the safety of all healthcare workers caring for patients with a suspected or confirmed HCID. All healthcare workers who may care for an individual with a suspected or confirmed HCID, and those who may undertake the buddy role, must be trained and competent in the donning, doffing and disposal of the HCID PPE ensemble described in this addendum.

Before using the ensemble described in this addendum, Healthcare workers must first complete the TURAS HCID Assessment PPE eLearning Module.

Healthcare workers should use the complementary resources below to reinforce their understanding of donning and doffing of the HCID assessment PPE ensemble and decontamination procedures for wellington boots.

• HCID assessment PPE donning training video
• HCID assessment PPE doffing training video
• HCID boot decontamination training video
• HCID Assessment PPE donning poster
• HCID Assessment PPE doffing poster
• HCID boot decontamination protocol (poster)

Healthcare workers should undertake donning and doffing practice sessions including verbal instructions from a buddy prior to undertaking a competency assessment. 

Healthcare workers are considered competent in the donning and doffing of HCID assessment PPE when they can do so independently without prompts from the buddy. This ensures the healthcare worker can primarily demonstrate the order and process for donning and doffing without a verbal reminder. The inclusion of a verbal reminder during live clinical management of a suspected or confirmed case of HCID then acts as a further secondary level of assurance.

Competency checks should be undertaken at regular intervals to ensure competence is maintained. This should ideally be every 6 months but at least annually as a minimum.

Note: HCID PPE training does not include face fit testing. This must be done separately and it is assumed that all healthcare workers required to wear HCID PPE have already had face fit testing carried out. Information relating to face fit testing and fit checking can be found in the TBP chapter of the NIPCM.

Further training and educational resources for HCID are available from the UK HCID Network. NHS Boards may choose to utilise the ‘Train the trainer’ course to support the training of staff in their local board.

Boards are required to have a supply of the full HCID assessment PPE ensemble for training purposes which will include FFP3 masks of the correct type and size required for those identified as HCID caregivers and buddies. Training should be targeted at those identified as HCID caregivers and buddies.

A competency checklist to support training and education is available for use.

4.1.3 Components of the HCID assessment PPE ensemble

• All the components of this ensemble have been tested for suitability, ease of wear and safety benefits.
• All components of HCID PPE should conform to all relevant standards.
• See appendix 1 for links to published articles which describe the simulation exercise undertaken to support development of the HCID assessment PPE ensemble and a link to the literature review to support development of this addendum.
• Appendix 2 details PPE components for purchasing.

Table 1: Components of the HCID assessment PPE Ensemble

Component	Requirement
FFP3 Respirator	The mask’s seal must not be disrupted by the hood. The elastic straps should be configured according to the manufacturer’s instructions. In addition, each time an FFP3 respirator is worn, the wearer should perform a fit check (according to the manufacturer’s guidance), to ensure that the mask is sited correctly, and an adequate seal has been achieved. More information can be found in the TBP chapter of the NIPCM.
Hood	The hood’s face opening must be in close contact with the face and gaps avoided.
Full-face visor	The bottom of the visor must be a minimum of 2 cm below the chin and the visor must be compatible with the FFP3 respirator that is being used.
Gown	Fluid-resistant to relevant standards The gown must be long enough to overlap the wellington boots by 10 to 15 cm but not be so long as to trail on the floor and cause a trip hazard.
Apron	Wide, extra-long, medium thickness The apron must not be so long as to cause a trip hazard. The top of the apron must be at the level of the clavicles. This may be achieved by breaking the neck loop and re-tying it to make the neck length shorter.
Inner gloves	Standard single-use disposable, short, non-sterile nitrile gloves. The cuff of each inner glove should be worn under the cuff of the gown.
Middle gloves	Single-use disposable longer-cuffed nitrile gloves. The cuff of each middle glove should be worn over the cuff of the gown. Each middle glove cuff must be attached to the corresponding sleeve of the gown by applying four lengths (approximately 10 cm each) of microporous tape. Taping ensures that the middle gloves are removed simultaneously as the gown is removed.
Outer gloves	Glove choice will depend on the activities being undertaken. For basic care, venepuncture and planned medical procedures, use single-use, disposable, standard nitrile gloves. For heavier duties, such as environmental cleaning and dealing with body fluid spills, use single-use, disposable, heavy-duty (domestic) gloves. The outer gloves may be removed and replaced as required during patient care.
Wellington Boots	Reusable surgical wellington boots must have a leg that is long enough to allow the gown and apron to overlap the top of the boot by at least 10cm. Boots that are at least half to one size larger than the wearer’s shoe size facilitate easier removal with a ‘step-out’ removal technique. However, the size required to achieve easier removal should be ascertained during the training exercises and each individual should know which size is suitable for them. Boots should not be of a size which may cause a trip hazard.

