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PPHSN Guidelines
For The Preparedness, Surveillance And
Response To Severe Acute Respiratory
Syndrome (SARS) in Pacific Island Countries
And Territories
March 28th 2003
SARS is a new disease syndrome. Our knowledge about the best way to
prevent and treat it is constantly evolving. These guidelines will be
continuously updated. Please regularly check PPHSN website for the most up
to date guidance
PPHSN. SARS Guidelines
28/03/2003
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Table of Contents
BASIC DISEASE FACTS ......................................................................................................... 4
Background ............................................................................................................................ 4
Description of disease ............................................................................................................ 4
Epidemiology ......................................................................................................................... 4
Agent and infectious dose ...................................................................................................... 4
SURVEILLANCE ..................................................................................................................... 5
WHO Case Definitions for hospital based surveillance ........................................................ 5
Surveillance and reporting ..................................................................................................... 6
Minimum dataset ................................................................................................................... 6
PREPAREDNESS – INITIAL ACTION AND RESPONSIBILITIES ..................................... 6
Outbreak response team (EpiNet or CDC other committee) ................................................. 6
Staff responsibilities for the various actions .......................................................................... 6
Clinical assessment of suspected patients .............................................................................. 6
Enhanced surveillance ........................................................................................................... 7
Communications (between members of team and with outside bodies, media etc.) ............. 7
Laboratory diagnosis .............................................................................................................. 7
Initial community interventions ............................................................................................. 7
External (international) reporting, requests for support, and coordination among agencies . 8
CASE MANAGEMENT – the clinical response ....................................................................... 8
Investigations ......................................................................................................................... 8
Management of suspect cases ................................................................................................ 8
Management of probable cases .............................................................................................. 9
Specific Treatment ................................................................................................................. 9
Hospital discharge and follow-up .......................................................................................... 9
HOSPITAL INFECTION CONTROL .................................................................................... 10
Care for patients with probable SARS ................................................................................. 10
MANAGEMENT OF CONTACTS OF SUSPECTED AND PROBABLE CASES .............. 11
General ................................................................................................................................. 11
Contacts of suspected cases on aircraft ................................................................................ 12
REFERENCES AND FURTHER SOURCES OF INFORMATION ..................................... 12
ANNEXES ............................................................................................................................... 13
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HISTORY OF GUIDELINE.................................................................................................... 13
ANNEX 1................................................................................................................................. 14
ANNEX 2................................................................................................................................. 15
ANNEX 3................................................................................................................................. 21
ANNEX 4................................................................................................................................. 22
ANNEX 5................................................................................................................................. 23
ANNEX 6................................................................................................................................. 25
ANNEX 7................................................................................................................................. 27
ANNEX 8................................................................................................................................. 28
ANNEX 9................................................................................................................................. 33
ANNEX 10............................................................................................................................... 36
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Severe Acute respiratory Syndrome (SARS)
BASIC DISEASE FACTS
Background
As of 27 March 2003, reports of over 1408 cases, including 53 deaths, of Severe Acute Respiratory
Syndrome (SARS), an atypical pneumonia of unknown aetiology, have been received by the World
Health Organization (WHO) since 16 November 2002. WHO is coordinating the international
investigation of this outbreak and is working closely with health authorities in the affected countries to
provide epidemiological, clinical and logistical support as required.
SARS was first recognised on the 26 February 2003 in Hanoi, Viet Nam, but it the epidemic started in
Guangdong in November 2002. Local transmission occurred in China, Vietnam, Singapore and
Canada. The worst-affected areas are Guangdong province and the Special Administrative Region of
Hong Kong in China, Hanoi in Vietnam, and Singapore.
The causative agent has yet to be identified, although the search has been currently narrowed to
members of the paramyxovirus and coronavirus families. The main symptoms and signs include high
fever (>38 degrees Celsius), cough, shortness of breath or breathing difficulties. Approximately 10
percent of patients with SARS develop severe pneumonia; some of whom have needed ventilator
support.
As of 27 March the majority of cases have occurred in people who have had very close contact with
other cases; for this reason, health care workers are at particular risk.
Description of disease
The syndrome begins with fever for 1-2 days, then a dry cough or dyspnea for 2-3 days. Atypical
pneumonia develops on day 4-5 in the majority of cases. It is initially unilateral but after a further 1-3
days it often becomes bilateral, progressing to extensive "white-out" on chest XRay.
The disease then takes 1 of 2 courses:
A) the patient improves (80-90% of cases) and recovers over the next 4-7 days; or
B) the patient deteriorates severely on day 6-7 with respiratory distress (10-20% of cases).
50% of patients in category B require mechanical ventilation. The mortality rate in this sub-group is
high. During the early phase of the outbreak, around 50% of type B cases have died, giving an overall
CFR of 5-10%. Risk factors for poor outcome are not clear, apart from the severity of illness and the
need for mechanical ventilation. So far SARS has affected predominantly adults aged 20-70 yrs. Very
few cases have occurred in children.
The modes of transmission and the causative agent have yet to be determined. Aerosol and/or droplet
spread is likely as is transmission from body fluids. Respiratory isolation, strict respiratory and
mucosal barrier nursing are recommended for cases. Cases should be treated as clinically indicated.
(see below for further details).
Epidemiology
Agent and infectious dose
Some laboratories have reported finding paramyxovirus or coronavirus particles on electron
microscopy of specimens taken from cases. However these findings await confirmation. The
infectious dose is unknown.
Source
From the knowledge available to date the source of an infection is another person who is ill with
SARS.
Occurrence
So far all cases reported from outside the affected areas have a history of travel in the previous 10
days through an affected area OR close contact with a case of SARS.
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Mode of transmission
It is likely that the agent is spread from person to person by droplet/aerosol spread. However it may
also be air-borne and transmission from contact with body fluids has not been excluded.
Period of communicability
Not known but particularly infectious once respiratory symptoms appear. A lower risk of transmission
is likely to be present during the prodromal phase.
Incubation period
The incubation period is thought to be 2-7 days exceptionally 10 days, most commonly 3-5 days
Vulnerable population sub-groups
Insufficient information available at this stage. But probably worse outcomes can be expected in
individuals with underlying respiratory and cardiac illnesses such as asthma, COPD and heart
disease.
Risk in the Pacific
The main risk in the Pacific is the importation of cases from affected areas with subsequent local
transmission to close contacts including health workers.
SURVEILLANCE
Please note that a SINGLE case of suspected/probable SARS is an outbreak.
WHO Case Definitions for hospital based surveillance
Suspected case
Clinicians should be alert for persons with onset of illness after February 1, 2003 with:
Fever (>38° C)
AND
One or more signs or symptoms of respiratory illness, including:
 cough,
 shortness of breath,
 difficulty breathing,
AND
A history of either of the following:
 close contact*, within 10 days of onset of symptoms, with a person who has been diagnosed
with SARS.
 history of travel, within 10 days of onset of symptoms, to an area** (see table below) in which
there are reported foci of transmission of SARS.
* close contact means having cared for, having lived with, or having had direct contact
with respiratory secretions and body fluids of a person with SARS.
Affected Areas** - Severe Acute Respiratory Syndrome (SARS)
Country
Canada
Singapore
China
Viet Nam
Area
Toronto
Singapore
Beijing, Guangdong Province, Hong Kong Special Administrative Region of
China, Shanxi, Taiwan
Hanoi
Last revised 27 March 2003
**An "Affected Area" is defined as a region at the first administrative level where the country is
reporting local transmission of SARS.
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Note
In addition to fever and respiratory symptoms, SARS may be associated with other symptoms
including: headache, muscular stiffness, loss of appetite, malaise, confusion, rash, and diarrhea.
Probable case
 A suspected case with chest X-ray findings of pneumonia or adult respiratory distress
syndrome.

