SARS

Guidance for hospitals on the prevention of spread of SARS

Case definitions for severe acute respiratory syndrome (SARS)

Information is available at:

Arrow Case definition and guidance on reporting, and management of SARS patients in the UK in the post-outbreak period

Areas within countries reporting focus of local transmission of SARS

Information is available at the World Health Organization website at <http://www.who.int/csr/sarsareas/en/>.

Guidance

In general, the guidance is that the precautions to control the spread of SARS in health care settings should be those general infection control measures taken against other respiratory infections that spread from person-to-person, of which tuberculosis and influenza are useful examples. Therefore hospital staff should refer to their infection control manuals and follow advice from their hospital infection control teams. The guidance given here is intended to supplement the general infection control guidance and is based on questions that have come to the SARS team at CDSC from health professionals in the UK. The answers are based on discussions within the team and with other colleagues, on standard infection control procedures and on SARS guidance published by Centers for Disease Control and Prevention (CDC), Health Canada and the World Health Organization. The guidance recognises that there have been relatively few probable cases in the UK to date, and their illnesses have been generally milder than in areas where most cases have occurred.

Where should patients who may have SARS be treated?
Patients who are defined as probable SARS cases (website for definitions) are likely to require hospital care for at least a few days, but many suspected cases in the UK have not required admission to hospital because their symptoms were relatively mild. Case definitions can be found at:

Arrow Case definition and guidance on reporting, and management of SARS patients in the UK in the post-outbreak period

The care of patients at home is described in a separate document at:

Arrow Guidance for primary care practitioners on investigation, management and reporting of SARS cases and contacts (including community infection control)

In hospital, patients with probable SARS should be nursed in a single room, preferably with negative pressure ventilation.

What precautions should be taken in A& E departments?
Ideally, patients referred to hospital with probable or suspect-high SARS should be admitted directly to a single hospital room without going via an A&E department, but some patients who meet the case definitions of suspected or probable SARS are likely to come to A&E departments. Therefore questions concerning fever, respiratory symptoms, and recent travel should be included in the initial assessment of patients as soon as possible after patient arrival. The most recent case definition for SARS should be used as a basis for such screening questions. If the patient meets the definition of a suspect of probable case, he or she should be put in a room or cubicle separate from other patients while they are awaiting further assessment and a decision to admit or send home. The infection control precautions of masks and hygiene should be applied by staff attending patients with suspected or probable SARS.

Masks and respirators

Detailed guidance on the use of masks and respirators is available at:

Arrow Information on face masks and respirators - Frequently Asked Questions

For additional information on masks and respirators see the Advice for Health Care Workers menu.

What mask / respirator should health care workers wear?
All healthcare workers who come into close contact with a suspected or probable case of SARS should wear a respirator conforming to EN149:2001 FFP3. If a respirator is not immediately available, a surgical face mask should be worn. Healthcare workers include community/ primary care teams, hospital clinical teams, ambulance staff, physiotherapists and other professional support staff, porters and domestic staff.

What is the correct way to use a respirator?
User instructions are supplied with the respirator. PLEASE READ THESE INSTRUCTIONS CAREFULLY and do a fit check or user seal check every time a respirator is worn. The checks are given in the user instructions. Fit is critically important. The respirator must seal tightly to the face or air will enter from the sides.

The respirator is one component of a number of infection control precautions. These include hand hygiene, gloves, goggles, visors, gowns or gown and apron. Protective equipment should be removed in the following order: gloves, respirator, goggles followed by hand hygiene.

What is the correct way to use a mask?
The mask should fit snugly over the face, with the coloured side out and the metal strip at the top. Position the strings to keep the mask firmly in place over the nose, mouth and chin. Mould the metallic strip to the bridge of the nose. Do not touch the mask again until it is removed. Healthcare workers should discard the mask as clinical waste according to local policy.

How often should masks or respirators be changed?
Masks or respirators used in close contact with a suspected or probable SARS case should be disposed of immediately after use as clinical waste according to local infection control policy. They should only be removed when the wearer is in a safe area, outside the patient’s room.

What protection should be worn for intubation and other aerosol-producing procedures?
If possible, aerosol-producing procedures should be avoided. These procedures include nebulised medication, diagnostic sputum induction, bronchoscopy, airway suctioning and intubation. If unavoidable, the procedure should take place in a negative pressure single room with as few staff present as possible. All staff present should wear a correctly fitted respirator with a filtration efficiency of EN149:2001 FFP3, goggles, visor, gloves, single use gown or gown and apron according to local policy.

Why and when should patients wear a mask?
Patients with suspected or probable SARS should wear a surgical mask during close contact with uninfected persons to prevent spread of infectious droplets. When the patient is unable to wear a mask, healthcare workers should wear a mask when in close contact with the patient. This applies to ambulance staff if treating a patient at home or during transit.

What about care at home?
See separate document at:

Arrow Guidance for primary care practitioners on investigation, management and reporting of SARS cases and contacts (including community infection control)

What about hand hygiene?
All people caring for a SARS patient should apply good hand hygiene (eg, frequent hand washing or use of alcohol-based hand rubs), particularly after contact with body fluids (eg respiratory secretions, urine, or faeces). Alcohol hand rubs should only be used on visibly clean hands. Hands which are soiled should be washed thoughly. Disposable gloves should be worn for any direct contact with body fluids of a SARS patient. However, gloves are not intended to replace proper hand hygiene. Immediately after activities involving contact with body fluids, gloves should be removed and discarded and hands should be cleaned. Gloves must never be washed or reused.

