A. Preparedness
Planning
SARS preparedness planning for healthcare facilities is addressed
in Supplement C. One component with particular relevance to
this Supplement is the education and training of healthcare workers
on infection control measures. Observations of healthcare
workers caring for SARS patients during the 2003 epidemic identified
numerous breaches in infection control, especially in the use of personal
protective equipment (PPE). These can be corrected through complete
and comprehensive training, provision of properly selected PPE, and
monitoring of PPE use. Most important, all healthcare settings need
to re-emphasize the importance of basic infection control measures,
including hand hygiene, for the control of SARS-CoV and other respiratory
pathogens.
Objective: Reinforce basic infection control practices
in healthcare facilities and among healthcare personnel.
Activities
- Educate
staff about the importance of strict adherence to and proper use
of standard infection control measures, especially hand hygiene (i.e.,
hand washing or use of an alcohol-based hand rub). For complete
recommendations on hand hygiene, refer to: Hand Hygiene in Healthcare Settings.
- Reinforce
education on the recommended procedures for Standard, Contact, and
Airborne Infection Isolation (AII) Precautions (see Guideline for Isolation Precautions in Hospitals).
- Ensure
that personnel have access to appropriate PPE, instructions and training
in PPE use, and respirator fit-testing.
B. Early Recognition and Prevention of Transmission in Outpatient Settings
Objective: Ensure
early recognition and prevention of transmission of SARS-CoV
and other respiratory viruses at the initial encounter with a healthcare
setting.
The 2003 outbreaks identified weaknesses in the way infection control
precautions are implemented at the time symptomatic patients first visit
a healthcare facility for evaluation. To address this deficiency, CDC
is incorporating measures to prevent the transmission of all respiratory
infections, beginning at the first point of contact with a potentially
infected person, as one component of Standard Precautions in healthcare
settings (see Appendix I1 and Guideline for Isolation Precautions in Hospitals).
These simple preventive measures apply in the absence and presence of
SARS-CoV transmission in the world. Once SARS-CoV transmission is detected,
efforts to enhance the early detection of patients with SARS-CoV disease
(described in Section III.C below) should be added to these new Standard
Precautions measures.
Activities
Visual alerts
- Post
visual alerts (in appropriate languages) at the entrance to outpatient
facilities (e.g., emergency departments, physicians' offices, outpatient
clinics) instructing patient and the persons who accompany them
to: 1) inform healthcare personnel of symptoms of a respiratory infection
when they first register for care, and 2) practice respiratory
hygiene/cough etiquette. Sample visual alerts will be posted
on CDC's SARS website: CDC's
SARS website.
Respiratory hygiene/cough etiquette
To contain respiratory secretions, all persons with signs and symptoms
of a respiratory infection, regardless of presumed cause, should be instructed
to:
- Cover
the nose/mouth when coughing or sneezing.
- Use
tissues to contain respiratory secretions.
- Dispose
of tissues in the nearest waste receptacle after use.
- Perform
hand hygiene after contact with respiratory secretions and contaminated
objects/materials.
Healthcare facilities should ensure the availability of materials for
adhering to respiratory hygiene/cough etiquette in waiting areas for
patients and visitors:
- Provide
tissues and no-touch receptacles (i.e., waste container with pedal-operated
lid or uncovered waste container) for used tissue disposal.
- Provide
conveniently located dispensers of alcohol-based hand rub.
- Provide
soap and disposable towels for hand washing where sinks are available.
Masking and separation of persons with symptoms of respiratory infection
- During
periods of increased respiratory infection in the community, offer
masks to persons who are coughing. Either procedure masks (i.e.,
with ear loops) or surgical masks (i.e., with ties) may be used to
contain respiratory secretions; respirators are not necessary. Encourage
coughing persons to sit at least 3 feet away from others in common
waiting areas. Some facilities may wish to institute this recommendation
year-round.
Droplet Precautions
- Healthcare
workers should practice Droplet Precautions (i.e., wear a surgical
or procedure mask for close contact), in addition to Standard Precautions,
when examining a patient with symptoms of a respiratory infection.
Droplet Precautions should be maintained until it is determined
that they are no longer needed (see Guideline
for Isolation Precautions in Hospitals).
