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Documents from the 
Household Precautions,
Cleaning Aircraft,
Flight Crew Precautions,
Air
Transport of SARS Patients
Interim Guidance on Infection Control
Precautions for Patients with Suspected Severe Acute Respiratory Syndrome
(SARS) and Close Contacts in Households
April 29, 2003, 10:00 AM ET |
Patients with
SARS pose a risk of transmission to close household contacts and health care
personnel in close contact. The duration of time before or after onset of
symptoms during which a patient with SARS can transmit the disease to others is
unknown. The following infection control measures are recommended for patients
with suspected SARS in households or residential settings. These recommendations
are based on the experience in the United States to date and may be revised as
more information becomes available.
- SARS patients should limit interactions outside the home and should not go
to work, school, out-of-home child care, or other public areas until 10 days
after the resolution of fever, provided respiratory symptoms are absent or
improving. During this time, infection control precautions should be used, as
described below, to minimize the potential for transmission.
- All members of a household with a SARS patient should carefully follow
recommendations for hand hygiene (e.g., frequent hand washing or use of
alcohol-based hand rubs), particularly after contact with body fluids (e.g.,
respiratory secretions, urine, or feces). See the "Guideline
for Hand Hygiene in Health-Care Settings" at for more details on hand
hygiene.
- Use of disposable gloves should be considered 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.
- Each patient with SARS should be advised to cover his or her mouth and
nose with a facial tissue when coughing or sneezing. If possible, a SARS
patient should wear a surgical mask during close contact with uninfected
persons to prevent spread of infectious droplets. When a SARS patient is
unable to wear a surgical mask, household members should wear surgical masks
when in close contact with the patient.
- Sharing of eating utensils, towels, and bedding between SARS patients and
others should be avoided, although such items can be used by others after
routine cleaning (e.g., washing with soap and hot water). Environmental
surfaces soiled by body fluids should be cleaned with a household disinfectant
according to manufacturer's instructions; gloves should be worn during this
activity.
- Household waste soiled with body fluids of SARS patients, including facial
tissues and surgical masks, may be discarded as normal waste.
- Household members and other close contacts of SARS patients should be
actively monitored by the local health department for illness.
- Household members or other close contacts of SARS patients should be
vigilant for the development of fever or respiratory symptoms and, if these
develop, should seek healthcare evaluation. In advance of evaluation,
healthcare providers should be informed that the individual is a close contact
of a SARS patient so arrangements can be made, as necessary, to prevent
transmission to others in the healthcare setting. Household members
or other close contacts with symptoms of SARS should follow the same
precautions recommended for SARS patients.
- At this time, in the absence of fever or respiratory symptoms, household
members or other close contacts of SARS patients need not limit their
activities outside the home.
Interim Guidance for Cleaning of
Commercial Passenger Aircraft Following a Flight with a Passenger with
Suspected Severe Acute Respiratory Syndrome (SARS)
May 8, 2003, 2:00 PM EST
Introduction
The Centers for Disease Control and Prevention (CDC) is tracking reports of
outbreaks of a respiratory illness called severe acute respiratory syndrome
(SARS). CDC has issued two types of notices to travelers: advisories and
alerts. A travel advisory recommends that
nonessential travel be deferred; a travel alert
does not advise against travel, but informs travelers of a health concern
and provides advice about specific precautions. CDC updates information on
its website on the travel status of
areas with SARS as
the situation evolves.
This guidance
is intended to assist commercial passenger airlines with selection of
appropriate post-flight cleaning measures to ensure the safety of their
passengers, flight-crew and cleaning personnel. Recommendations are based on
standard infection control practices and on available epidemiologic
information concerning the infectivity of the etiologic agent of SARS.
Transmission
of SARS has been associated with direct contact or close proximity to
symptomatic patients. Once passengers have left an aircraft, the main source
of infectious particles from a sick passenger will have been removed.