Table 2: Components of the Buddy PPE ensemble

(See table 4 for differences in Buddy PPE selection depending on HCID transmission type, room provision and zone access)

Component	Requirement
Single pair of gloves	Single-use disposable longer-cuffed gloves.
FFP3 Respirator	The mask’s seal must not be disrupted by the hood. The elastic straps should be configured according to the manufacturer’s instructions. In addition, each time an FFP3 respirator is worn, the wearer should perform a fit check (according to the manufacturer’s guidance), to ensure that the mask is sited correctly, and an adequate seal has been achieved. More information can be found in the TBP chapter of the NIPCM.
Fluid Resistant Surgical Mask (FRSM)	Type II fluid resistant surgical mask.
Full-face visor	The bottom of the visor must be a minimum of 2 cm below the chin and the visor must be compatible with the FFP3 respirator that is being used if appropriate.
Gown	Fluid-resistant gown.
Wellington Boots	Reusable surgical wellington boots must have a leg that is long enough to allow the gown and apron to overlap the top of the boot by at least 10 cm. Boots that are at least a half to one size larger than the wearer’s shoe size facilitate easier removal with a ‘step-out’ removal technique. However, the size required to achieve easier removal should be ascertained during the training exercises and each individual should know which size is suitable for them. Boots should not be of a size which may cause a trip hazard

4.1.4 Donning (putting on) HCID assessment PPE and Buddy ensemble

Prior to donning the HCID assessment PPE ensemble and caring for a patient with a suspected HCID, the HCID caregiver should ensure that they feel well, are well hydrated and have been to the toilet.

It is important to identify zones in the care area designated for care of a suspected or confirmed HCID. The zone descriptors and associated permitted activity outlined in table 3 and 4 have been developed to help aid local boards in developing zones and denote risk determined by the activities undertaken within them and the potential exposure to blood, body fluids or aerosols associated with the suspected or confirmed HCID case. Tape may be used on the floor to demarcate zones.

Table 3: Zone Descriptors

Zone	Description
Red	An area where there is a risk to healthcare workers of direct exposure to a patient suspected or confirmed with HCID, for example within the patient room where direct care is provided. Doors to the red and amber area should remain shut during care provision and at all times other than on entry and exit.
Amber	An area situated in the vicinity of the individual with suspected or confirmed HCID* which therefore poses a potential threat of indirect exposure to healthcare workers from infectious particles in the environment, on equipment during doffing of PPE or from doffed and discarded PPE (waste), for example an ante room or an area demarcated as the amber zone outside the isolation room. *The optimum placement for a patient with a suspected or confirmed airborne HCID is a negatively pressured room with a negatively pressured ante room (amber zone). The pressure cascade in a negatively pressured room should be ante room to patient room or in the absence of an ante room, corridor to patient room. Positive pressure ventilated lobby (PPVL) rooms are not recommended for use for the care of a HCID patient due to the risk of air leakage from the ante room to the corridor. However, where a PPVL room is available, this may provide greater protection than a standard single room without specialised ventilation. There is a risk of infectious particles leaking into the corridor in the following room provisions: Where the ante room (if present) is not negatively pressurised, PPVL room Where the patient room has no specialist ventilation It is not possible to quantify this risk and more research is required. When identifying the most appropriate place to provide care to a HCID patient, the external corridor space, proximity to other rooms and location on the ward/clinical area should be taken into account. An HCID patient must not be placed in a positive pressure room. For all specialist ventilated isolation rooms annual verification should be undertaken. Planned preventative maintenance should be ongoing to ensure the rooms are functioning as required.
Green	An area demarcated as the green zone and separated from the individual with suspected or confirmed HCID by a physical barrier, where no clinical care or doffing practices take place and where no contaminated equipment and/or waste associated with the suspected or confirmed HCID case is present therefore posing no threat of HCID exposure to healthcare workers.