OR
A person with an unexplained respiratory illness resulting in death, with an autopsy
examination demonstrating the pathology of Respiratory Distress Syndrome without an
identifiable cause.
Surveillance and reporting




If travel questionnaires are issued to arriving passengers or passengers from affected areas
are requested to identify themselves, record number of arrivals with a travel history that puts
them in the at risk group (travel to an affected area within the previous 10 days).
Report all suspected/probable cases immediately to National Public Health Authorities, using
the PPHSN reporting form (see ANNEX 2).
Report all suspected/probable cases immediately to PPHSN Coordinating Body (CB) Focal
point or WHO Suva using the PPHSN reporting form (a copy of the completed form used to
report to the National Public Health Authorities) (see contacts list in ANNEX 1)
Report to PacNet or PacNet-restricted.
Minimum dataset



[Optional: upon arrival, affected area visited in the last 10 days and presence of symptoms]
Please see PPHSN reporting form for data items.
For PacNet or PacNet-restricted, same as on reporting form, EXCEPT reporter and patient
details (you can send the form on PacNet or PacNet-restricted, but delete the 2nd page).
PREPAREDNESS – INITIAL ACTION AND RESPONSIBILITIES
This will depend on local arrangements within each country.
Outbreak response team (EpiNet or CDC other committee)
For the purpose of proper SARS control in hospital environment, this team should include a member
experienced in hospital infection control, and who can advise on isolation and barrier nursing
issues.
Priority functions of the team are to:
 identify facilities where suspected and probable cases of SARS can be nursed.
 perform an inventory of supplies required for nursing such patients (using WPRO SARS
Preparedness Kit contents list).
 plan how contacts of suspect/probable cases will be managed
 liaise with customs/immigration authorities on the best way to provide information to arriving
passengers, record travel details for surveillance and plan of action if an ill individual arrives ill
on a plane with suspected SARS.
Staff responsibilities for the various actions

Individual countries to decide
Clinical assessment of suspected patients



Clinicians must be aware of the symptoms and signs of SARS.
Patients with symptoms of SARS should be triaged immediately to designated examination
rooms or wards to minimize exposure to other patients and staff.
Patients with suspected SARS should be issued with surgical masks.
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
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Medical and nursing staff must take precautions when examining the patient ie barrier
nursing.
Obtain and record detailed clinical, travel and contact history including occurrence of acute
respiratory diseases in contact persons during the last 10 days.
Obtain chest X-ray (CXR) and full blood count (FBC).
(See example patient management flow chart in ANNEX 4)
Enhanced surveillance


Complete PPHSN reporting form and send immediately to National Health Authorities, with a
cc to PPHSN-CB Focal Point. Also send immediately the form WITHOUT reporter and patient
details (i.e. page 2) to PacNet or PacNet-restricted
Identify close contacts and give information to contacts. Screen any contacts with compatible
symptoms as for suspected cases.
Communications (between members of team and with outside bodies, media etc.)


Ensure that lines of communication are clear.
Identify spokesperson for the team who will be the focal point for media briefings and will
liaise with international agencies eg WHO/SPC (this could be the EpiNet team Focal Point or
another person).
Laboratory diagnosis

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

The agent causing SARS remains to be established. There are no specific diagnostic tests.
For suspected cases where the diagnosis of SARS is by exclusion and the patient is not very
ill (ie no chest X-ray changes compatible with SARS). It is reasonable to take specimens for
diagnostic purposes. However health care workers must take full barrier nursing
precautions to protect themselves from aerosols or splashing/splattering of blood or
other body fluids.
For probable cases where the diagnosis of SARS is very likely and particularly if the patient
has significant respiratory symptoms. The clinicians must perform a risk/ benefit analysis.
There have been documented cases of transmission to HCWs during
diagnostic/therapeutic procedures, particularly those prone to the generation of
aerosols. Therefore the priority should be for tests likely to influence the clinical management
of the patient.
If specimens are collected for diagnostic testing (rather than clinical management), they
should be stored under appropriate conditions. At this stage, the two laboratories in our region
that have agreed to receive specimens are:
o Institute Pasteur, Noumea
o WHO Collaborating Centre for Reference and Research on Influenza, Australia
(See Contact List in ANNEX 1 for addresses)
Initial community interventions



