SARS - Serious and Airborne No Matter What the Public is Told.

CDC Website ^ | March 26, 2003 | CDC

[Nov3]

	SARS
		FAQ
		Guidance for Clinicians
		Guidance for Health Departments
		Travel Advisory
		Case Definition
		Airline, Airport, & Air Travel Workers
		Specimen Collection & Shipping
		Infection Control
		Respiratory Protection
		Quarantine
		News
		World Health Organization

Public Inquiries
English (888) 246-2675
Español (888) 246-2857
TTY (866) 874-2646
Mon-Fri 8am-11pm EST
Sat-Sun 10am-8pm EST

Centers for Disease Control and Prevention
1600 Clifton Rd.
Atlanta, GA 30333
USA
(404) 639-3311

SARS Home > Airline, Airport, & Air Travel Personnel >

Interim Guidance: Air Medical Transport for Severe Acute Respiratory Syndrome (SARS) Patients
March 26, 2003, 6:30 PM EST

Download PDF version formatted for print (131 KB/4 pages)

Introduction

The current outbreak of Severe Acute Respiratory Syndrome (SARS) has included reports of cases in southeast Asia, North America and Europe, and required urgent air evacuation of patients with severe illness. 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 transport of two patients during this outbreak.

Currently recommended infection control measures for hospital 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 possible, a single 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 may 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

• 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 recommended for transport of SARS patients. The flight deck/cockpit crew in aircraft with forward-to-aft cabin airflow and separate patient-care compartment are not required to wear respirators unless they enter the patient-care compartment.
• Aft-to-forward cabin airflow may create a significant risk of airborne transmission to both cabin and flight deck personnel. If an aircraft with aft-to-forward airflow must be used, all personnel on board must wear fit-tested N-95 respirators throughout the flight.
• Aircraft that re-circulate cabin and flight deck air without HEPA filtration should not be selected for SARS patient transport.
• Aircraft ventilation should remain on at all times during transport of SARS patients, including during ground delays.
• Aircraft that provide separate upwind cabin space for crew members to perform necessary personal activities (eating, drinking, handling contact lenses, etc.) should be selected for flights likely to exceed 4 hours.

III. Patient Placement

The in-flight environment may preclude the creation of a true negative pressure room; 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.
• If the AMT aircraft uses vertical litter tiers, 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 and filtration 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 are 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 after removal of gloves.
• Disposable fluid-resistant gowns should be worn for all patient care activity.
• Gowns are 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.
• Fit-tested N-95 respirators are approved for in-flight use and should be worn by personnel in the patient-care cabin at all times.
• Fit-tested N-95 respirators should be worn by cockpit/flight-deck crew if an aircraft cannot provide forward-to-aft airflow.
• 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.
• Respirators may not be removed to eat or drink. Personal activities that require removal of respirators should not be performed in the patient-care cabin.
• The patient may 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.
• Cardiopulmonary resuscitation (CPR) should only be performed using a resuscitation bag-valve mask equipped with HEPA filtration of expired air.

V. Mechanically Ventilated Patients

• Mechanical ventilators for SARS patients must provide HEPA 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 zip-lock 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 filtration. Portable suction devices should be fitted with in-line HEPA 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, all exits and doors should be opened and the interior of the aircraft should be aired out with the aircraft air conditioning running at maximum capacity for a specified time based on aircraft-specific engineering features. Personnel boarding the aircraft must wear N-95 respirators until this "airing out" is complete.
• 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) twice daily for 10 days for evidence of fever or respiratory illness.

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 response situations.

Acknowledgements

This guidance was prepared in cooperation with and with contributions from:

United States Department of Defense

US Transportation Command (USTRANSCOM)
Headquarters Air Mobility Command (HQ AMC)
US Pacific Command (USPACOM)
Headquarters Pacific Air Forces (HQ PACAF)
US 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)

Top of Page		CDC Home | Search CDC | Health Topics A-Z Page last modified March 26, 2003, 6:30 PM EST Privacy Policy | Accessibility

[Quix]

Given, as I understand it (from a forgotten expert or article in terms of ref),

that:

"the atmosphere/air is so thoroughly mixed, it is believed that every person that is alive, has breathed some part of the breath of every other person who has ever lived and is alive."

this disease could be a very serious problem--and an exceedingly stupid Chinese move--unless they've developed an antidote/vaccine etc. to protect themselves with.

