Priority Activities
- Screen incoming travelers from severe acute respiratory syndrome (SARS)-affected areas for SARS, and provide guidance about monitoring their health and reporting illness.
- Provide guidance to outbound travelers about active SARS-affected areas and measures to reduce the risk of acquiring SARS-associated coronavirus (SARS-CoV) disease during travel.
- If SARS-CoV transmission in the United States presents an increased risk of exporting SARS-CoV to other countries, then screen outbound travelers to prevent such exportation.
- Ensure the appropriate evaluation and management of SARS cases and potentially exposed passengers and crew members on conveyances.
Activities Directed to Inbound Travelers
The nature and scope of activities related to travelers entering or in the United States will differ depending on the extent of SARS-CoV transmission in the United States and in the country or countries from which the passenger has traveled (see Appendix E1 in the original guideline document). When SARS-CoV transmission is absent or limited in the United States, then efforts will focus on promptly identifying cases imported from SARS-affected areas and preventing further spread from such cases. Guidelines have been developed for various groups who might be arriving from areas affected by SARS-CoV (http://www.cdc.gov/ncidod/sars/hostingarrivals.htm;
http://www.cdc.gov/ncidod/sars/business_guidelines.htm). If active transmission of SARS-CoV is occurring in a U.S. city or area, then it will be important to prevent spread to other areas in the United States, possibly by limiting or restricting non-essential travel into or from the affected area.
Objective: Prevent spread from SARS-CoV-infected travelers entering the United States.
Basic Activities
- Inform incoming travelers about SARS, and provide guidance on monitoring their health and reporting illness to the appropriate authorities. This may be accomplished by use of:
- Evaluate travelers who report SARS-like symptoms (e.g., fever or respiratory symptoms) during travel, and collect locating information for the other passengers and crew (See "Activities Related to SARS on Conveyances," below).
- Respond to reports of ill passengers on airplanes or other conveyances arriving from areas with SARS-CoV disease.
Enhanced Activities
- If the level of transmission in another country is high, incoming passengers from that country might require enhanced screening and evaluation through:
- Visual inspection of all travelers as they disembark
- Screening of travelers for symptoms of SARS-CoV disease and recent high-risk exposures to SARS-CoV (e.g., SARS-CoV patients or high-risk settings) through a self-administered questionnaire
- Temperature screening
- Quarantine inspectors at CDC quarantine stations and public health workers in locations near other ports of entry may be required to meet all airplanes or other conveyances arriving from areas with SARS to question crew members about any ill passengers and to visually inspect passengers upon disembarkation.
- If the level of SARS-CoV transmission in a U.S. area is sufficiently high to present a substantial risk to travelers, then non-essential travel to this area may be limited, cancelled, or subjected to increased surveillance measures.
- Other activities that may be considered but whose effectiveness is unclear (especially given the resources required for implementation) include:
- Ten-day quarantine of all passengers arriving from SARS-affected areas
- Collection of locating information on all arriving passengers
Activities Directed to Outbound Travelers
Activities related to outbound travelers will vary based on the extent of SARS-CoV transmission in the United States and at the destination (see Appendix E1 in the original guideline document). If there is little SARS-CoV transmission in the United States, the goal is to inform travelers about the risk of SARS and appropriate measures to reduce the risk of acquiring SARS-CoV infection during travel (http://www.cdc.gov/ncidod/sars/travel_advice.htm). If there is extensive SARS-CoV transmission in the United States, then preventing the exportation of SARS-CoV will be an added objective.
Objective: Minimize outbound travelers' risk for exposure to SARS-CoV during travel or the risk of spreading SARS-CoV to other localities.
Basic Activities
- Issue travel notifications (see Table below).
- Provide educational materials to travelers on measures to reduce the risk of SARS-CoV disease.
Enhanced Activities
- If there are locations with extensive SARS-CoV transmission where control measures do not appear to be effective, further travel restrictions (e.g., cancellation of flights) to those locations may be considered (see "Roles and Responsibilities" in the Implementation field).