Provide suitable information to arriving passengers (particularly those who have traveled
through affected countries) about the risks of SARS and where they can go to for advice and
assistance (as example, see Advice to Arriving Travelers in ANNEX 5).
Simple health education messages should be communicated to the public via appropriate
media (see Health Advices from Hong Kong in ANNEXES 6 and 7 for examples).
WHO has not recommended restricting travel to any destination in the world. However, all
travellers should be aware of the main symptoms and signs of SARS, as given above. On the
other hand, the CDC, the French Department of Health, Health Canada, New Zealand
Ministry of Health and Singapore advise persons planning elective or nonessential travel to
the worst-affected areas to postpone their trips until further notice. This careful attitude helps
to avoid SARS long-distance spread through travel to and from infected zones and prevents
the importation of SARS "home" (lots of close contacts...). This is particularly important in
places where control measures may not be easy to implement (and SARS importation may
have serious public health consequences).
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External (international) reporting, requests for support, and coordination among agencies


Report all suspect and probable cases to PPHSN/WHO using the PPHSN reporting form
Contact PPHSN-CB Focal Point or WHO South Pacific if additional information or assistance
is required (see contact list in ANNEX 1).
CASE MANAGEMENT – the clinical response
Investigations
CXR
 Chest radiographs might be normal during the febrile prodrome and throughout the course of
illness. However, in a substantial proportion of patients, the respiratory phase is characterized
by early focal infiltrates progressing to more generalized, patchy, interstitial infiltrates. Some
chest radiographs from patients in the late stages of SARS have also shown areas of
consolidation.
 In typical severe cases, chest x-ray findings begin with a small unilateral patchy shadow, and
progress over 24 - 48 hours to become bilateral, generalized, interstitial/confluent infiltrates.
Patchy chest x-ray changes are sometimes noted in the absence of chest symptoms. Acute
respiratory distress syndrome might be observed in the end stage. Post-mortem lung tissue
shows generalized alveolar damage and lymphocytosis without obvious viral inclusion bodies.
FBC
 Initially the blood picture is often normal. However, by day 3 - 4 of the illness, lymphopenia is
commonly observed (>50%), and less commonly, there might be thrombocytopenia. If SARS
is complicated by secondary bacterial infection, neutrophilai may occur.
Other
 Elevated hepatic transaminases and creatine phosphokinase levels are seen early in the
respiratory phase of the disease.
Management of suspect cases
In-flight care of suspected case of SARS
 If a passenger on a flight from an affected area becomes noticeably ill with a fever and
respiratory symptoms, the following action is recommended for cabin crew:
o The passenger should be, as far as possible, isolated from other passengers and
crew
o The passenger should be asked to wear a protective mask and those caring for the ill
passenger should follow the infection control measures recommended for cases of
SARS
o A toilet should be identified and made available for the exclusive use of the ill
passenger
o The captain should radio ahead to alert the airport of destination so that quarantine or
health authorities are altered to the arrival of a suspect case of SARS
o On arrival, the ill passenger should be placed in isolation and assessed by port health
authorities
General care of suspected case of SARS
 Patients with symptoms of SARS should be triaged immediately to designated examination
rooms or wards to minimize exposure to other patients and staff.
 Patients with suspected SARS should be issued with surgical masks
 obtain and record detailed clinical, travel and contact history including occurrence of acute
respiratory diseases in contact persons during the last 10 days
 obtain chest X-ray (CXR) and full blood count (FBC)
if CXR is normal:
 provide advice on personal hygiene, avoidance of crowded areas and public transportation,
remain at home until well with daily clinical follow-up [Singapore teaches patients under
"domestic quarantine" to take and record their own temperatures 4-hourly, which the health
worker reviews daily].
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
discharge with advice to seek medical care if respiratory symptoms worsen
if CXR demonstrates uni- or bi-lateral infiltrates with or without interstitial infiltration
 SEE MANAGEMENT OF PROBABLE CASES
Management of probable cases

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


hospitalize under isolation or cohorted with other SARS cases (see section on Hospital
infection control)
Cases need to be in the best isolation facility that can be arranged (this will vary for PICs) and
must be nursed using strict barrier techniques including gown or preferably overalls, gloves,
boots or over-shoes, HEPA or N95-100 mask (or at least a surgical mask if nothing else
available) and goggles - not pleasant to use in PIC climate!
samples for laboratory investigation (if possible) and exclusion of known causes of atypical
pneumonia:
o throat and/or nasopharyngeal swabs 1
o blood for culture and serology (acute specimen and convalescent specimen taken
after 3 weeks)
o urine
o bronchoalveolar lavage
o post mortem examination as appropriate
Samples should be investigated in laboratories with proper containment facilities (BL3).
CXR as clinically indicated
treat as clinically indicated
Specific Treatment

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
Treatment regimens have included several antibiotics to presumptively treat known bacterial
agents of atypical pneumonia.
In several locations, therapy has included antiviral agents such as oseltamivir or ribavirin; the
effectiveness of these treatments is uncertain..
Steroids have also been administered orally or intravenously to patients in combination with
ribavirin and other antimicrobials. Intravenous steroids may be associated with improved
outcomes in severe cases.
At present, the most efficacious treatment regime, if any, is unknown.
Empirical antibiotic therapy should cover causes of community acquired pneumonia including
both typical and atypical respiratory pathogens.
Hospital discharge and follow-up
The period of communicability of the agent that causes SARS is unknown at this time. WHO advises
that patients are fit for discharge if:
Clinical symptoms/findings:

Afebrile for 48 hours

No cough
Laboratory tests: if previously abnormal

White cell (lymphocyte) count returning to normal

Platelet count returning to normal

Creatinine phosphokinase returning to normal

Liver function tests returning to normal
Radiological findings:

1
Improving chest x-ray changes
best specimen for (known) respiratory viruses is nasal swab
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Follow-up for convalescent cases
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Discharged convalescent patients should be asked to return to hospital If they have an
elevated temperature of 38 degrees and above on two consecutive occasions they should
report to the health care facility from which they were discharged.
Follow up is recommended at one week (or before if decided so by the clinician) at which time
they should have a repeat chest x-ray, full blood count and any other blood tests that were
previously abnormal.
The patient should be followed up by the health care facility from which they were discharged.
If possible they should not return to their home island.
Subsequent follow-ups are recommended until the chest x-ray and patient’s health returns to
normal.
As part of the follow-up convalescent serology should be taken is taken at 3 weeks (if an
acute serum specimen was taken) after the date of the presenting symptoms and provided to
the health care facility from which they were discharged.
Until more is known about the aetiological agent, and the potential for continued carriage (and
hence the risk of continuing transmission) a cautious approach is warranted.
WHO advises that following discharge from hospital convalescent cases should be advised to
wait for a minimum of 14 days, before considering returning to work/school/college. This is
twice the known maximum incubation period. During this period they should stay indoors,
keeping contact with others to a minimum. Clear instructions should be given to convalescent
cases to return to the health care facility from which they were discharged [see above] if their
condition deteriorates and any further symptoms develop.
HOSPITAL INFECTION CONTROL
Please see NEW ZEALAND MOH Infection Control advice for the management of patients with
suspected Severe Acute Respiratory Syndrome (SARS) in ANNEX 8 for an example of measures that
can be adapted depending on the resources available. Alternatively see WHO publication Infection
Control for VHF in the African Health Care Setting for simple guidance. This is available on the
PPHSN website (http://www.spc.int/phs/PPHSN/Outbreak/SARS_Outbreak.htm).
Care for patients with probable SARS
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WHO advises strict adherence with the barrier nursing of patients with
SARS using precautions for airborne, droplet and contact transmission.
Triage nurses should rapidly divert persons presenting to their health
care facility with flu-like symptoms to a separate assessment area to
minimise transmission to others in the waiting areas.
Suspect cases should wear surgical masks until SARS is excluded.
Probable and suspected cases MUST be nursed SEPARATELY, and
suspected cases must NEVER be placed with other patients for
observation.
Patients with probable SARS should be isolated and accommodated as follows in descending
order of preference:
o Negative pressure rooms with the door closed
o Single rooms with their own bathroom facilities
o Cohort placement in an area with an independent air supply and exhaust system.
Note Turning off air conditioning and opening windows for good ventilation is recommended if
an independent air supply is not possible.

Disposable equipment should be used wherever possible in the treatment and care of patients
with SARS. If devices are to be reused, they should be sterilised in accordance with
manufacturers’ instructions. Surfaces should be cleaned with broad spectrum (bactericidal,
fungicidal, and virucidal) disinfectants of proven efficacy.
PPHSN. SARS Guidelines
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
Patient movement should be avoided as much as possible. Patients being moved should wear a
surgical mask to minimise dispersal of droplets. NIOSH standard masks (N95), often used to
protect against other highly transmissible respiratory infections such as tuberculosis, are preferred
if tolerated by the patient. All visitors, staff, students and volunteers should wear a N95 mask on
entering the room of a patient with confirmed or suspected SARS. Surgical masks are a less
effective alternative to N95 masks.

Handwashing is the most important hygiene measure in preventing the spread of infection.
Gloves are not a substitute for handwashing. Hands should be washed before and after
significant contact with any patient, after activities likely to cause contamination and after
removing gloves. Alcohol-based skin disinfectants formulated for use without water may be used
in certain limited circumstances.

Health care workers (HCWs) are advised to wear gloves for all patient handling. Gloves should
be changed between patients and after any contact with items likely to be contaminated with
respiratory secretions (masks, oxygen tubing, nasal prongs, tissues).

Particulate filter personal respiratory protection devices capable of filtering 0.3um particles
(N95) or other relevant mask should be worn at all times when attending patients with suspected
or probable SARS.

Gowns (waterproof aprons) and head covers should be worn during procedures and patient
activities that are likely to generate splashes or sprays of respiratory secretions.

HCWs must wear protective eyewear or face-shields during procedures where there is
potential for generation of aerosols or splashing, splattering or spraying of blood or other body
substances.

Standard precautions should be applied when handling any clinical wastes. All waste should be
handled with care to avoid injuries from concealed sharps (which may not have been placed in
sharps containers). Gloves and protective clothing should be worn when handling clinical waste
bags and containers. Where possible, manual handling of waste should be avoided. Clinical
waste must be placed in appropriate leak-resistant biohazard bags or containers labelled and
disposed of safely.
MANAGEMENT OF CONTACTS OF SUSPECTED AND PROBABLE CASES
General



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

SARS has only been reported to have been transmitted from cases to close contacts. These
include people living with or caring for cases at home or in hospital, who have prolonged
exposure to droplet spread and/or body fluids including respiratory secretions. The incubation
period is reported to be short, typically 2 to 7 days.
Close contacts should be informed that they may be at risk of contracting the infection. They
should be advised to seek medical care urgently if they develop fever and respiratory
symptoms within ten days of their contact with a case.
No restriction of activities is recommended for close contacts who have no symptoms. (NB in
Hong Kong and Singapore the authorities are recommending that the children of probable
cases be kept away from school for 10 days from the date the parent was hospitalised as a
precaution
Provide reassurance.
Record name and contact details.
Provide advice in the event of fever or respiratory symptoms to:
o immediately report to doctor/physician/health authority
o not report to work until advised by health authority
o avoid public places until advised by health authority
o minimize contact with family members and friends
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Contacts of suspected cases on aircraft

If a passenger or member of aircrew has suspected/probable SARS on arrival and the
immediate medical assessment of the ill passenger excludes SARS as a possible cause of
his/her illness, the passenger should be referred to local health care facilities for any
necessary follow up. If however, the initial medical assessment conducted in the airport
concludes that the passenger is a suspect or probable case of SARS the following action
should be taken:
Contacts
 All contacts of the ill passenger should be identified during the flight. For the purposes of air
travel a contact is defined as:
o passengers sitting in the same seat row or 2 rows in front or behind the sick
passenger
o all flight attendants on the flight
o anyone having intimate contact, providing care or otherwise having contact with
respiratory secretions of the sick passenger
o any one on the flight living in the same household as the ill passenger
o If it is a flight attendant who is considered to be a suspect or probable SARS
case all the passengers are considered to be contacts.