[Nov3]

The 4% rate is based on there being lots of available hospital beds and ventilators.

Hopefully it won't get bad enough to overwhelm the the hospitals. Oh I think the 4% death rate depends on China accurately reporting the outcomes of their cases. I think that is highly doubtful.

[Cold Heat]

Exactly! The facilities would become totally overloaded. Anti virals would deplete. It could be bad, especially for the elderly and very young.

[Nov3]

It could be bad, especially for the elderly and very young.

It is killing healthy 30 year old men in hospital enviroments.

[meyer]

It is killing healthy 30 year old men in hospital enviroments.

What really bothers me about this is that I've got a nasty chest cold right now. Got a little fever, a deep cough, and lots of bad stuff coming up when I cough. No different from the annual cold that I always seem to get, but its bothering me a little more since this SARS outbreak.

If I don't post tomorrow, you'll know what happened. And no, none of you are in my will. :^)

[Cold Heat]

Yes, I know.

The death rate from this must be wrong due to lack of data from China.

[Nov3]

LOL

[Cold Heat]

Everyone seems to have what you describe. I do as well. The little SOB's are gone, but my allergies have taken over.

[Geezerette]

There are some natural anti-virals. One of the best is Oil of Oregano. It's potent, and for best results, taken sub-lingually (under the tongue). The first few seconds, you will think the top of your head is going to blow off, but after a minute or two, you have a really clean feeling in your mouth. Symptoms dissipate, has been my experience.

An Israeli virologist has a compound made up of elderberries, which has been proved to be another anti-viral, called Sambucol. I have seen FReepers' comments about Sambucol, that it is terrific in stomping out a cold or flu. I got two bottles on sale lately, and intend to use them if something like this breaks out.

Other than that, I will pray.

g

[jriemer]

This section:

Airframe Selection and Cabin Airflow

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 (business to coach class) and a separate cockpit cabin are recommended for transport of SARS patients. The flight deck/cockpit crew in aircraft with forward-to-aft cabin airflow and separate patient-care compartment are not required to wear respirators unless they enter the patient-care compartment.

Aft-to-forward cabin airflow (coach to business class) may create a significant risk of airborne transmission to both cabin and flight deck personnel. If an aircraft with aft-to-forward airflow must be used, all personnel on board must wear fit-tested N-95 respirators throughout the flight.

This will seriously degrade transoceanic flight traffic but not address the root cause of the problem. Any passenger on an international flight with airborne disease is a risk well to themselve and others before the considering whether or not the aircraft has the "best" air handling equipment to minimize contamination.

This akin to discussing if a car owner should get their breaks adjusted when one of the passengers has a heart attack. The problem is not the airplane.

The airlines are flying airplanes not airborn hospitals. They never have and in this economic climate they will go out of business long before they ever will.

[Jim Noble]

What is your evidence that the airborne nature of SARS has ever been debated by anyone?

[meyer]

Everyone seems to have what you describe. I do as well. The little SOB's are gone, but my allergies have taken over.

Yeah, I hate the flu! I'm not really feeling too bad, though a little weak. Hopefully, improvement will start soon. I think I'm at the low point.

Anyway, Just took my asperin and I'm drinking iced tea and lemonade by the gallon. Doubled up the OJ as well. I am also goosing up my vitamin C intake, but only the 250 mg - I'm not a fan of megadoses. Its my non-professional opinion that the folks that benefit the most from megadoses are usually those that sell them (sorry, little extra rant there).

heck, I must be feeling a little better if I can rant again!

[PoisedWoman]

Many thanks for posting this. I'm facing corneal transplant May 7, a day surgery, and will send copy of this article to my ophthalmologist, as eye precautions are mentioned several times. Perhaps I'll postpone elective surgery until SARS goes away...

[phroebe]

I am one of the lucky one who survived scarlet fever.

Same here; I don't recall it being particularly awful, but then, my whole family took being frequently sick for granted in those years, and I didn't yet know any better when I was a kid.

Now for my standard soapbox rant (directed toward anybody who cares):

People, keep your immune systems strong! If you get colds or flu often (as in annually or more) and describe yourself as "healthy", that should be a BIG clue that you could be a lot healthier!