C. Early Detection and Isolation of Patients Potentially at Risk for
SARS-CoV Disease
Early detection and isolation of patients who may be infected with SARS-CoV
are the most important interventions to prevent the introduction of SARS-CoV
into a healthcare setting. However, because measures to control SARS-CoV
can impose a considerable burden, especially if multiple patients with
respiratory illnesses are being seen in an outpatient setting or admitted
to a hospital for treatment of pneumonia, the intensity of early detection
and control measures should be based on the level of SARS-CoV transmission
in the world. See CDC's SARS website (CDC's SARS website)
for current information on SARS-CoV transmission worldwide.
Objective 1 : In the absence of SARS-CoV
transmission in the world, implement screening to
detect the re-emergence of SARS-CoV, and ensure appropriate triage
and management of patients with possible SARS-CoV disease.
In the absence of person-to-person SARS-CoV transmission, the likelihood
that a patient being evaluated for fever or lower respiratory illness,
with or without pneumonia, has SARS-CoV disease will be exceedingly low
unless there are both typical clinical findings and some accompanying
epidemiologic evidence that raises the suspicion of exposure to SARS-CoV.
Therefore, patients with respiratory infections should not be considered
as possible cases of SARS-CoV disease unless they have severe pneumonia
(or acute respiratory distress syndrome) of unknown etiology that requires
hospitalization and an epidemiologic history that raises the
suspicion of SARS-CoV exposure.
Activities
Screening and triage
- Only
patients requiring hospitalization for radiographically confirmed
pneumonia (or acute respiratory distress syndrome) of unknown etiology
should be screened for SARS epidemiologic risk factors. The suspicion
for SARS-CoV disease is raised if, within 10 days of symptom onset,
the patient:
- Has
a history of travel to mainland China, Hong Kong, or Taiwan1,
or close contact2 with
an ill person with a history of recent travel to one of these areas, OR
- Is
employed in an occupation associated with a risk for SARS-CoV exposure
(e.g., healthcare worker with direct patient contact; worker in a laboratory
that contains live SARS-CoV), or
- Is
part of a cluster of cases of atypical pneumonia without an alternative
diagnosis
Evaluate persons with such a clinical and exposure history according
to Figure 1 in Clinical Guidance on the Identification and Evaluation
of Possible SARS-CoV Disease among Persons Presenting with Community-Acquired
Illness.
Outpatient infection control
- Follow
the infection control recommendations for respiratory hygiene/cough
etiquette and Droplet Precautions outlined in Section III.B above.
Disposition
- No
special infection control measures are recommended following discharge
from an outpatient setting.
Hospitalization
Objective 2: In the presence of person-to-person transmission
of SARS-CoV in the world, ensure the prompt identification
and appropriate management of patients with possible and known SARS-CoV
disease.
Activities
Screening and triage
Once person-to-person SARS-CoV transmission has been documented anywhere
in the world, the probability that a patient presenting with early clinical
symptoms of SARS actually has SARS-CoV disease increases if the patient
has an epidemiologic link to a geographic location in which SARS-CoV
transmission has been documented.
- Screen
all patients with fever or lower respiratory symptoms, with or
without pneumonia, to determine if, within 10 days of the onset of
symptoms, they had:
- Close
contact with a person suspected of having SARS-CoV disease, or
- A
history of foreign travel (or close contact with an ill person with
a history of travel) to a location with documented or suspected SARS-CoV
transmission, or
- Exposure
to a domestic or occupational location with documented or suspected
SARS-CoV (including a laboratory that contains live SARS-CoV), or close
contact with an ill person with such an exposure history
- For
persons with a high risk of exposure to SARS-CoV (e.g., persons previously
identified through contact tracing or self-identified as close contacts
of a laboratory-confirmed case of SARS-CoV disease; persons who are
epidemiologically linked to a laboratory-confirmed case of SARS-CoV
disease), the clinical criteria should be expanded to include, in
addition to fever or respiratory symptoms, the presence of any other
early symptoms of SARS-CoV disease (subjective fever, chills, rigors,
myalgia, headache, diarrhea, sore throat, rhinorrhea). The more common
early symptoms include chills, rigors, myalgia, and headache. In
some patients, myalgia and headache may precede the onset of fever
by 12-24 hours. However, diarrhea, sore throat, and rhinorrhea may
also be early symptoms of SARS-CoV disease.
