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AARC SARS Guidance Document

Statement of Intent: The purpose of this document is to provide guidance to respiratory care staff and managers involved in addressing SARS issues at their facilities and in their practice. The content of this document is based on information found on the web site of the Centers For Disease Control and Prevention (CDC). Because new information about SARS is being published constantly, using the website links in this document will provide the reader access to the latest available information.

Basic Information About SARS
Source: http://www.cdc.gov/ncidod/sars/factsheet.htm

In addition to the following basic information about SARS, frequently asked questions about SARS are found on the CDC website at http://www.cdc.gov/ncidod/sars/faq.htm

A new disease called SARS
Severe acute respiratory syndrome (SARS) is a respiratory illness that has recently been reported in Asia, North America, and Europe. This fact sheet provides basic information about the disease and what is being done to combat its spread. To find out more about SARS, go to www.cdc.gov/ncidod/sars/ and www.who.int/csr/sars/en/ .

Symptoms of SARS
In general, SARS begins with a fever greater than 100.4°F [>38.0°C]. Other symptoms may include headache, an overall feeling of discomfort, and body aches. Some people also experience mild respiratory symptoms. After 2 to 7 days, SARS patients may develop a dry cough and have trouble breathing.

How SARS spreads
The primary way that SARS appears to spread is by close person-to-person contact. Most cases of SARS have involved people who cared for or lived with someone with SARS, or had direct contact with infectious material (for example, respiratory secretions) from a person who has SARS. Potential ways in which SARS can be spread include touching the skin of other people or objects that are contaminated with infectious droplets and then touching your eye(s), nose, or mouth. This can happen when someone who is sick with SARS coughs or sneezes droplets onto themselves, other people, or nearby surfaces. It also is possible that SARS can be spread more broadly through the air or by other ways that are currently not known.

Who is at risk for SARS
Most of the U.S. cases of SARS have occurred among travelers returning to the United States from other parts of the world with SARS. There have been very few cases as a result of spread to close contacts such as family members and health care workers. Currently, there is no evidence that SARS is spreading more widely in the community in the United States.

Possible cause of SARS
Scientists at the CDC and other laboratories have detected a previously unrecognized coronavirus in patients with SARS. The new coronavirus is the leading hypothesis for the cause of SARS.

CDC RECOMMENDATIONS FOR HEALTH CARE WORKERS:

Transmission of SARS to health-care workers appears to have occurred after close contact with sick people before recommended infection control precautions were put into use.

Updated Interim Domestic Infection Control Guidance in the Health-Care and Community Setting for Patients with Suspected SARS

May 1, 2003
Source: http://www.cdc.gov/ncidod/sars/infectioncontrol.htm

The CDC is issuing revised interim guidance concerning infection control precautions in the health-care and community settings. To minimize the potential for transmission, these precautions are recommended as feasible given available resources, until the epidemiology of disease transmission is better understood.
For all contact with suspect SARS patients, careful hand hygiene is urged, including hand washing with soap and water; if hands are not visibly soiled, alcohol-based handrubs may be used as an alternative to hand washing.

Access www.cdc.gov/handhygiene for detailed information on hand hygiene.

For the inpatient setting:

If a suspected SARS patient is admitted to the hospital, infection control personnel should be notified immediately. Infection control measures for inpatients (www.cdc.gov/ncidod/hip/isolat/isolat.htm) should include:
Standard precautions (e.g., hand hygiene); in addition to routine standard precautions, health-care personnel should wear eye protection for all patient contact.
Contact precautions (e.g., use of gown and gloves for contact with the patient or their environment)
Airborne precautions (e.g., an isolation room with negative pressure relative to the surrounding area and use of an N-95 filtering disposable respirator for persons entering the room)
If airborne precautions cannot be fully implemented, patients should be placed in a private room, and all persons entering the room should wear N-95 respirators. Where possible, a qualitative fit test should be conducted for N-95 respirators; detailed information on fit testing can be accessed at http://www.osha.gov/SLTC/etools/respiratory/oshafiles/fittesting1.html. (Summarized in Appendix C) If N-95 respirators are not available for health-care personnel, then surgical masks should be worn. Regardless of the availability of facilities for airborne precautions, standard and contact precautions should be implemented for all suspected SARS patients.

