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Severe Acute
Respiratory Syndrome (SARS) |
This updated guidance is intended to assist air medical transport (AMT)
service providers in using specialized and/or specially equipped aircraft
to transport SARS patients while ensuring the safety of patients and
transport personnel. It should not be generalized to commercial passenger
aircraft. The recommendations are based on standard infection control
practices, AMT standards, and epidemiologic information from investigations
of SARS, including experience from air transport of patients during
the 2003 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 Isolation Precautions. Respiratory protection
using respirators providing at least 95% filtering efficiency (e.g.,
NIOSH-certified N-95 or higher-level filtering facepiece respirator)
with appropriate fit-testing
is recommended.
A. Air Transport of SARS Patients: General Considerations
- SARS patients should be transported on a dedicated AMT mission
with the minimum number of crew members. Whenever possible,
no passengers or patients who do not have SARS should be on board. If
a parent is accompanying a sick child, the parent should use personal
protective equipment (PPE) during transport as described in “Infection
Control,” below.
- If possible, a primary caregiver should be assigned to the SARS
patient.
- The number of caregivers should be limited to those required to
provide essential care during the trip.
- Infection control measures should focus on:
- Source control (i.e., confining the spread of respiratory
secretions at the patient level)
- Engineering controls to limit airborne dissemination of
the virus
- Containment of the area of contamination (i.e., designating “clean” and “dirty” areas
on the aircraft)
- Use of PPE
- Use of safe work practices to prevent exposure
The size and type of aircraft will influence the extent to which these
measures can be implemented. When available, use of a portable isolation
unit may be considered.
- Consideration must be given to the need for “PPE breaks” during
long trips. Personnel will need to use the lavatory and have meals;
removal of respiratory protection is unavoidable. An area at the
front of the plane (or “upwind” from the patient, depending
on cabin air flow), as far as possible from the patient, should be
designated for this purpose.
- All SARS patient transport involving U.S. citizens should be coordinated
with CDC Quarantine Station staff and
other appropriate state and federal health authorities, including
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 aircraft-servicing locations, patient rest-stop
hospitals, countries that will be over-flown, and/or final destinations.
B. Airframe Selection and Cabin Airflow
Cabin airflow characteristics may reduce exposure of occupants to airborne
infectious particles. Whenever possible, aircraft used to medically
evacuate patients with SARS should have separate air-handling systems
for the cockpit and cabin, with cockpit air at positive pressure relative
to the cabin.
1. Fixed-wing pressurized aircraft
- AMT service providers should consult the 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 time and aircraft configuration required
to perform a post-mission airing-out of the aircraft.
- Aircraft with forward-to-aft cabin air flow and a separate cockpit
cabin are strongly preferred for transport of SARS patients. Aft-to-forward
cabin air flow may increase the risk of airborne exposure of cabin
and flight deck personnel. 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 space for crew members to perform necessary
personal activities (e.g., eating, drinking) in an area that does
not share air with the patient-care cabin should be selected for
flights likely to exceed 4 hours.
2. Rotor-wing and non-pressurized aircraft
- In aircraft with uncontrolled interior air flow, such as rotor-wing
and small, non-pressurized fixed-wing aircraft, all personnel should
wear disposable N-95 or higher-level respirators during transport
of SARS patients. 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.
C. Patient Placement
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 air flow as possible.
- A bathroom for use by the patient(s) with SARS should be close
by.
- In AMT aircraft with vertical litter tiers and top-to-bottom air
flow, SARS litter patients should be placed in the lowest position
in the tier.
- Ambulatory SARS patients should be seated next to the cabin sidewall.
- Patients should wear a surgical mask, if tolerated, to reduce droplet
production.
- If transport of a non-SARS patient simultaneously with SARS patient(s)
cannot be avoided, the non-SARS patient should wear an N-95 or higher-level
respirator during transport and should be positioned upwind and as
far as possible from 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.
D. Infection Control
1. Designation of an “isolation area”
- Where space permits, a perimeter should be established for designating “clean” and “dirty” areas
for the purpose of defining where gowns and gloves must be donned
and removed. The distance will depend on the area required for patient
care support; a minimum distance of 6 feet from the patient is recommended.
A bathroom for use by the patient should be within the isolation
area.
- Materials required for patient care, including PPE, should be organized
outside the isolation area. Receptacles for soiled linen, waste,
and reusable equipment should be placed inside the isolation area.
- Patient movement should be restricted to the designated isolation
area.
- Personnel who are within the isolation area must wear full PPE.
2. Source control
- If the patient is able, s/he should be instructed to wear a surgical
mask
3. Personal protective equipment and procedures
- The following PPE should be available for use by direct care providers:
- Non-sterile patient-care gloves
- Disposable isolation gowns
- Goggles or face shield (Corrective eyeglasses alone are
not appropriate protection.)
- Fit-tested, disposable respirators (Disposable N-95 respirators
are approved for in-flight use.)
- Hand hygiene product (e.g., alcohol-based hand rub)
- Disposable non-sterile gloves, gown, and eye and respiratory
protection must be worn for all patient contact.
- Eye protection, gown, and gloves should be removed and discarded
in designated receptacles after patient care
is completed (e.g., between patients) or when soiled or damaged.
The respirator should remain on until the wearer is in the area designated
as safe for respirator removal.
- Hands must be washed with soap and water or a waterless, alcohol-based
hand rub immediately after removal of PPE.
- Oxygen delivery with simple and non-rebreather face masks may
be used for patient oxygen support during flight.
- Manually assisted 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 (e.g., nebulizer treatments) should
be avoided during transport.
E. Patients Requiring Mechanical Ventilation
- 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.
F. Management of Clinical Specimens
- Standard Precautions should 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.
G. Waste Disposal
- Dry solid waste (e.g., used gloves, dressings), 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.
H. 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 manufacturers’ recommendations.
- Cleaning personnel should wear non-sterile gloves and disposable
isolation gown or coveralls over their usual cleaning uniform. Eye
protection to prevent contact with germicides should be worn according
to existing organization procedures for environmental cleaning and
disinfectionwhile 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 and disinfected
in accordance with 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.
- Reusable equipment should be cleaned and disinfected according
to manufacturer's instructions.
- Following completion of cleaning tasks, including cleaning and
disinfection of reusable equipment, cleaning personnel should carefully
remove and dispose of personal protective gear and wash hands thoroughly
with soap and water or an alcohol-based hand rub.
I. 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 in the
event that the aircraft experiences maintenance delays or weather
diversions.
- Flight planning should identify emergency or unexpected diversion
airfields and coordinate with authorities in advance.
- Upon termination of the mission, 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; and
description of any recognized breach(es) in infection control precautions.
- AMT services should designate persons 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
symptoms that would require evaluation and follow-up.
J. 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 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.
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