However, infection may occur if residual infectious particles on
environmental surfaces are brought into direct contact with the eyes, nose
or mouth, e.g., by unwashed hands. Therefore,
hand hygiene is of primary
importance for all personnel working on commercial passenger aircraft.
I.
Notification of Ground and Cleaning Crew
CDC has issued
guidelines for Airline Flight Crew Members to notify a U.S. Quarantine
Station of any ill passengers that meet specified criteria. In addition, the
ground and cleaning crews of the airline should be notified at the same time
so that preparations can be made for appropriate cleaning of the aircraft
after passengers have disembarked.
II.
Cleaning and Disinfection
Routine post-flight cleaning of passenger aircraft should incorporate
appropriate hand hygiene to minimize risks of disease transmission. CDC has
issued interim guidelines for airline cleaning crews conducting routine
cleaning on passenger aircraft without a recognized SARS case. Cleaning of
aircraft used for air medical (air-ambulance) transport of active SARS
patients requires higher level cleaning as described in the
air
medical transport guidance.
When cleaning
commercial passenger aircraft after a flight with a possible SARS patient:
 | Compressed
air that might re-aerosolize infectious material should not be used for
cleaning the aircraft. There currently is no evidence to suggest that
special vacuuming equipment or procedures are necessary. |
| Cleaning
personnel should wear non-sterile disposable gloves while cleaning the
passenger cabin and lavatories. |
| Gloves
should be removed and discarded if they become soiled or damaged and after
cleaning activities are concluded. |
| Hands
should be washed with soap and water or an alcohol-based hand sanitizer
immediately after gloves are removed. |
| Frequently
touched surfaces in the passenger cabin (e.g., armrests, seatbacks, tray
tables, light and air controls, and adjacent walls and windows) and
passenger lavatory surfaces should be wiped down with an EPA-registered
low- or intermediate-level chemical household germicide* and allowed to
air dry in accordance with manufacturer’s instructions. |
| Special
cleaning of upholstery, carpets, or storage compartments is not indicated.
|
III.
Occupational health for cleaning crews
Cleaning crew managers should be aware of the symptoms described in the
CDC Q & A and
should direct cleaning personnel to report to their occupational health
service if they develop symptoms within ten days of cleaning an aircraft
after a flight that had a possible SARS patient on board.
* There are no disinfectant products currently registered by the U.S.
Environmental Protection Agency (EPA) specifically for the inactivation of
the newly identified viruses associated with SARS. However, related viruses
with physical and biochemical properties similar to the possible SARS agents
are known to be readily inactivated by EPA-registered chemical germicides
that provide low- or intermediate-level disinfection during general use.
|
The Centers for
Disease Control and Prevention (CDC) is tracking reports of outbreaks of a
respiratory illness called severe acute respiratory syndrome (SARS). CDC issues
two types of notices to travelers: advisories and alerts. A travel
advisory recommends that nonessential travel be deferred; a
travel alert does not advise against travel, but informs
travelers of a health concern and provides advice about specific precautions.
CDC updates information on its website on the travel status of
areas with SARS as the
situation evolves.
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 persons or objects that are contaminated with
infectious droplets and then touching the eye, nose, or mouth. This can happen
when someone who is sick with SARS coughs or sneezes droplets onto themselves,
other persons, or nearby surfaces. It is also possible that SARS can be spread
more broadly through the air or by other ways that are currently not known.
General
infection control precautions
As with many
infectious illnesses, the first line of defense to prevent transmission is
careful hand hygiene. As a general rule, it is good practice to wash hands
frequently with soap and water; if hands are not visibly soiled, alcohol-based
hand rubs may be used as an alternative. According to principles of health-care
infection control, in a health-care–related emergency, flight crew personnel
should wear disposable gloves for direct contact with blood or body fluids of
any passenger. However, gloves are not intended to replace proper
hand hygiene. Immediately after activities involving contact with
body fluids, gloves should be carefully removed and discarded and hands should
be cleaned. Gloves must never be washed or reused.