For the outpatient setting:

Persons seeking medical care for an acute respiratory infection should be asked about possible exposure to someone with SARS or recent travel to a area with SARS. If SARS is suspected, provide and place a surgical mask over the patient’s nose and mouth. If masking the patient is not feasible, the patient should be asked to cover his/her mouth with a disposable tissue when coughing, talking or sneezing. Separate the patient from others in the reception area as soon as possible, preferably in a private room with negative pressure relative to the surrounding area.
All health-care personnel should wear N-95 respirators while taking care of patients with suspected SARS. In addition, health care personnel should follow standard precautions (e.g., hand hygiene), contact precautions (e.g., use of gown and gloves for contact with the patient or their environment) and wear eye protection for all patient contact.
For more information, see the triage guidelines in Appendix A.

For home or residential setting:

Placing a surgical mask on suspected SARS patients during contact with others at home is recommended. If the patient is unable to wear a surgical mask, it may be prudent for household members to wear surgical masks when in close contact with the patient. Household members in contact with the patient should be reminded of the need for careful hand hygiene including hand washing with soap and water; if hands are not visibly soiled, alcohol-based handrubs may be used as an alternative to hand washing. For more information, see the household guidelines in Appendix B.

Interim Domestic Guidance for Management of Exposures to Severe Acute Respiratory Syndrome (SARS) for Health-Care Settings

May 20, 2003

Source: http://www.cdc.gov/ncidod/sars/exposureguidance.htm

Given the currently available information on the epidemiology of SARS, the following outlines interim guidance for the management of exposures to SARS in a health-care facility.

Surveillance of Health-Care Personnel

Surveillance of health-care personnel is necessary to ensure that workers who are ill receive appropriate care and are isolated to prevent transmission. Health-care facilities that care for SARS patients should implement surveillance of health-care workers who have any contact with SARS patients or their environment of care. Recommendations for surveillance include:

	•	Develop and maintain a listing of all personnel who enter the rooms of SARS patients, or who are involved in the patient’s care in other parts of the hospital.
	•	Instruct personnel who have contact with SARS patients, or their environment of care, to notify occupational health, infection control or their designee if they have unprotected exposure to a SARS patient or if they develop fever or respiratory symptoms.
	•	Monitor employee absenteeism for increases that may suggest emerging respiratory illness in the workforce. Notify local and state health authorities of clusters or unusual increases in respiratory illness, including atypical pneumonia.

Management of Asymptomatic, Exposed Health-Care Workers

	1.	To date, there is no evidence to suggest that SARS is transmitted from asymptomatic individuals. However, according to recent reports, health-care workers who developed SARS may have been a source of transmission within health-care facilities during the early phases of illness when symptoms were mild and not recognized as SARS. To minimize the risk of transmission from unrecognized SARS infections among health-care workers, health-care workers who have unprotected high-risk exposures to SARS should be excluded from duty (e.g. administrative leave) for 10 days following the exposure. Unprotected high-risk exposure is defined as presence in the same room as a probable SARS patient during a high-risk aerosol-generating procedure or event and where recommended infection control precautions are either absent or breached. Aerosol-generating procedures or events include aerosolized medication treatments, diagnostic sputum induction, bronchoscopy, endotracheal intubation, airway suctioning, positive pressure ventilation via facemask (e.g.,BiPAP,CPAP), during which air may be forced out around the facemask , high frequency oscillatory ventilation (HFOV), and close facial contact during a coughing paroxysm. Health-care workers who are excluded from duty should limit interactions outside the home, and should not go to work, school, church, or other public areas.
	2.	Health-care workers who have other unprotected exposures to patients with SARS need not be excluded from duty, but should undergo active surveillance for symptoms, including measurement of body temperature at least twice daily for 10 days following the exposure. Prior to reporting for duty each day, the health-care worker should be interviewed regarding respiratory symptoms and have their temperature measured by employee health or other designee.
	3.	Health-care workers who have cared for, or otherwise been exposed to SARS patients while adhering to recommended infection control precautions, should be instructed to be vigilant for fever and respiratory symptoms, including measurement of body temperature at least twice daily for 10 days following the last exposure to a SARS patient. These health-care workers should be contacted by occupational health, infection control or their designee regularly over the 10 day period following exposure to inquire about fever or respiratory symptoms.