- If the level of SARS-CoV transmission in the United States presents an increased risk for exportation, then some or all of the following might be implemented:
- Pre-departure screening (e.g., temperature screening, visual screening) of outbound travelers
- Health certifications (i.e., requiring travelers to have a medical
examination before departure, with a doctor's statement that they are free of SARS-CoV symptoms and have not had close contact to a SARS-CoV patient in the past 10 days)
- Stop lists (i.e., maintaining lists of SARS cases and close contacts at ports of departure against which travelers' names can be checked to prevent them from traveling)
Table: Travel Notice Definitions
The Centers for Disease Control and Prevention (CDC) issues different types of notices for international travelers. On May 20, 2004, these definitions were refined to make the announcements more easily understood by travelers, health care providers, and the general public http://www.cdc.gov/travel/outbreaks.htm#noticekey. The definitions provided below describe both the levels of risk for the traveler and the recommended preventive measures for each level of risk.
| Notice |
Scope1 |
Risk for travelers2 |
Preventive measures3 |
| In the News |
Reports of sporadic cases |
No increased risk over baseline for travelers observing standard recommendations |
Keep travelers informed, and reinforce standard prevention recommendations |
| Outbreak Notice |
Outbreak in a limited geographic area or setting |
Increased but definable risk that is limited to specific settings |
Remind travelers about standard and enhanced recommendations for the region |
| Travel Health Precaution |
Outbreak of greater scope affecting a larger geographic area |
Increased risk in some settings, along with risk for spread to other areas |
Inform travelers about specific precautions to reduce risk during the stay and what to do before and after travel |
| Travel Health Warning |
Evidence that outbreak is expanding outside the area or populations initially affected |
Increased risk because of evidence of transmission outside defined settings and/or inadequate containment measures |
In addition to the specific precautions cited above, postpone nonessential travel |
1The term "scope" incorporates the size, magnitude, and rapidity of spread of an outbreak.
2Risk for travelers is dependent on patterns of transmission, as well as severity of illness.
3Preventive measures other than the standard advice for the region may be recommended depending on the circumstances (e.g., travelers may be requested to monitor their health for a certain period after their return, or arriving passengers may be screened at ports of entry).
Activities Related to SARS on Conveyances
A SARS patient on a conveyance presents a risk of transmission to
other passengers and crew and to non-passengers on arrival and a risk of
further spread from passengers who become infected. Many of the activities listed below are performed by CDC staff at the eight current quarantine stations and by public health workers in locations
near other ports of entry with assistance by CDC quarantine station staff from that region.
Objective: Protect co-passengers and crew members from SARS-CoV-infected passengers and from transmission associated with passengers exposed to the index case.
Activities
Management of a Potential SARS Patient on a Conveyance
- Separate the potential SARS patient as completely as possible from
other passengers and the crew. The ill passenger should wear a surgical mask.
- Ensure that persons caring for the ill passenger follow infection control measures recommended for cases of SARS (see the National Guideline Clearinghouse [NGC] summary Supplement I: Infection Control in Healthcare, Home and Community Settings and http://www.cdc.gov/ncidod/sars/airpersonnel.htm).
- If possible, designate a separate toilet for the exclusive use of the ill passenger.
- Notify the airport or land port authorities at the destination so that health authorities are informed and prepared to meet the conveyance upon arrival, to manage the ill passenger, and to evaluate other passengers.
Management on Arrival
- Separate the ill passenger from exposed, well co-passengers at the soonest moment, both in transit and after arrival.
- Place the ill passenger in an isolation facility (if available), and assess.
- Assess other passengers for illness, types of exposures to the ill passenger, and other potential SARS-CoV exposures. Emergency medical services (EMS) personnel and local emergency department staff can perform these evaluations using appropriate precautions (see the NGC summary Supplement I: Infection Control in Healthcare, Home and Community Settings and
http://www.cdc.gov/ncidod/sars/airpersonnel.htm).