Evaluate persons with an exposure history suggesting possible SARS-CoV
disease according to Figure 2 in Clinical Guidance on the Identification
and Evaluation of Possible SARS-CoV Disease among Persons Presenting
with Community-Acquired Illness.
- Patients
who require hospitalization for pneumonia and who do not have a
known epidemiologic link to a setting in which SARS-CoV has been
documented should be screened for additional risk factors using the
questions that apply when no SARS-CoV is documented in the world
(i.e., employment in an occupation at particular risk for SARS-CoV
exposure; part of a cluster of atypical pneumonias without an alternative
diagnosis).
- Healthcare
workers who are the first points of contact (e.g., triage and reception)
should be trained to perform SARS-CoV screening. If screening personnel
are not available, healthcare providers should screen symptomatic
patients for SARS-CoV disease risk factors before initiating history-taking
and physical examination. If SARS symptoms and risk factors are present,
follow the clinical
algorithm for patient management.
Outpatient infection control
- Patients
with fever or lower respiratory symptoms, with or without pneumonia,
who have been exposed to SARS-CoV or who have SARS risk factors
should be suspected of having SARS-CoV disease and isolated as soon
as possible. Such patients should be given a mask (surgical or procedure)
to wear and immediately placed in a private examination room or cubicle.
If available, an AII room (AIIR) should be used.
- Where
limited space and examination room capacity preclude these measures,
the patient should sit as far away as possible from other patients
in the waiting area.
- Family
members or friends who accompany the patient should be considered
at risk for SARS-CoV disease and screened for fever and lower respiratory
symptoms. If either is present, infection control measures to prevent
SARS-CoV transmission should be applied.
- Healthcare
workers should wear gown, gloves, respiratory protection, and eye
protection (if needed) as described in Section III.D.5 below.
Disposition
- Hospital
admission or discharge of a possible SARS patient should generally
be based on the patient's clinical condition and healthcare needs.
If diagnostic, therapeutic, or supportive regimens do not necessitate
hospitalization, patients with possible SARS-CoV disease should not
be hospitalized.
- Exceptions
include persons for whom no other alternative for providing safe
infection control is available. Such persons include travelers, homeless
persons, and persons who would be returned to an environment where
infection control measures are not feasible or practical (e.g., crowded
dormitories, prisons and jails, detention centers, homeless shelters,
other multi-person single-room dwellings). These persons should be
hospitalized and isolated as recommended in Section D below. As soon
as appropriate arrangements can be made for out-of-hospital care,
the patient can be discharged. Alternatively, the patient may be
admitted to a designated residential facility for isolation of convalescing
SARS-CoV disease cases, if one exists.
- During
transport between locations, patients should wear a mask. Public
transportation (e.g., bus, train) should be avoided. Recommendations
for emergency medical transport are provided in Section IV below.
Hospitalization
- Follow
recommended precautions for hospitalization of a patient with known
or possible SARS-CoV disease as described in Section D below.
D. Infection Control Precautions for Hospitalized SARS Patients
The following
recommendations apply to patients who have laboratory evidence
of SARS-CoV disease or for whom the attending clinicians and health department
strongly suspect SARS-CoV disease. The level of precautions described will
rarely be needed in the absence of SARS-CoV transmission in the world
but will be
used increasingly once SARS-CoV transmission is detected.
Contact
and AII Precautions, in addition to Standard Precautions, should
be applied when caring for patients with known or possible SARS-CoV
disease. (Droplet Precautions also are required but are subsumed
within AII Precautions.) These precautions should be maintained for
the duration of potential infectivity (see Clinical
Guidance on the Identification and Evaluation of Possible SARS-CoV
Disease among Persons Presenting with Community-Acquired Illness
Version 2)
or until a diagnosis of SARS-CoV disease has been ruled out. See Appendix
I2.
The
objective of all of the following activities is to prevent the transmission
and acquisition of SARS-CoV in the hospital.