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
Contacts should provide, to the health authorities, identification and details of their place(s) of
residence for the next 14 days.
Contacts should be given information about SARS and advised to seek immediate medical
attention if they develop any symptoms of SARS within 10 days of the flight.
When seeking medical attention they should ensure that all those treating them are aware
that they have been in contact with a suspect case of SARS.
Contacts should be allowed to continue to travel so long as they are well.
If over time it becomes apparent that the suspect case is a probable case of SARS, the health
authority where the case is being cared for should inform other health authorities in those
areas in which the contacts reside that active surveillance of each contact should be
undertaken until 10 days after the flight. Active surveillance may consist of:
o If possible daily temperature check and interview by health care worker
o At the minimum the contacts should be contacted by a health worker and the advice
about seeking medical attention if any of the symptoms of SARS occur reinforced.
In some circumstances it may be recommended that contacts remain at home and minimise
contact with others including their own families until 10 days after the flight.
REFERENCES AND FURTHER SOURCES OF INFORMATION
http://www.spc.int/phs/PPHSN/Outbreak/SARS_Outbreak.htm
http://www.info.gov.hk/dh/ap.htm
http://www.phls.co.uk/topics_az/SARS/menu.htm
http://www.cdc.gov/ncidod/sars/
http://www.who.int/csr/sars/en/
http://www.moh.govt.nz/sars
PPHSN. SARS Guidelines
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ANNEXES
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ANNEX 1 – List of Key Contacts
ANNEX 2 – PPHSN Reporting Form
ANNEX 3 – Affected Areas – SARS
ANNEX 4 – SARS Patient Management Flow Chart (example)
ANNEX 5 – Advice to arriving travellers (2 examples, incl. The Solomon Islands)
ANNEX 6 – Health Advice on the Prevention of Respiratory Tract Infections
(example from Hong Kong MOH)
ANNEX 7 – Health Advice on the Prevention of Respiratory Tract Infections in Public Places
(example from Hong Kong MOH)
ANNEX 8 – New Zealand infection control advice for managing patients with SARS
ANNEX 9 – Assessment of Risk and Capacities to Respond to a Multi-country outbreak of
Severe Acute Respiratory Syndrome
ANNEX 10 – WPRO SARS Preparedness Kit contents list.
HISTORY OF GUIDELINE
Compiled by:
Dr Kevin Carroll
on behalf of PPHSN
Reviewed by:
Dr Tom Kiedrzynski
Epidemiologist (Ag)
Secretariat of the Pacific Community, PPHSN-CB Focal Point
The PPHSN SARS Task Force consists of:
Dr Alain Berlioz, Pharmacist-biologist, New Caledonia Pasteur Institute
Dr Mary Beers Deeble, Senior Lecturer, Director, MAE, NCEPH, ANU
Dr Kevin Carroll, MO/Epidemiologist, WHO South Pacific
Dr Rob Condon, Public Health Physician/Epidemiologist, SARS Outbreak Response Group, WPRO
Dr Tom Kiedrzynski, Notifiable Disease Specialist/Epidemiologist (Ag), SPC
Dr Kamal Kishore, Senior Lecturer, Medical Microbiology, FSMed
Dr Joe Koroivueta, Consultant Virologist, Fiji MoH
Dr Ilisapeci Kubuabola, MAE student, Fiji MOH
Dr Michael O'Leary, Regional Medical Epidemiologist, CDC/PIHOA
Dr Hitoshi Oshitani Regional Adviser in Communicable Disease Surveillance and Response / Team
Leader of SARS Preparedness Team, WPRO
Dr Salanieta Saketa, National Epidemiologist/MO, Fiji MoH
Revision date(s)
25.03.2003
Review date
28.03.2003
PPHSN. SARS Guidelines
28/03/2003
13
ANNEX 1
CONTACTS
PPHSN-CB Focal Point
Dr Tom Kiedrzynski
Epidemiologist (Ag)
Secretariat of the Pacific Community, PPHSN-CB Focal Point
SPC PO Box D5
98848 Noumea cedex
New Caledonia
Tel:
+(687) 26 20 00 or 01 43
Fax:
+(687) 26 38 18
Out of hours
+(678) 25 92 36
E-mail: [email protected]
WHO South Pacific
Dr Kevin Carroll
MO/Epidemiologist
WHO South Pacific
PO Box 113
Suva, Fiji
Tel
+(679) 3304 600
Fax
+(679) 3300 462
Out of hours
+(679) 99202971
Email [email protected]
Emergency Hotline to WPRO
WHO WPRO Outbreak Ops Room
After Hours Duty Officer
Dr. Hitoshi Oshitani
Dr. Robert Condon
+63-2-528 9833; +63-2-528 9781
+63-2-528 9782; +63-2-528 9650
+63-920 640 9696
+63-918 921 4217
+63-919 3922023
Institute Pasteur
Alain Berlioz-Arthaud,
Laboratoire de Biologie Medicale,
Institut PASTEUR de NouvelleCaledonie,
BP 61,
98845 Noumea,
New Caledonia.
Tel : +(687) 27.02.85
Fax : +(687)27.33.90
Email : [email protected]
WHO Collaborating Centre for Reference and Research on Influenza, Australia
Ian Barr
WHO Collaborating Centre for Reference and Research on Influenza
45 Poplar Road, Parkville.
Victoria, Australia 3052
Tel
+(61) 3 9389 1761
Fax
+ (61) 3 9389 1881
Email [email protected]
PPHSN. SARS Guidelines
28/03/2003
14
ANNEX 2
PPHSN Reporting Form
Severe acute respiratory syndrome (SARS) outbreak
PPHSN. SARS Guidelines
28/03/2003
15
PPHSN Reporting Form
Severe acute respiratory syndrome (SARS) outbreak
Report of suspected or probable cases
This form is to be used for reporting suspected or probable cases of respiratory illness,
which may be associated with the outbreaks of respiratory illness in Hong Kong SAR,
Guangdong province (China) and Hanoi (Vietnam). The cases to be reported are those
conforming to the case definitions provided by the WHO and reproduced at the bottom of
this form.
Please return this form to
PPHSN-CB Focal Point at SPC
Fax: +(687) 26 38 18
e-mail: [email protected]
AND/OR
WHO South Pacific
Fax: +(679) 330 04 62
e-mail: [email protected]
WHO case definitions for hospital based surveillance
Suspected case
A person presenting to a health care facility after 1st February 2003 with a history of:
 High fever (>38 o C)
And:
 One or more respiratory symptoms (cough, shortness of breath, difficulty breathing)
And one or more of the following:
 Close contact*, within 10 days of onset of symptoms, with a person who has been diagnosed
with SARS.
 History of travel, within 10 days of onset of symptoms to an area in which there are reported
foci of transmission of SARS (see ANNEX 3).
* Close contact means having cared for, having lived with, or having had direct contact with respiratory secretions
and body fluids of a person with SARS.
Probable Case