For starters, eat well! That means cut out whatever junk food you're addicted to, and for God's sake, stay out of all those places that serve fast food! Not only is "fast food" an oxymoron (it may fill you up, but it's crap nutritionally), but those morons they have working in back don't even care if they forget to wash after using the toilet or accidentally sneeze on your so-called "happy meal". Prepare as much of your food as you can yourself, from scratch when possible, using fresh ingredients. Include lots of fresh vegetables and fruits. Drink at least 4x as much water as your next favorite beverage.

If you're reasonably healthy to begin with, it is really not that difficult to become one of the few who don't get colds or flus 90+% of the times they're directly exposed, or have them last less than 2 days in the rare instances that they do get them. The major reason we remain "the few", IMHO, is that "the most" will not do the very simple things that it takes.

I used to have bad hayfever too, for 3 months out of every year, but now I can walk into a cloud of pollen and am not affected by it at all.

[Eric Cassano]

CDC: Mystery illness spreads more easily than first thought

Yeah, no kidding.

CDC = Centers for Disease Control Coddling

[Euro-American Scum]

The virus itself is untreatable. Completely.

Captain Trips.

[Nov3]

Do a search on the site. The airborne nature and general contagiousness were debated heavily in February and early March. It was said that significant personal contact was necessary.

That certainly is not the case.

[Nov3]

I'm facing corneal transplant May 7, a day surgery, and will send copy of this article to my ophthalmologist, as eye precautions are mentioned several times. Perhaps I'll postpone elective surgery until SARS goes away...

Why are you getting the Cornea transplant? I had to have a cornea transplant as the result of a failed Lasik surgery in August 2001. I had just gotten home September 11.

[Cold Heat]

I have been following that advice. Actually, this cold that I got came from my son and was the first one I have had in a few years.

I cannot explain the hay-fever however. I have always had sinus problems, but as I age it seems to get worse. The pine tree pollen is ongoing now. It is so bad that everything turns yellow.

Everything!

[meyer]

Same here; I don't recall it being particularly awful, but then, my whole family took being frequently sick for granted in those years, and I didn't yet know any better when I was a kid.

Now for my standard soapbox rant (directed toward anybody who cares):

I care!

People, keep your immune systems strong! If you get colds or flu often (as in annually or more) and describe yourself as "healthy", that should be a BIG clue that you could be a lot healthier!

I can tell you with a good deal of certainty that my propensity to catching a cold or the flu rises in direct proportion to the increasingly rare instances when I go out "clubbing". I don't get out much, but I was out last weekend with my freshly divorced friend. Tipped a few cold ones, got a headache. One week later, a nasty cold. Score: Beer - 1, Meyer - 0.

For starters, eat well! That means cut out whatever junk food you're addicted to, and for God's sake, stay out of all those places that serve fast food! Not only is "fast food" an oxymoron (it may fill you up, but it's crap nutritionally), but those morons they have working in back don't even care if they forget to wash after using the toilet or accidentally sneeze on your so-called "happy meal". Prepare as much of your food as you can yourself, from scratch when possible, using fresh ingredients. Include lots of fresh vegetables and fruits. Drink at least 4x as much water as your next favorite beverage.

I second the notion of using fresh foods as much as possible and minimizing the use of fast foods. Whole grains instead of refined flours (which are exceedingly hard to find). Plenty of fruits and veggies. Keep a glass of water handy all the time. Good advice in general.

If you're reasonably healthy to begin with, it is really not that difficult to become one of the few who don't get colds or flus 90+% of the times they're directly exposed, or have them last less than 2 days in the rare instances that they do get them. The major reason we remain "the few", IMHO, is that "the most" will not do the very simple things that it takes.

I don't know what the average is, but I tend to get a cold/flu kind of thing about once every year. Considering that we share phones and computers at work and people come to work sick all of the time, I don't think that's too bad. Still don't like it though. Disrupts everything.

I used to have bad hayfever too, for 3 months out of every year, but now I can walk into a cloud of pollen and am not affected by it at all.

My hay fever has subsided over the years, but I do still carry a very strong allergy to cats - it gives me asthma at times along with the runny nose/watery eyes. I have to limit my time spent with cats and I have to wash my hands every time I touch one.