The routine use
of personal protective equipment, such as masks, by airline personnel or
passengers has drawn considerable attention as a possible approach to prevent
transmission of SARS. The effectiveness of masks and other personal protective
equipment to prevent transmission of infectious diseases is dependent on proper
use for specific tasks involving anticipated contact over a discrete period of
time, such as in the health-care setting. It is unclear what benefit routine,
prolonged use of personal protective equipment, by airline personnel or the
public, would have in settings such as commercial airline flights. For example,
a mask may protect the wearer's mouth and nose from large droplets transmitted
over short distances between persons. However, it does not prevent transmission
with infectious droplets that might occur through direct contact with an
infected person or recently touched inanimate objects. When used over long
periods, a mask or other piece of personal protective equipment may become
contaminated; this presents a particular problem when equipment such as gloves
or a mask is being removed after use. Without attention to hand hygiene, a
person's hands could easily spread these infectious materials to the eyes, nose,
or mouth. Because of these concerns, there is no basis to suggest that the
routine use of masks or other personal protective equipment by airline personnel
or the public on commercial airliners would be beneficial.
Management of possible cases of SARS during a flight
If you are
concerned that a passenger traveling from one of the areas listed above may be
ill with a fever or respiratory illness, you should try to keep him or her
separated from close contact with the other passengers as much as possible.
Provide a surgical mask for the ill passenger to wear if it is available and can
be tolerated (i.e., if the severity of the passenger’s respiratory difficulty
does not preclude the use of a mask). A surgical mask can reduce the number of
droplets coughed into the air. If a surgical mask is not available, provide the
passenger with tissues and ask him or her to cover their mouth and nose when
coughing. When an ill passenger is unable to wear a surgical mask, flight crew
personnel should wear surgical masks when in close contact with the patient. CDC
does not recommend the routine use of equipment such as N95 respirators for
flight crew personnel. The captain is required by law to report the illness to
the nearest U.S.
Quarantine Station prior to arrival. Quarantine officials will arrange for
appropriate medical assistance to be available when the airplane lands.
While in
areas with SARS
To minimize the
possibility of infection, you may wish to avoid close contact with large numbers
of people as much as possible. CDC does not recommend the routine use of masks
or other personal protective equipment while in public areas.
Be aware of the
symptoms of SARS (see
Basic Information About SARS). If you become ill and you are concerned about
SARS, you should contact a health-care provider. Prior to visiting the office or
emergency room, tell the health-care provider about your possible exposure so
that arrangements can be made, if necessary, to prevent transmission to others
in the health-care setting. If you do not have information about a local
health-care provider in the country you are visiting, you can contact the U.S.
embassy or consulate to ask about finding a health-care provider. Let your
employer know you are concerned about possible exposure to SARS and ask your
employer about health-care options. Do not travel while sick, and limit your
contact with others as much as possible to help prevent the spread of any
infectious illness you may have.
When you
return home from areas with SARS
CDC is handing
out health alert cards
to people returning from areas with SARS. If you become sick after you return
home, contact a health-care provider prior to visiting their office or emergency
room and tell them about your symptoms and the countries you visited. This way
arrangements can be made, if necessary, to prevent transmission to others in the
health-care setting.
Interim Guidance: Air Medical Transport
for Severe Acute Respiratory Syndrome (SARS) Patients
May 8,
2003, 2:30 PM |
Introduction
Introduction
The Centers for Disease Control and Prevention (CDC) is tracking reports of
outbreaks of a respiratory illness called severe acute respiratory syndrome
(SARS). CDC has issued two types of notices to travelers: advisories and
alerts. A travel advisory recommends that
nonessential travel be deferred; a travel alert
does not advise against travel, but informs travelers of a health concern
and provides advice about specific precautions. CDC updates information on
its website on the travel status of
areas with SARS as
the situation evolves.