A suspect case with chest x-ray findings of pneumonia or Adult Respiratory Distress
Syndrome
OR
 A person with an unexplained respiratory illness resulting in death, with an autopsy
examination demonstrating the pathology of Respiratory Distress Syndrome without an
identifiable cause.
Note
In addition to fever and respiratory symptoms, SARS may be associated with other symptoms including: headache,
muscular stiffness, loss of appetite, malaise, confusion, rash, and diarrhea.
PPHSN. SARS Guidelines
28/03/2003
16
Reporter details
Name of person completing this form: _ _ _ _ _ _ _ _ _ _ _ _ _
Date of report to PPHSN _ _/ _ _ /_ _ _
Name of reporter: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Position: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Institution/Organisation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Country:____________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Contact telephone number: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
E-mail: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Mobile phone number: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Fax no. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Patient details
Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Sex:
Female 
Male 
Date of birth:
Surname: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _/ _ _/ _ _ _ _
Country of residence
(If different from home address)
___________
Home address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
City/town: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Postcode: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Country: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Home telephone: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
PPHSN. SARS Guidelines
28/03/2003
Mobile phone: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
17
Patient history
In the last 10 days, has the patient been in contact
with anyone who is a suspect or probable case of
SARS?
Yes
No
If yes:
Type of contact: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
(e.g. family member, friend, etc)
Name of the SARS
contact:
_____________________________________
Place of the contact: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Has the patient traveled since 1 February 2003 in
one of the countries reported in the ANNEX?
Yes
No
If yes
Country visited
Length of the stay
From
1
2
3
4
To
_____ _____ _____ ____
__/__/____
__/__/____
_____ _____ _____ ____
__/__/____
__/__/____
_____ _____ _____ ____
__/__/____
__/__/____
_____ _____ _____ ____
__/__/____
__/__/____
Date of return to (name country)
Country of departure
____________
PPHSN. SARS Guidelines
28/03/2003
__/__/____
Airport of arrival in
Country
___________
18
Clinical details
Date of onset of illness
Clinical
diagnosis
_ _/ _ _ / _ _ _ _

Pneumonia
Fever  38C
Yes
No

ARDS
Cough
Yes
No

Other: _ _ _ _ _ _ _ _ _
Myalgia
Yes
No

Fully recovered (symptom free)

Recovering

Stable

Getting worse

Not very ill

Moderately ill

Severely ill

Died
Current status:
Shortness of
breath/difficulty breathing
Yes
No
Severity of illness:
Other, please specify:
____________
Admitted to hospital?
Yes
__/__/__
No
Admission status:
Currently admitted
Date of
admission
_ _ / _ _/ _ _ _ _
Hospital
_________________
Transferred to other
hospital
Date of
admission
_ _ / _ _/ _ _ _ _
Hospital
_________________
Discharged
Date of
discharge
_ _ / _ _/ _ _ _ _
PPHSN. SARS Guidelines
28/03/2003
(Name and country)
(Name and country)
19
Tests performed and laboratory results
Chest X-ray
____________________________
Date
_ _/ _ _/ _ _ _ _
Results:
Normal
Abnormal:
____________________________
____________________________
Date
_ _/ _ _/ _ _ _ _
Results:
Normal
Abnormal:
____________________________
____________________________
Date
_ _/ _ _/ _ _ _ _
Results:
Normal
Abnormal:
____________________________
Cell blood
count
Date
_ _/ _ _ /_ _
Result

Normal

Thrombocytopenic

Leucocytopenic
Date
_ _/ _ _ /_ _
Result

Normal

Thrombocytopenic

Leucocytopenic
Date
_ _/ _ _ /_ _
Result

Normal

Thrombocytopenic

Leucocytopenic
(If performed)
PPHSN. SARS Guidelines
28/03/2003
20
ANNEX 3
Affected Areas* - Severe Acute Respiratory Syndrome (SARS)
Last revised by WHO – 27 March 2003
Country
Area
Canada
Toronto
Singapore
Singapore
China
Beijing, Guangdong Province, Hong
Kong Special Administrative Region of
China, Shanxi, Taiwan
Hanoi
Viet Nam
*An "Affected Area" is defined as a region at the first administrative level where the country is
reporting local transmission of SARS.
PPHSN. SARS Guidelines
28/03/2003
ANNEX 4
SARS Patient Management Flow Chart (Example)
Patient arrival at hospital
Patient Triaged on arrival
Using SARS case definitions
Reassurance
Advice
Usual care
No
Potential
Case of
SARS
Yes
Place mask on Patient
and transfer to isolation area
HCWs should wear mask or N95 respirator mask
PRIOR to entering room to examine patient
No
•Provide advice on
personal hygiene,
avoidance of crowded
areas and public
transportation, remain
at home until well.
•Discharge with advice
to seek medical care if
respiratory symptoms
worsen
SUSPECTED case
Of SARS
(WHO definition)
Yes
Yes
CXR and FBC, other specimen collection
No
Inform Public health
authorities
PPHSN. SARS Guidelines
28/03/2003
PROBABLE case of SARS (WHO definition)
Yes
Admit to designated
isolation facility.
Treat as indicated
Contact tracing
Advice to contacts
Health Education
Public health
authorities
informed
ANNEX 5
Advice To Arriving Travelers (examples)
During your recent travel if you have traveled through the affected areas listed below
during the past 10 days, you may have been exposed to cases of severe acute respiratory
syndrome. The usual incubation period for this illness is 2-7 days. You should monitor
your health. If you become ill with fever accompanied by cough or difficulty in breathing,
and you have been in one of the affected areas during the past 10 days you should seek
medical advice (please see list below). To help the doctor make a diagnosis, tell him or
her about your recent travel to these regions and whether you were in contact with
someone who had these symptoms. Please save this card and give it to your physician if
you become ill.
Affected Areas* - Severe Acute Respiratory Syndrome (SARS)
Country
Area
Canada
Toronto
Singapore
Singapore
China
Guangdong Province, Hong Kong Special
Administrative Region of China, Taiwan
Province
Viet Nam
Hanoi
Last revised 24 March 2003
*An "Affected Area" is defined as a region at the first administrative level where the country is reporting
local transmission of SARS.
List of Medical Practioners/Facilities where Assistance Can Be Obtained
Name
PPHSN. SARS Guidelines
28/03/2003
Address
Telephone
Fax