1. Patient placement
- Admit
patients with SARS-CoV disease to an AIIR. An AIIR is a single-patient
room in which environmental conditions are controlled to minimize
the possibility of airborne transmission of infectious agents. These
rooms have specific requirements for controlled ventilation, including:
1) a specified number of required air exchanges per hour (ACH) (i.e.,
6 for old buildings; 12 for new construction or renovation), 2)
monitored negative pressure relative to hallways, and 3) air exhausted
directly to the outside preferably or passed through a high-efficiency
purifying air (HEPA) filter if recirculated. These requirements are
detailed in the Guideline
for Environmental Infection Control in Healthcare Facilities, 2003.
- If
there is a lack of AIIRs and/or a need to concentrate infection control
efforts and resources, patients may be cohorted on a floor or nursing
unit designated for the care of SARS patients only, rather than placed
in AIIRs throughout the hospital. This strategy physically isolates
SARS patients and also makes it possible to dedicate resources and
appropriately trained staff to their care. Experience in some settings
in Taiwan and Toronto demonstrated that cohorting SARS patients, without
use of AIIRs, effectively interrupted transmission. Thus, although
single AIIRs are recommended for SARS isolation, other strategies may
provide effective overall infection control, particularly if air-handling
systems in existing rooms/units/floors can be modified to allow these
areas to operate under negative pressure relative to surrounding areas.
- Even
if a facility has chosen to cohort SARS patients, properly designed
and operated AIIRs are preferred for 1) patients who are known to have
transmitted SARS-CoV to other persons and 2) patients in whom the risk
of SARS is being assessed.
- Designate "clean" and "dirty" areas
for isolation materials. Maintain a stock of clean patient care and
PPE supplies outside the patient's room. Decide where contaminated
linen and waste will be placed. Locate receptacles close to the point
of use and separate from the clean supplies. Also designate the location
where reusable PPE (e.g., goggles, face shields) will be placed for
cleaning and disinfection before reuse.
- Limit
the amount of patient-care equipment brought into the room to that
which is medically necessary. Provide each patient with patient-dedicated
equipment (e.g., thermometer, blood pressure cuff, stethoscope).
- Limit
staff to the number sufficient to meet patient-care needs. Using staff
who have been specially trained to care for patients with SARS may
reduce opportunities for exposure, increase adherence to recommended
infection control practices, and promote continuity of care.
2. Patient
transport
- Limit
patient movement and transport outside the AIIR to medically necessary
purposes. Whenever possible, use portable equipment to perform
x-rays and other procedures in the patient's room.
- If
transport or movement is necessary, ensure that the patient wears a
surgical mask, puts on a clean patient gown, and performs hand hygiene
before leaving the room. If a mask cannot be tolerated (e.g., due to
the patient's age or deteriorating respiratory status), apply the most
practical measures to contain respiratory secretions.
- Limit
contact between SARS patients and others by using less traveled hallways
and elevators when possible.
3. Visitors
- Limit
visits to patients with known or possible SARS-CoV disease to persons
who are necessary for the patient's emotional well-being and care.
- Visitors
who have been in contact with the patient before and during hospitalization
are a possible source of SARS-CoV. Therefore, schedule and control
visits to allow for appropriate screening for SARS-CoV disease before
entering the hospital and appropriate instruction on use of PPE and
other precautions (e.g., hand hygiene, limiting surfaces touched) while
in the patient's room.
4. Hand hygiene
Hand hygiene
(i.e., hand washing or use of an alcohol-based hand rub) should be
performed after contact with a patient on precautions for SARS-CoV
disease or their environment of care. Current guidelines for hand hygiene
are provided at: Hand Hygiene
in Healthcare Settings.
5. Personal
protective equipment (PPE)
Gloves, gown, respiratory protection, and eye protection (as needed)
should be donned before entering a SARS patient's room or designated
SARS patient-care area. This level of protection is required for the
majority of patient contacts. Additional guidance for performing an aerosol-generating
procedure on patients with SARS Co-V disease is provided in Section III.D.11
below. Instructions on how to safely don, use, and remove PPE are being
developed and will be provided at CDC's SARS website when
available. Removal of PPE in a manner that prevents contamination of
clothing and skin is a priority.
- Gown and gloves - Wear
a standard isolation gown and pair of nonsterile patient-care gloves
for all patient contacts. The gown should fully cover the front torso
and arms and should tie in the back. Gloves should cover the cuffs
of the gown.