- Transfer the ill passenger to a local health care facility for further evaluation, if needed. Protocols and memoranda of agreement with ambulance services and hospitals with appropriate infection control measures in place should be established in advance (see "Preparedness Planning," below.)
Management of Passengers and Crew on the Same Conveyance
- Collect locating information for all passengers and crew. This information should be obtained directly from passengers, if possible. If a potential SARS case on a conveyance is not detected until after arrival, this information can be obtained from passenger manifests, staff lists, and/or customs forms.
- Inform all passengers on board about SARS, and advise them to seek
immediate medical attention if fever or respiratory symptoms develop within 10 days of the flight. Pay particular attention to close contacts of the case.
- Consider temporary detention of the plane and arrangements for monitoring and quarantine of all passengers and crew in some circumstances (e.g., if the ill passenger had contact with a laboratory-confirmed SARS case and had significant respiratory symptoms during a prolonged flight). Home quarantine may be used for persons who live in or near the port of arrival; a designated facility should be arranged for the others (see the NGC summary Supplement D: Community Containment Measures, Including Non-hospital Isolation and Quarantine).
De-escalation of Control Measures
Objective 1: Downgrade or remove travel notifications as appropriate.
Activities
- CDC will downgrade a travel health warning to a travel health precaution when there is:
- Adequate and regularly updated reporting of surveillance data from the area
- No evidence of ongoing transmission outside defined settings for 20 days (two incubation periods) after date of onset of symptoms for the last confirmed case without an epidemiologic link, as reported by public health authorities
- CDC will remove a travel health precaution when there is:
- Adequate and regularly updated reporting of surveillance data from the area
- No evidence of new cases for 30 days (three incubation periods) after the date of onset of symptoms for the last case, as reported by public health authorities
- Limited or no recent instances of exported cases from the area. An exported case is an ill person who meets the definition for a probable or confirmed case of SARS-CoV disease and who acquired SARS-CoV infection in the area in question and then traveled outside the affected area to another region and was diagnosed there (i.e., the person was not identified as a part of contact tracing activities, and travel was not restricted). This criterion excludes intentional or planned evacuations.
Objective 2: Reduce measures used for inbound travelers as appropriate.
Activities
For All Passengers Arriving from Areas with SARS-CoV Transmission:
- Continue general education for passengers from a particular area until the travel health precaution has been lifted (30 days after the onset of symptoms for the last case in that area). Because travel patterns may make it difficult to determine passengers' points of origin, it may be more practical to continue general education until travel health precautions have been lifted for all areas.
- Continue evaluating travelers who report symptoms of SARS during travel until the travel health precaution for that area has been lifted (30 days after the onset of symptoms for the last case from that area).
For Passengers Arriving from Areas Under a Travel Health Warning:
- Continue the use of screening questionnaires until the area of origin is downgraded from a travel health warning to a travel health precaution.
- Continue meeting conveyances from SARS-affected areas and visually inspecting passengers until the area of origin is downgraded from a travel health warning to a travel health precaution.
Objective 3: Reduce other measures used for outbound travelers as appropriate.
Activities
- Continue pre-departure fever and symptom screening for passengers
departing from areas with ongoing unlinked transmission, but consider
discontinuing these activities 20 days after the onset of symptoms for the last unlinked case.
- Continue stop lists until there are no longer any cases under isolation or contacts under quarantine.
Objective 4: Reduce measures for management of passengers with SARS-CoV disease on conveyances as appropriate.
Activities
- Continue meeting any flight with an ill passenger on board who has SARS-like symptoms. If the passenger is seriously ill, evaluate
and follow-up according to established protocols.