SOLOMON ISLANDS - MINISTRY OF
HEALTH AND MEDICAL SERVICES
ADVISORY ON
SEVERE ACUTE RESPIRATORY
SYNDROME (SARS)
The Centre for Disease Control and
Prevention (CDC) and the World Health
Organization (WHO) have received reports
of patients with severe acute respiratory
syndrome (SARS) from Canada, China,
Hong Kong Special Administrative Region
of China, Indonesia, Philippines, Singapore,
Thailand, Vietnam, Germany and the United
Kingdom. The cause of these illnesses is
unknown and is being investigated. Early
manifestations in these patients have
included influenza-like symptoms such as
fever, muscle pains, headache, sore throat,
dry cough, shortness of breath, or difficulty
breathing.
Based on currently available evidence, close
contact with an infected person is needed for
the infective agent to spread from one person
to another.
This illness can be severe and, due to global
travel, has spread to several countries in a
relatively short period of time. Therefore,
there is cause for concern.
PPHSN. SARS Guidelines
28/03/2003
WHO has not recommended restricting
travel to any destination in the world.
However, all travelers should be aware of the
main symptoms and signs of SARS. People
who have these symptoms and within the
previous 10 days have been in close contact
with a person who has been diagnosed with
SARS, or a history of travel to areas where
cases of SARS have been spreading (see
list), should seek medical attention and
inform health authorities of recent travel.
Travelers who develop these symptoms are
advised not to undertake further travel until
fully recovered.
Please note that this situation is rapidly
evolving and that the advice given will be
constantly changing as more evidence about
the causation and options for treatment
becomes available.
The public is advised to consult the home
page of the WHO SARS website:
http://www.who.int/csr/sars/en/ for daily
updates on the outbreak and relevant press
releases.
This advisory is given by the Ministry of Health
in collaboration with Immigration, Quarantine
and Travel Agencies in Solomon Islands, aimed
at preventing introduction of SARS into the
country and ensuring the health and well being of
the local population and visiting friends.
To ensure that appropriate health measures are
provided in case of an emergency, please respond to
the following questions:
Have you been to the following places / countries
within the last 10 days?






Guangdong Prov., China
Hongkong, SAR, China
Singapore
Hanoi, Vietnam
ROC / Taiwan
Toronto, Canada
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
If “Yes” are you experiencing the following
symptoms?



High Fevers
Coughs
Breathing Difficulties
Yes / No
Yes / No
Yes / No
If “Yes” to any of the above locations AND “Yes” to
any of the above symptoms, please report to the
Quarantine Desk at the arrival lounge.
If you state “Yes” to any of the above locations and
“No” to all of the above symptoms, you are advised to
report to the nearest hospital or see your doctor in the
event that you start to have these symptoms within the
next 7 days and present this advisory.
Full Name……………………………….…………….
Passport No.…………………………………………..
Nationality:……………………………………………
Address in Solomon Islands:
………………………………………………………
………………………………………………………
ANNEX 6
Health Advice on the
Prevention of Respiratory Tract Infections
(Hong Kong MOH)
Background

In view of a recent outbreak of febrile respiratory illness among health care staff in
Prince of Wales Hospital, the Department of Health is conducting a detailed
investigation with the Hospital Authority and the Hong Kong University and Chinese
University of Hong Kong to identify the cause of infection. The situation will be
monitored closely.

The Department of Health has informed the World Health Organization (WHO) about
the latest developments. Hong Kong is working closely with the WHO on disease control
and prevention.
Advice applicable to all

As a precautionary measure, members of the public are advised to take precautionary
measures to prevent respiratory tract infections:
o
Build up good body immunity. This means taking a proper diet, having regular
exercise and adequate rest, reducing stress and avoiding smoking
o
Maintain good personal hygiene, and wash hands after sneezing, coughing or
cleaning the nose
o
Maintain good ventilation
o
Avoid visiting crowded places with poor ventilation
o
Consult their doctor promptly if they develop respiratory symptoms
For schools and pre-school institutions

Child Care Centres / Kindergartens / Schools are advised to refer to the 'Guidelines on
Prevention of Communicable Diseases in Child Care Centres / Kindergartens / Schools'
published by the Department of Health in 2000 for general information on the
prevention of communicable diseases in school and institutional settings. This is
downloadable from the DH's website http://www.info.gov.hk/dh. Specific advice in the
school and institutional setting that helps to prevent respiratory tract infections
includes :
o
Cleanse used toys and furniture properly
o
Keep hands clean and wash hands properly
o
Cover nose and mouth when sneezing or coughing
o
Wash hands when they are dirtied by respiratory secretions e.g. after sneezing
o
Use liquid soap for hand washing and disposable towel for drying hands
o
Do not share towels
For other institutional settings

A 'Guidelines on Prevention of Communicable Diseases in Residential Care Homes for
the Elderly and People with Disabilities' published by the Department of Health is also
available for general information on the prevention of communicable diseases in the
PPHSN. SARS Guidelines
28/03/2003
particular institutional setting. This is downloadable from the DH's website
http://www.info.gov.hk/dh.
For health care workers in clinic setting

There is as at date no unusual upsurge of pneumonia cases in the community.