What about health care workers (HCWs) who develop (or might develop) symptoms within ten days of contact with SARS cases?
In places with most SARS cases, a number of healthcare workers have developed SARS after caring for infected patients with SARS. Personal protective equipment appropriate for standard, contact, and airborne precautions (eg hand hygiene, gown, gloves, and European Standard EN 149:2001 FFP3) in addition to eye protection, have been recommended for healthcare workers to prevent transmission of SARS in healthcare settings. It is helpful if the hospital ward keeps a list of staff who have attended a patient with probable SARS to facilitate the management of contacts (see the answer on the management of contacts)

If a healthcare worker develops fever or respiratory symptoms during the ten days following contact with a SARS patient, he or she should report their illness as soon as possible to their GP or a designated hospital doctor (according to local arrangements) and their occupational health service. They should stay off duty for seven days after the resolution of fever and respiratory symptoms. During this period, possibly infected workers should avoid close contact with persons both in the hospital and in the general community

How should staff who are in contact with, or have cared for, a patient in the UK with probable or highly suspected SARS be followed up?
Hospital staff who care for, or have direct contact with respiratory secretions and/or body fluids of a person with SARS, will be close contacts by definition.

Healthcare staff are free to continue with usual activities unless they become unwell or have not followed normal infection control procedures. Any person who develops symptoms of SARS within 10 days of being a close contact of a suspected or probable case should be advised to seek medical advice and inform medical staff of their contact with a suspected SARS case.

A list of staff who are close contacts, with the dates that they last had contact with the case should be made. The staff close contacts should be contacted to explain the follow up arrangements (which may be done by occupational health, the hospital infection control team, the local CPHM or Health Protection / CD&EH team at the local NHSScotland board or GP, depending on local agreements). The staff contacts should be provided with information on SARS, and asked to report any fever or respiratory symptoms. If the close contact develops symptoms consistent with SARS they should be assessed at home following the earlier part of this guidance.

On day ten following the last contact with the case, a check should be made that any member of staff who was a close contact, and is now not at work, has remained well.

How should healthcare workers returning from an affected area* be managed?
Healthcare staff who have visited affected areas should return to work as normal,

unless:

they are unwell and have symptoms consistent with SARS, in which case they should stay off work and phone their GP for assessment

or

they are well, but have been in close contact with a SARS case, involved in the care of a SARS case, or worked in a healthcare setting where cases were being treated. Healthcare staff in this group should avoid contact with patients for14 days after departure from an affected area, contact their local occupational health department, and monitor their own health for 14 days, seeking medical advice if they become unwell.

* As from 24 June 2003 the UK, in line with the World Health Organisation (WHO), has removed all restrictions on travel to areas of the world previously affected by SARS.

What precautions should be taken by relatives visiting SARS cases in hospital?
Family members of SARS patients are likely to fall into the definition of a close contact and should be advised accordingly. Close contacts with either fever or respiratory symptoms should not be allowed to enter the hospital as visitors and should be educated about this policy. A system for assessing SARS close contacts who are visitors to the patient in hospital for fever or respiratory symptoms should be in place. Hospitals should educate all visitors about use of infection control precautions when visiting SARS patients and their responsibility for adherence to them, especially on hand washing on leaving the patient's room. The hospital's policy on children visiting should be followed.

What decontamination procedures should be used for equipment and rooms used by patients with probable or highly suspected SARS?
The hospital’s normal decontamination procedures, described in hospital infection control manuals, should be followed.

What special precautions should be taken to decontaminate ventilators used by patients with suspected or probable SARS?
The standard procedures for decontaminating ventilators should be sufficient if the manufacturers’ guidance and hospital infection control manuals are followed.

What is the guidance on post mortem examinations on people who have died from suspected or probable SARS (as defined by the case definitions)?
If a post-mortem examination is made on a patient who dies meeting the case definition of a probable case, precautions should be taken against the risk of infection from aerosols created during the examination. For autopsies and postmortem assessment of SARS cases, personal protective equipment (PPE) should include:

  • Protective garments: surgical scrub suit, surgical cap, impervious gown or apron with full sleeve coverage, face shield, shoe covers and double surgical gloves with an interposed layer of cut-proof synthetic mesh gloves.
  • Respiratory protection: respirators to the European Standard EN 149:2001 FFP3.

Safety procedures (which are standard) should include:

  • prevention of percutaneous injury,
  • removing protective outer garments when leaving the immediate autopsy area and discarded in appropriate laundry or waste receptacles, either in an antechamber to the autopsy suite or immediately inside the entrance if an antechamber is not available.
  • hand washing upon glove removal.
  • The general precautions described in The infection hazards of human cadavers (CDR Review Vol 5, No 5) should be followed. Embalming is not advisable.

What precautions should be taken with lab specimens?
Blood and other Specimens for Routine Biochemistry and Haematology, Microbiology, or Serology, may be handled using Standard precautions. Details should be found in the hospital infection control manuals. More information on specimens is in the microbiology guidance at:

Arrow Guidance on microbiological sampling and investigation of possible cases of SARS during the inter-epidemic period

How do you interpret SARS test results?
SARS coronavirus (SARS CoV) has been demonstrated to be the cause of SARS.

Although no test for SARS is widely available yet in the UK or Europe, the Influenza Reference Laboratory of the UK’s Health Protection Agency, has developed and is using several tests to identify the SARS virus. Current tests detect RNA and antibodies to the new coronavirus.

SARS will continue to be diagnosed on the basis of symptoms and exposures, as described in thecurrent SARS case definition positive serology test results are incorporated in the case definition.

Arrow Case definition and guidance on reporting, and management of SARS patients in the UK in the post-outbreak period

More detailed information on interpreting SARS test results is available at:

Arrow Fact sheet for clinicians: interpreting SARS test results

10 July 2003

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