Within the Scottish Ambulance Service (SAS), the patient saloon within the ambulance and any area in which the patient is being treated, for example patients own home, would be considered the red zone. SAS staff should identify a suitable area for donning and doffing of PPE.

Minimising contamination of PPE in the red zone helps to reduce the consequences of any errors during doffing. The following techniques may be employed.

• Maintain distance from the patient where possible.
• Avoid touching or leaning on objects and surfaces where possible (consider adopting a 'clasped hands' position).
• Consider changing outer pair of gloves between care events.

 

4.1.6 Removal (doffing) of HCID assessment PPE and Buddy ensemble

5.0 Management and disposal of used PPE after doffing

A large amount of waste may be generated when caring for suspected or confirmed cases of HCID. It is therefore important to seek advice from and alert the local waste management team at the earliest opportunity to enable the initiation of local waste protocols for HCID.

All components of the HCID assessment PPE and buddy PPE ensemble should be single-use disposable, except for wellington boots. Boots should be quarantined in a designated container until the HCID result is known and action taken as outlined in table 5. Wellington boots must only be re-used if the case is HCID negative.   Guidance for the decontamination of wellington boots is available should the patient subsequently test HCID negative. 

Note: In NHSScotland, sporicidal wipes are not commonly used and a chlorine based solution of 1000ppm should be used to decontaminate the boots where there is no visible soiling and patient case is confirmed HCID negative.

Table 5 - PPE Waste Disposal and Wellington Boot Management

HCID case	PPE Waste Disposal	Wellington Boot Management
Confirmed	PPE waste including reusable PPE should be held in a secure location and disposed of as Category A waste as per SHTN 03-01.	Wellington boots should be held securely along with other PPE waste in a secure location and disposed of as Category A waste.
Suspected	If results are positive treat PPE waste as for a confirmed case, see above. If results are negative the waste can be disposed of as clinical waste.	If results are positive treat Wellington boots as for a confirmed case, see above. If results are negative wellington boots can be decontaminated. See guidance above.

 

6.0 Exposure safety and PPE Breach

To ensure the safety of all individuals it is vital that:

• there is provision of HCID assessment PPE and buddy PPE training which includes exposure awareness and clear guidance on the immediate management of any sharp’s injuries or exposures or PPE breaches
• there is ongoing monitoring of competence
• all the instructions regarding donning, doffing, and checks at every stage in the process are followed carefully
• a register of all Healthcare workers entering the patient's room is kept for a period of time relevant to the incubation period of the pathogen or disease as per local board procedures
• practice contamination reduction measures described in section 4.1.5 where possible
• any exposures or injury are recorded as per local board reporting or as required by HSE

More information on exposure safety and VHF is available. 

Appendix 1: Key reading to support the UK HCID assessment PPE ensemble

The HCID assessment PPE ensemble, including specifications, and donning and doffing protocols in this guidance are based on evidence provided by simulation experiments undertaken by HSE in conjunction with academic institutions and NHS providers.

1. Hall S, Poller B, Bailey C, et al. Use of ultraviolet-fluorescence-based simulation in evaluation of personal protective equipment worn for first assessment and care of a patient with suspected high-consequence infectious disease. J Hosp Infect. 2018; 99: 218-228.
2. Poller B, Hall S, Bailey C, et al. ‘VIOLET’: a fluorescence-based simulation exercise for training healthcare workers in the use of personal protective equipment. J Hosp Infect. 2018; 99(2): 229-235.
3. Poller B, Tunbridge A, Hall S, et al. A unified personal protective equipment ensemble for clinical response to possible high consequence infectious diseases: A consensus document on behalf of the HCID programme. J Infect. 2018; 77(6): 496-502.