This
guidance is intended to assist air medical transport (AMT) service providers
using specialized aircraft to transport SARS patients while ensuring the
safety of patients and transport personnel. It should not be generalized to
commercial passenger aircraft. These interim recommendations are based on
standard infection control practices, AMT standards, and epidemiologic
information from ongoing investigations of SARS, including experience from
air transport of patients during this outbreak.
Currently
recommended infection
control measures for hospitalized patients with SARS include Standard
Precautions (with eye protection to prevent droplet exposure), plus Contact
and Airborne Precautions. Respiratory protection using respirators providing
at least 95% filtering efficiency (e.g., N-95) with
appropriate fit-testing is recommended.
I. Air Transport of SARS Patients, General Considerations
| SARS
patients should be transported on a dedicated AMT mission minimizing crew
size. There should not be any patients or passengers who do not have SARS
on board. If a parent is to accompany a sick child, the parent should use
protective equipment during transport as described in section IV, below.
|
| If
possible, a single primary-caregiver should be assigned to the SARS
patient. |
| All SARS
patient movement involving U.S. citizens should be coordinated with
appropriate state and federal health authorities, including the
Centers for Disease
Control and Prevention (CDC) (24 hour response number: (770) 488-7100)
and the Department of State, before movement begins. International
movement of SARS patients might require special approvals by countries
that will be over-flown, aircraft-servicing locations, patient rest-stop
hospitals, and/or final destinations. |
II.
Airframe Selection and Cabin Airflow
Cabin airflow characteristics may reduce exposure of occupants to airborne
infectious particles; however, based on current understanding of how SARS is
transmitted, airflow alone does not provide complete protection of personnel
when sharing airspace with an infectious SARS patient. N-95 (or better)
respirators are recommended for personnel in any part of an aircraft that
shares air (directly or through the ventilation system) with the
patient-care cabin.
Fixed-wing, pressurized aircraft:
| AMT
service providers should consult manufacturer(s) of their aircraft to
identify cabin airflow characteristics, including: HEPA filtration and
directional airflow capabilities, air outlet location, presence or absence
of air mixing between cockpit and patient-care cabin during flight, and
the time and aircraft configuration required to perform a post-mission
airing-out of the aircraft. |
| Aircraft
with forward-to-aft cabin airflow and a separate cockpit cabin are
preferred for transport of SARS patients. Aft-to-forward cabin airflow may
increase the risk of airborne exposure of cabin and flight deck personnel.
|
| Aircraft
ventilation should remain on at all times during transport of SARS
patients, including during ground delays. Aircraft that re-circulate cabin
and flight-deck air without HEPA filtration should not be selected for
SARS patient transport. |
| Aircraft
that provide space for crew members to perform necessary personal
activities (eating, drinking, handling contact lenses, etc.) in an area
that does not share air with the patient-care cabin should be selected for
flights likely to exceed 4 hours. |
Rotor-wing, and non-pressurized aircraft:
| In
aircraft with uncontrolled interior airflow such as rotor-wing and small,
non-pressurized fixed-wing aircraft, all personnel should wear disposable,
N-95 or better respirators during transport of SARS patients. |
III. Patient Placement
The in-flight environment might preclude the creation of a true negative
pressure space; however, some aircraft designs permit a downwind zone of
relative airflow isolation. The airflow of each aircraft should form the
basis for litter and seat assignments. In general:
| SARS
patients should be positioned as far downwind with regard to cabin airflow
as possible. |
| In AMT
aircraft with vertical litter tiers and top-to-bottom airflow, SARS litter
patients should be placed in the lowest position in the tier. |
| Ambulatory
SARS patients should be seated next to the cabin sidewall. |
| If a
non-SARS patient must be transported simultaneously with SARS patient(s),
the non-SARS patient must wear an N-95 respirator during transport and
should not be positioned downwind from, or within 3 feet of, the SARS
patient. |
| If several
SARS patients are transported, they may be moved as a group (cohorted) in
an aircraft that provides appropriate airflow characteristics as described
above. |
IV.