- Respiratory
protection - Wear
a NIOSH-certified N-95 filtering facepiece respirator for entering
an AIIR or designated SARS patient-care area.3 If
N-95 or higher level of respiratory protection is not available,
then wear a snug-fitting surgical mask to prevent nose and mouth
contact with large respiratory droplets. Discard respirators upon
leaving the patient room or area.
- Eye
and face protection -- It is not yet known whether routine eye protection
is needed to prevent SARS-CoV transmission. Routinely wear eye protection
when within 3 feet of a patient with SARS-CoV. If splash or spray of
respiratory secretions or other body fluids is likely, protect the
eyes with goggles or a face shield, as recommended for Standard Precautions.
The face shield should fully cover the front and wrap around the side
of the face. Corrective eyeglasses or contact lenses alone are not
considered eye protection.
- Use
safe work practices when wearing PPE:
- Avoid
touching the face with contaminated gloves
- Avoid
unnecessary touching of surfaces and objects with contaminated gloves
6. Medical waste
Medical waste has not been implicated in the transmission of SARS-CoV.
Therefore, no special handling procedures are recommended for SARS-CoV-contaminated
medical waste.
- Contain
and dispose of SARS-CoV-contaminated medical waste in accordance
with facility-specific procedures and/or local or state regulations
for handling and disposal of medical waste, including used needles
and other sharps.
- Discard
as routine waste used patient-care supplies that are not likely to
be contaminated (e.g., paper wrappers).
- Wear
disposable gloves when handling waste. Perform hand hygiene after removal
of gloves.
7. Textiles (linen and laundry)
Contact with textiles has not been implicated in the transmission of
SARS-CoV. Therefore, no special handling procedures are recommended for
linen and laundry that may be contaminated with SARS-CoV.
- Store
clean linen outside patient rooms, taking into the room only linen
needed for use during the shift.
- Place
soiled linen directly into a laundry bag in the patient's room. Contain
linen in a manner that prevents the linen bag from opening or bursting
during transport and while in the soiled linen holding area
- Wear
gloves and gown when directly handling soiled linen and laundry (e.g.,
bedding, towels, personal clothing) as per Standard and Contact Precautions.
Do not shake or otherwise handle soiled linen and laundry in a manner
that might aerosolize infectious particles.
- Wear
gloves for transporting bagged linen and laundry.
- Perform
hand hygiene after removing gloves that have been in contact with
soiled linen and laundry.
- Wash
and dry linen according to routine
standards and procedures.
8. Dishes and eating utensils
Dishes and eating utensils have not been implicated in SARS-CoV transmission.
Therefore, no special precautions, beyond those for Standard Precautions,
are recommended for dishes and eating utensils used by a patient with
known or possible SARS-CoV disease.
- Wash
reusable dishes and utensils in a dishwasher with recommended
water temperature.
- Wear
gloves when handling patient trays, dishes, and utensils.
9. Patient-care equipment
- Follow
standard practices for handling and reprocessing used patient-care
equipment, including medical devices. Wear gloves when handling
and transporting used patient-care equipment. Wipe heavily soiled
equipment with an EPA-approved hospital disinfectant before removing
it from the patient's room. Follow current recommendations for
cleaning and disinfection or sterilization of reusable patient-care
equipment.
- Wipe
external surfaces of portable equipment for performing x-rays and other
procedures in the patient's room with an EPA-approved hospital disinfectant
upon removal from the patient's room.
10. Environmental cleaning and disinfection
Cleaning and disinfection of environmental surfaces are important components
of routine infection control in healthcare facilities. Although little
is known about the extent of environmental contamination in SARS patients'
rooms, epidemiologic and laboratory evidence suggests that the environment
could play a role in transmission. Therefore, cleaning and disinfection
are critical to the control of SARS-CoV transmission. Environmental cleaning
and disinfection for SARS-CoV follows the same principles generally used
in healthcare settings.
Cleaning and disinfection of occupied patient rooms
- Consider
designating specific, well-trained environmental services personnel
for cleaning and disinfecting of SARS patient rooms/units. Fully
define the scope of cleaning that will be done each day; identify
who will be responsible for cleaning and disinfecting the surfaces
of patient-care equipment (e.g., IV pumps, ventilators). Consider
using a checklist to promote accountability for cleaning responsibilities.