Management of Symptomatic, Exposed Health-Care Workers

	1.	Any health-care worker who has cared for or been exposed to a SARS patient who develops fever or respiratory symptoms within 10 days following exposure should not report for duty, but should stay home and report symptoms to the appropriate facility point of contact immediately. If the symptoms begin while at work, the health-care worker should be instructed to immediately apply a surgical mask and leave the patient care area. Symptomatic health-care workers should use infection control precautions (see Appendix B) to minimize the potential for transmission and should seek health-care evaluation. In advance of clinical evaluation, health-care providers should be informed that the individual may have been exposed to SARS so arrangements can be made, as necessary, to prevent transmission to others in the health-care setting.
	2.	If symptoms improve or resolve within 72 hours after first symptom onset, the person may be allowed, after consultation with infection control and local public health authorities, to return to duty and infection control precautions can be discontinued.
	3.	For persons who meet, or progress to meet the case definition for SARS (e.g., develop fever and respiratory symptoms), infection control precautions should be continued until 10 days after the resolution of fever, provided respiratory symptoms are absent or improving.
	4.	If the illness does not progress to meet the case definition, but the individual has persistent fever or unresolving respiratory symptoms, infection control precautions should be continued for an additional 72 hours, at the end of which time a clinical evaluation should be performed. If the illness progresses to meet the case definition, infection control precautions should be continued as described above. If case definition criteria are not met, infection control precautions can be discontinued after consultation with local public health authorities and the evaluating clinician. Factors that might be considered include the nature of the potential exposure to SARS, the nature of contact with others in the residential or work setting, and evidence for an alternative diagnosis.
	5.	Persons who meet, or progress to meet the case definition for suspected SARS (e.g., develop fever and respiratory symptoms), or whose illness does not meet the case definition, but who have persistent fever or unresolving respiratory symptoms over the 72 hours following onset of symptoms, should be tested for SARS coronavirus infection. Collection of appropriate specimens for laboratory testing (See Appendix H for collection of respiratory specimens) should be coordinated with and guided by local/state public health authorities and consultation with the CDC .

Prevention of Unprotected Exposures

Prevention of unprotected exposures will limit the need for exclusion from duty. Health-care facilities should address the following:

	•	Review current procedures for early detection and isolation of suspected SARS patients
	•	Educate all health-care personnel on the signs and symptoms of SARS and recommended infection control practices
	•	Review use of personal protective equipment with health-care personnel, including physicians, who may care for SARS patients
	•	Follow current CDC recommendation for aerosol-generating procedures in suspected or probable SARS patients

Management of Symptomatic, Exposed Visitors

Close contacts (e.g., family members) of SARS patients are at risk for infection. Close contacts with either fever or respiratory symptoms should not be allowed to enter the health-care facility as visitors and should be educated about this policy. A system for screening SARS close contacts who are visitors to the facility for fever or respiratory symptoms should be in place. Health-care facilities should educate all visitors about use of infection control precautions when visiting SARS patients and their responsibility for adherence to them. Patient education information is available at: http://www.cdc.gov/ncidod/sars/factsheetcc.htm and are abridged in Appendix I

Regarding the Appendices of This Document

The appendices in this document (many of which have not been referenced to this point) are from the CDC website and provide detailed information about minimizing risks for caregivers of SARS patients. Each contains critical information for respiratory therapists and should be carefully reviewed.

Appendix A - Updated Interim Domestic Guidelines for Triage and Disposition of Patients Who May Have Severe Acute Respiratory Syndrome (SARS)

Appendix B - Interim Guidance on Infection Control Precautions for Patients with Suspected Severe Acute Respiratory Syndrome (SARS) and Close Contacts in Households

Appendix C - Fit Testing

Appendix D - Case Definition for suspected Severe Acute Respiratory Syndrome (SARS)

Appendix E - Interim Domestic Infection Control Precautions for Aerosol-Generating Procedures on Patients with Severe Acute Respiratory Syndrome (SARS)

Appendix F-Interim Recommendations for Cleaning and Disinfection of the SARS Patient Environment

Appendix G - Interim Domestic Guidance on the Use of Respirators to Prevent Transmission of SARS

Appendix H - Guidelines for Collection of Specimens from Potential Cases of SARS

Appendix I - Information For Close Contacts Of SARS Patients

Appendix J -Isolation and Quarantine

Appendix K - Updated Interim Guidance: Pre-Hospital Emergency Medical Care and Ground Transport of Suspected Severe Acute Respiratory Syndrome Patients

Appendix L - Interim Guidance: Air Medical Transport for Severe Acute Respiratory Syndrome (SARS) Patients

Appendix M - Treatment

Appendix N - SARS Training and Reference Materials