Infection Control
General:
| Personnel
should not wear leather or other “flight” gloves while providing patient
care. |
| Eating,
drinking, application of cosmetics, and handling of contact lenses should
not be done in the immediate patient care area. |
| Handling
or storage of medication or clinical specimens should not be done in areas
where food or beverages are stored or prepared. |
Protective equipment and procedures:
|
Disposable, non-sterile gloves must be worn for all patient contact.
|
| Gloves
should be removed and discarded in designated trash bags after patient
care is completed (e.g., between patients) or when soiled or damaged.
|
| Hands must
be washed or disinfected with waterless hand sanitizer immediately after
removal of gloves. |
| Disposable
fluid-resistant gowns should be worn for all patient care activity.
|
| Gowns
should be removed and discarded in designated trash bags after patient
care is completed or when soiled or damaged. |
| Goggles or
face-shields must be worn for all patient care within 6 feet of the
patient. Corrective eyeglasses alone are not appropriate protection.
|
|
Disposable, N-95 respirators are approved for in-flight use. Personnel
using N-95 respirators should be fit-tested. |
| If air is
shared between the cockpit/flight deck and the patient-care cabin,
cockpit/flight deck crew should wear disposable N-95 respirators.
|
| For
cockpit crews, aircraft aviator tight-fitting face-pieces capable of
delivering oxygen that has not mixed with cabin air may be used in lieu of
a disposable N-95 respirator. |
| Personal
activities that require removal of respirators should not be performed in
the patient-care cabin. |
| Patients
should wear a paper surgical mask to reduce droplet production, if
tolerated. |
| Oxygen
delivery with simple and non-rebreather facemasks may be used for patient
oxygen support during flight. |
| Positive
pressure ventilation should be performed using a resuscitation bag-valve
mask. If available, units equipped for HEPA or equivalent filtration of
expired air should be used. |
|
Cough-generating procedures should be avoided during transport (e.g.,
nebulizer treatments). |
V.
Mechanically Ventilated Patients
| Mechanical
ventilators for SARS patients should provide HEPA or equivalent filtration
of airflow exhaust. |
| AMT
services should consult their ventilator equipment manufacturer to confirm
appropriate filtration capability and the effect of filtration on positive
pressure ventilation. |
VI.
Clinical Specimens
| Standard
precautions must be used when collecting and transporting clinical
specimens. |
| Specimens
should be stored only in designated coolers or refrigerators. |
| Clinical
specimens should be labeled with appropriate patient information and
placed in a clean self-sealing bag for storage and transport. |
VII.
Waste Disposal
| Dry solid
waste (e.g., used gloves, dressings, etc.), should be collected in
biohazard bags for disposal as regulated medical waste in accordance with
local requirements at the destination medical facility. |
| Waste that
is saturated with blood or body fluids should be collected in leak-proof
biohazard bags or containers for disposal as regulated medical waste in
accordance with local requirements at the destination medical facility.
|
| Sharp
items such as used needles or scalpel blades should be collected in
puncture resistant sharps containers for disposal as regulated medical
waste in accordance with local requirements at the destination medical
facility. |
| Suctioned
fluids and secretions should be stored in sealed containers for disposal
as regulated medical waste in accordance with local requirements at the
destination medical facility. Handling that might create splashes or
aerosols during flight should be avoided. |
| Suction
device exhaust should not be vented into the cabin without HEPA or
equivalent filtration. Portable suction devices should be fitted with
in-line HEPA or equivalent filters. Externally vented suction should not
be used during ground operation. |
| Excretions
(feces, urine) may be carefully poured down the aircraft toilet.
|
VIII.