- Environmental
services personnel should wear PPE as described in Section III.D.5
above. These staff should be trained in proper procedures for PPE
use, including removal of PPE, and the importance of hand hygiene.
- Keep
cleaning supplies outside the patient room (e.g., in an anteroom or
storage area).
- Keep
areas around the patient free of unnecessary supplies and equipment
to facilitate daily cleaning.
- Use
any EPA-registered hospital detergent-disinfectant. Follow manufacturer's
recommendations for use-dilution (i.e., concentration), contact time,
and care in handling.
- Clean
and disinfect SARS patients' rooms at least daily and more often when
visible soiling/contamination occurs. Give special attention to frequently
touched surfaces (e.g., bedrails, bedside and over-bed tables, TV control,
call button, telephone, lavatory surfaces including safety/pull-up
bars, doorknobs, commodes, ventilator surfaces) in addition to floors
and other horizontal surfaces.
- Because
so little is known about environmental transmission of SARS-CoV,
placement of patients in rooms that do not have carpeting is preferred
because non-carpeted floors are easier to clean and disinfect. If
use of carpeted rooms cannot be avoided, vacuuming should be done
daily, and personnel should wear the recommended PPE. Follow current
CDC environmental guidelines for vacuuming and shampooing carpeted
floors in patient rooms.
- After
an aerosol-generating procedure (e.g., intubation), clean and disinfect
horizontal surfaces around the patient. Clean and disinfect as soon
as possible after the procedure.
- Clean
and disinfect spills of blood and body fluids in accordance with
current recommendations for Standard
Precautions.
Cleaning and disinfection after patient discharge or transfer
Follow standard facility procedures for terminal cleaning of an isolation
room.
- Clean
and disinfect all surfaces that were in contact with the patient
or may have become contaminated during patient care.
- Wipe
down mattresses and headboards with an EPA-approved hospital disinfectant.
- Privacy
curtains should be removed, placed in a bag in the room and then
transported to be laundered.
- No
special treatment is necessary for window curtains, ceilings, and
walls unless there is evidence of visible soil.
- Do
not spray (i.e., fog) occupied or unoccupied rooms with disinfectant.
This is a potentially dangerous practice that has no proven disease
control benefit.
11. Aerosol-generating
procedures
Because aerosol-generating procedures may pose a greater risk of SARS-CoV
transmission, additional precautions are recommended for healthcare workers
who perform or assist with these procedures. Procedures that stimulate
coughing and promote the generation of aerosols include aerosolized or
nebulized medication administration, diagnostic sputum induction, bronchoscopy,
airway suctioning, endotracheal intubation, positive pressure ventilation
via face mask (e.g., BiPAP, CPAP), and high-frequency oscillatory ventilation.
Healthcare
facilities should review their strategies to protect healthcare workers
during these procedures, including the use of PPE and safe work practices.
Healthcare workers who perform these procedures should be alerted to
the fact that there may be an increased risk for SARS-CoV transmission
when these procedures are performed.
Infection control measures
- Limit
performance of aerosol-generating procedures on SARS patients to
those that are considered medically necessary. Clinically appropriate
sedation during intubation and bronchoscopy may minimize resistance
and coughing during the procedure.
- Limit
the number of healthcare workers in the room during an aerosol-generating
procedure to those essential for patient care and support.
- Perform
aerosol-generating procedures in an AIIR. If an AIIR is not available,
perform the procedure in a private room, away from other patients.
If possible, increase air exchanges, create a negative pressure relative
to the hallway, and avoid recirculation of the room air. If recirculation
of air from such rooms is unavoidable, pass the air through a HEPA
filter before recirculation, as recommended for Mycobacterium
tuberculosis.
- Air-cleaning
devices, such as portable HEPA filtration units, may be used to further
reduce the concentration of contaminants in the air. Keep doors closed
except when entering or leaving the room, and minimize entry and exit
during the procedure.
- Submicron
filters on exhalation valves of mechanical ventilators may prevent
contaminated aerosols from entering the environment. Although the effectiveness
of this measure in reducing the risk of SARS-CoV transmission is unknown,
the use of such filters is prudent during high-frequency oscillatory
ventilation of patients with SARS-CoV disease.