A systematic literature review was undertaken to support the development of this addendum. Recommendations, Good Practice Points and the final addendum content were developed by a dedicated task and finish group with representation from the following sectors and networks:  

• Infectious diseases services
• Maternity services
• Critical care services
• Emergency department services
• National Procurement
• Scottish Ambulance Service
• Health and Safety
• Infection Control Managers Network
• Infection Control Doctors Network
• Senior Infection Prevention and Control Nurses Network
• Primary care services
• NHS Education for Scotland

 

Appendix 2: HCID Assessment PPE components and specifications for purchasing

Item	NHSScotland Component Specification
FFP3 Respirator	HX3 ALPHA SOLWAY (NDS) 3030V ALPHA SOLWAY (NDS) 3530 ALPHA SOLWAY (NDS) 3V ALPHA SOLWAY (NDS) Alphasol+ ALPHA SOLWAY (NDS)   8833 3M (NDS) 9332+ 3M (NDS) 1863+ 3M UK (NDS) 1873V+ 3M UK (NDS) 9330 3M UK (NDS)
Hood*	AlphaTec® 2500 Cape Hood – Model 507, Ansell Ltd. (SUPPLY CHAIN COORDINATION LIMITED (SCCL)) AlphaTec® 2500 Cape Hood – Model 503, Ansell Ltd. (SCCL) *Health boards can purchase directly from SCCL via the online catalogue.
Full-face visor	FACE VISOR ALPHA S 20V0401, ARCO (NDS)
Gown	690102 Surgical Gown Ultimate L – 119cm shoulder to bottom hem (NDS) 690104 Surgical Gown Ultimate XL - 129cm shoulder to bottom hem (NDS) 690105 Surgical Gown Ultimate XLL - 144cm shoulder to bottom hem (NDS) GOWN SURGICAL ESS POLY REINFORCED L 120CM ST - S3510CEC, Medline (NDS) GOWN SURGICAL ESS POLY REINFORCED XLL - S3513CEB, Medline (NDS)
Apron	APRON GREEN POLYTHENE 51CM X 150CM 50MU, UN440050, MEDIQ (NDS)
Inner gloves	GLOVE EXAMINATION NITRILE N/S, Small (NDS) GLOVE EXAMINATION NITRILE N/S, Medium (NDS) GLOVE EXAMINATION NITRILE N/S, Large (NDS) GLOVE EXAMINATION NITRILE N/S, XLarge (NDS)
Middle gloves	GLOVE EXAM NITRILE-XTRA N/S LONG CUFF XSMALL, (NDS) GLOVE EXAM NITRILE-XTRA N/S LONG CUFF SMALL,  (NDS) GLOVE EXAM NITRILE-XTRA N/S LONG CUFF MEDIUM,  (NDS) GLOVE EXAM NITRILE-XTRA N/S LONG CUFF LARGE,  (NDS) GLOVE EXAM NITRILE-XTRA N/S LONG CUFF XLARGE,  (NDS)
Outer gloves	GLOVE EXAMINATION NITRILE N/S, Small (NDS) GLOVE EXAMINATION NITRILE N/S, Medium (NDS) GLOVE EXAMINATION NITRILE N/S, Large (NDS) GLOVE EXAMINATION NITRILE N/S, XLarge (NDS)
Wellington Boots	583912 - Dunlop Pricemastor White Non-Safety Wellington Boots (ARCO DIRECT)

Note. Product codes are correct at the time of publishing, however, they are subject to change.

Any changes will be managed by the NDS supply chain Pecos content manager (PCM).

All products, apart from the hoods, are available to order via PECOS. Hoods can be ordered directly from the supply chain.

Process for ordering

Those responsible for ordering the PPE should access the HCID PPE PPE catalogue within PCM.

All items for ordering will be visible there with the current SKU as displayed in the catalogue. The items can then be ordered via Pecos using the current SKU as displayed in the catalogue.

Any queries should be directed to the national procurement team at nss.ppecell@nhs.scot