Cleaning and Disinfection
| After
transporting a SARS patient, exits and doors should be closed and aircraft
air conditioning turned on at maximum capacity for several minutes in
accordance with the airing time specified by aircraft-manufacturers to
provide at least one complete air-exchange. Non-pressurized aircraft
should be aired out with exits and doors open long enough to ensure a
complete air-exchange. Blowers and high-powered fans that might
re-aerosolize infectious material should not be used for airing out
aircraft. |
| Cleaning
should be postponed until airing out is complete. |
| Compressed
air that might re-aerosolize infectious material should not be used for
cleaning the aircraft. |
|
Non-patient-care areas of the aircraft should be cleaned and maintained
according to manufacturer’s recommendations. |
| Cleaning
personnel should wear non-sterile gloves, disposable gowns and face
shields while cleaning patient-care areas. |
|
Patient-care areas (including stretchers, railings, medical equipment
control panels, and adjacent flooring, walls and work surfaces likely to
be directly contaminated during care) should be cleaned using an
EPA-registered* hospital disinfectant in accordance with aircraft
manufacturer’s recommendations. |
| Spills of
body fluids during transport should be cleaned by placing absorbent
material over the spill and collecting the used cleaning material in a
biohazard bag. The area of the spill should be cleaned using an
EPA-registered hospital disinfectant. Ground service personnel should be
notified of the spill location and initial clean-up performed. |
|
Contaminated web seats or seat cushions should be placed in a biohazard
bag and labeled with the location and type of contamination for later
disposal or cleaning. |
|
Contaminated reusable patient care equipment should be placed in biohazard
bags and labeled for cleaning and disinfection at the AMT service medical
equipment section. |
| Personnel
should wear non-sterile gloves, disposable gowns and face shields while
cleaning reusable equipment. |
| Reusable
equipment should be cleaned and disinfected according to manufacturer’s
instructions. |
IX.
Logistical Planning and Post-Mission Follow-Up
| Sufficient
infection control supplies should be on board to support the expected
duration of the mission plus additional time should the aircraft
experience maintenance delays or weather diversions. |
| Flight
planning should identify emergency or unexpected diversion airfields, and
coordinate with authorities in advance. |
| Upon
mission termination, the AMT team should provide the following information
to their medical director: mission number/date; address of the
team/aircraft basing; duration of patient transport; names, contact
information, and crew positions (including estimated duration of direct
patient care provided) of mission personnel. |
| AMT
services should designate individuals responsible for performing
post-mission monitoring of mission personnel and reporting results to the
AMT service medical director. |
| Mission
personnel should be monitored (directly or by telephone) at least once
daily for 10 days for evidence of fever or respiratory illness that would
require
evaluation and follow-up. |
* There
are no disinfectant products currently registered by the U.S. Environmental
Protection Agency (EPA) specifically for the inactivation of the newly
identified viruses associated with SARS. However, related viruses with
physical and biochemical properties similar to the possible SARS agents are
known to be readily inactivated by EPA-registered chemical germicides that
provide low- or intermediate-level disinfection during general use.
X. Ground/In-Flight Emergency Procedures
AMT service providers should have a written plan addressing patient handling
during in-flight and/or ground emergency situations. Activities such as
donning life vests and litter-patient emergency egress may create special
exposure risks. Use of N-95 respirators must be weighed against time
constraints and on-board emergency conditions (e.g., smoke in the cabin,
sudden cabin decompression). Gowns and latex gloves represent a fire/flash
hazard and should not be worn during ground or in-flight emergency
situations.
Acknowledgements:
This guidance was prepared in cooperation with and with contributions from:
United
States Department of Defense
U.S.
Transportation Command (USTRANSCOM)
Headquarters Air Mobility Command (HQ AMC)
U.S. Pacific Command (USPACOM)
Headquarters Pacific Air Forces (HQ PACAF)
U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID)
United
States Department of State
Commission on Accreditation of Air Medical Transport Services (CAMTS)
Aerospace Medicine Association (AsMA)
Air Medical Physician Association (AMPA)
      
             
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