PPE for aerosol-generating procedures
The optimal combination of PPE for preventing SARS-CoV transmission
during aerosol-generating procedures has not been determined. Wearing
PPE during these procedures protects the respiratory tract from inhalation
of droplet nuclei and the mucous membranes, skin, and clothing from contact
with infectious respiratory secretions. PPE should cover the torso, arms,
and hands as well as the eyes, nose, and mouth. PPE must be compatible
with the needs of healthcare worker protection and patient care. The
following PPE is recommended:
- Disposable
isolation gown, preferably with fluid-resistant properties, to
protect the body and exposed areas of the arms. A disposable full-body
isolation suit is an option and may provide greater protection of
the skin, especially around the neck. Surgical hoods, which fully
cover the head, neck, and face, (with the addition of an N-95 or
higher-level disposable particulate respirator), have been used in
some settings. It is unknown whether covering exposed areas of skin
or hair on the head will further reduce the risk of transmission.
- Pair
of disposable gloves that fit snuggly over the gown cuff.
- Eye
protection (i.e., goggles) to protect the eyes from respiratory splash
or spray. Goggles should fit snuggly (but comfortably) around the eyes.
A face shield may be worn over goggles to protect exposed areas of
the face but should not be worn as a primary form of eye protection
for these procedures.
- Respiratory
protection -- During aerosol-generating procedures, there must be minimal
respirator face-seal leakage to fully protect the worker from exposure
to aerosolized infectious droplets. The following respiratory protection
options should be considered:
- Disposable
particulate respirators (e.g., N-95, N-99, or N-100) are sufficient
for routine respiratory protection for Airborne Infection Isolation
and are the minimum level of respiratory protection required for
healthcare workers who are performing aerosol-generating procedures.
To ensure adequate protection, healthcare workers must be fit-tested
to the respirator
model that they will wear and also know how to check
the face-piece seal. A fit-check should be performed each time a
respirator is put on, before entering the patient room. Workers who
cannot wear a disposable particulate respirator because of facial
hair or other fit limitations should wear a loose-fitting (i.e.,
helmeted or hooded) PAPR.
- Healthcare
facilities in some SARS-affected areas routinely used higher levels
of respiratory protection for performing aerosol-generating procedures
on patients with SARS-CoV disease. It is unknown whether these higher
levels of protection will further reduce transmission. Factors that
should be considered in choosing respirators in this setting include
availability, impact on mobility, impact on patient care, potential for
exposure to higher levels of aerosolized respiratory secretions, and
potential for reusable respirators to serve as fomites for transmission.
Higher levels of respiratory protection include:
- PAPR
with loose-fitting face piece that forms a partial seal with the
face
- PAPR
with hood that completely covers the head and neck and may also
cover portions of the shoulder and torso
- PAPR
with tight-fitting face piece (half and full face-piece)
- Full
face-piece elsastomeric negative-pressure (non-powered) respirators
with N, R, or P-100 filters.
1 The
2003 SARS-CoV outbreak likely originated in mainland China, and neighboring
areas such as Taiwan and Hong Kong are thought to be at higher risk
due to the large volume of travelers from mainland China. Although
less likely, SARS-CoV may also reappear from other previously affected
areas. Therefore, clinicians should obtain a complete travel history.
If clinicians have concerns about the possibility of SARS-CoV disease
in a patient with a history of travel to other previously affected
areas (e.g., while traveling abroad, had close contact with another
person with pneumonia of unknown etiology or spent time in a hospital
in which patients with acute respiratory disease were treated), they
should contact the local or state health department.
2 Close
contact: A person who has cared for or lived with a person with SARS-CoV
disease or had a high likelihood of direct contact with respiratory
secretions and/or body fluids of a person with SARS-CoV disease. Examples
of close contact include kissing or hugging, sharing eating or drinking
utensils, talking within 3 feet, and direct touching. Close contact
does not include activities such as walking by a person or briefly
sitting across a waiting room or office.
3 Respirators
should be used in the context of a complete respiratory protection
program as required by the Occupational Safety and Health Administration
(OSHA). This includes training, fit-testing, and fit-checking to ensure
appropriate respirator selection and use. To be effective, respirators
must provide a proper sealing surface on the wearer's face. Detailed
information on a respiratory protection program is provided at this
OSHA web page. |
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