- Continue to collect locating information as long as the passenger has symptoms compatible with SARS-CoV disease and has traveled
from an area with ongoing unlinked transmission (under a travel advisory). For areas that have been downgraded to a travel health precaution, locating information may not be needed unless the ill passenger meets the epidemiologic criteria for likely exposure to SARS-CoV (see the NGC summary Supplement B: SARS Surveillance, Appendix B1).
- The need for monitoring and quarantine of contacts of a passenger from an area on travel health precaution should be determined after the ill passenger has been fully evaluated.
Roles and Responsibilities
Refer to the original guideline document for a discussion on the roles and responsibilities related to managing international travel-related SARS transmission risk.
Preparedness Planning
Legal Authority for Restricting Movement
In advance of the possible reappearance of SARS-CoV, public health officials should:
- Work closely with their legal counterparts to ensure that the legal authority for movement restrictions at the local, state, and federal levels is known and understood and to establish boundaries of authority and processes to address multi-jurisdictional issues (see the NGC summary Supplement A: Command and Control).
- Develop plans for making decisions on movement restrictions, such as: 1) requirements for pre-departure screening, 2) requirements for arrival screening and/or quarantine, 3) travel prohibitions on cases and contacts, 4) restrictions related to use of mass transit systems, and 5) cancellation of non-essential travel.
- Work closely with local, state, and federal law enforcement to develop plans for enforcement of these restrictions.
Engagement of Key Partners
In advance of the possible reappearance of SARS-CoV, public health officials should:
- Begin preparedness planning by identifying key partners representing: 1) law enforcement (local, state, and federal), 2) legal community, 3) emergency medical services (for evaluation of ill arriving passengers and transportation to the hospital), 4) hospital personnel, 5) transportation industry personnel, and 6) other emergency management personnel. The partners should be involved in the planning process.
- Develop plans for the training, mobilization, and deployment of pertinent public health and other staff.
- Conduct training programs and drills.
- Provide respirator fit-testing and training in use of personal protective equipment (PPE) for persons at risk for exposure to possible SARS cases.
- Plan for the diversion of conveyances carrying supplies for maintenance of critical infrastructure around key transportation hubs that may be affected by SARS-CoV.
Protocols for Management of Ill Arriving Passengers
Public health officials and CDC quarantine staff, in collaboration with legal and law enforcement authorities, should develop protocols for the management of ill arriving passengers at ports of entry, including provisions for:
- Meeting flights with a reported ill passenger
- Establishing notification procedures and communications links
- Separating the ill passenger during assessment
- Assessing the ill passenger and referring for evaluation and care
- Transporting the ill passenger to a designated health care facility (see the NGC summary Supplement D: Community Containment Measures, Including Non-hospital Isolation and Quarantine)
- Collecting locating information on other passengers and crew
- Collecting the flight manifest, customs declarations, and other information for contact tracing
- Identifying any other ill passengers and separating them from well passengers
- Quarantining contacts if necessary, including transportation to a quarantine facility
- Providing enforcement for uncooperative ill passengers or contacts
See the NGC summary Supplement A: Command and Control.
Memoranda of Agreement (MOA) with Health Care Facilities, Transport Services, Emergency Medical Systems, and Physicians
- State and local public health officials should work with federal quarantine staff to develop memoranda of agreement (MOAs) with hospitals near ports of entry; these facilities must be equipped to isolate, evaluate, and manage possible SARS patients (see the NGC summary Supplement C: Preparedness and Response in Healthcare Facilities).
- Agreements should include arrangements with a designated emergency medical service for on-site assessment of ill passengers and transportation to a hospital for evaluation.
See the NGC summary Supplement A: Command and Control.
Designation of Quarantine Facility
State and local public health officials should identify a facility for travelers who are designated as contacts and who require quarantine but cannot be quarantined at home.
Roles and Responsibilities
Roles and responsibilities should be outlined for the various partners and the various levels of jurisdiction (local, state, and federal) for each component of the response.
For additional information and material on prevention of SARS travel-related risks, see http://www.cdc.gov/ncidod/sars/travel.htm.