All clinic staff should enforce strict infection control measures appropriate for their
particular setting, especially observance of good personal hygiene.

If staff fall sick, they should report to their seniors and take sick leave as appropriate.

Where considered necessary, for example, treating or nursing a patient with respiratory
symptoms, staff may wear masks.

The Department of Health will continue to monitor the situation of the pneumonia cases
and issue advice accordingly.

Patients with respiratory symptoms are advised to wear mask to reduce the chance of
spread of the infection.
Caring for sick family members with respiratory illness

Patients should consult a doctor if they are unwell.

They should follow instructions given by the doctor including the use of drugs as
prescribed and taking adequate rest as appropriate.

Adhere to good personal hygiene practices.

Ensure adequate ventilation.

Patients should put on masks to reduce the chance of spread of infection to carers.

Carers may also put on masks to reduce the chance of acquiring infection through the
airways.
Advice to relatives visiting patients with pneumonia

Visitors to warded patients are advised to take due precautions in infection control, e.g.
wearing face mask and gowns and to wash hands thoroughly afterwards before coming
into contact with other people.
Notification of infections
If unusual patterns of illnesses/sick leave in any setting are detected, please notify
the respective Regional Office of the Department of Health. The contact numbers are
as follows :
PPHSN. SARS Guidelines
28/03/2003
ANNEX 7
Health Advice on the Prevention of
Respiratory Tract Infections in Public Places
(Hong Kong MOH)
Members of the public are advised to avoid frequenting crowded public places to
prevent the spread of respiratory tract infections. When visiting crowded places such as
cinemas and restaurants, the following precautionary measures should be taken :

Maintain good personal hygiene. Cover nose and mouth when sneezing or coughing

Dispose of used tissue paper properly

Keep hands clean. Wash hands when they are dirtied by respiratory secretions e.g.
after sneezing

Do not share towels

Consult your doctor promptly if you develop respiratory symptoms, and follow
instructions given by your doctor including the use of drugs as prescribed and
adequate rest as appropriate

Patients should put on masks to reduce the chance of spread of infection
Workers in public places should take the following precautionary measures to
reduce the chance of spread of infection :

Maintain good personal hygiene. Cover nose and mouth when sneezing or coughing

Wash hands after sneezing, coughing or cleaning the nose

Consult your doctor promptly if you develop respiratory symptoms

Allow plenty of fresh air into the indoor environment

If the facilities are mechanically ventilated, ensure frequent air exchanges and
proper maintenance and cleansing of the system

Ensure that toilet flushing apparatus is functioning properly

Provide toilets with liquid soap and disposable tissue towels or hand dryers

Cleanse and disinfect the facilities (including furniture and toilet facilities) regularly
(at least once a day), using diluted household bleach (i.e. adding 1 part of household
bleach to 99 parts of water), rinse with water and then mop dry

If the facilities are contaminated with vomitus, wash / wipe with diluted domestic
bleach (mixing 1 part of bleach with 49 parts of water) immediately
PPHSN. SARS Guidelines
28/03/2003
Infection Control ~ Doing it Right, Each Time
Prepared by the Infection Control team, C&C DHB, 19 March 2003.
ANNEX 8
New Zealand MOH
Infection Control advice for the management of patients with
suspected Severe Acute Respiratory Syndrome (SARS)*
For detailed case definition and clinical management recommendations please consult the
bulletin sent electronically to all C&C DHB staff on 18 March. Notify the Clinical
Microbiologist/Infectious Diseases physician on call of any new suspected cases.

SARS – should be suspected in patients presenting with symptoms of atypical pneumonia and a
story within the last 10 days of recent travel or stay in South-East Asia or recent close contact
with unwell travellers to that region or other areas of reported transmission of SARS. The pattern
of illness suggests that SARS is infectious but at this stage the causative organism is unknown –
the emphasis must therefore be on minimising contact by good infection control procedures as
detailed below.
To minimise exposure of other patients, staff and hospital visitors, the World Health Organisation
and the US Centers for Disease Control & Prevention advise:
1. That all suspected SARS patients are managed in isolation using:
• Standard (blood/body fluid) Precautions especially use of barrier protection when dealing with any
blood or body fluids; use of masks (see airborne precautions below) plus eye protection if patients are
coughing or procedures are done which are likely to generate splashes or sprays of respiratory secretions
(eg. taking respiratory samples or suctioning) and scrupulous handwashing after removing gloves (see
contact precautions below). WHO recommends that HCWs must wear protective eyewear or faceshields during procedures where there is potential for generation of aerosols or splashing,
splattering or spraying of blood or other body substances (this recommendation is not included in
original NZ guidelines).
plus
• Airborne Precautions placement of the patient in a negative pressure air-conditioned room and use of
respiratory protection – particulate filter respirator masks (TB masks - Tecnol PCM 2000 mask) - by all
staff and visitors,
plus
• Contact Precautions use of non-sterile gloves and disposable, impervious isolation gown by all staff
and visitors for any contact with the patient, the patient’s body fluids, with patient care equipment or with
used linen or with waste
2. Patient masking for transport (ambulance or internal trolley transport) and short visits to other
clinical departments (eg. Radiology)
• Patient movement outside negative pressure rooms should be avoided as much as possible.
• A standard surgical mask (eg. Tecnol Procedure mask 6001 or any other droplet containing mask)
must be placed over the patient’s mouth and nose for transport through corridors and public areas
(eg. between clinical areas such as Emergency Department and Radiology / wards /units) or for
investigation in departments such as Radiology.
• Attending staff do not then require masks but should continue use of gloves and gown for direct
contact with the patient, with blood or body fluids or with patient equipment.
• Receiving departments should be advised of the patient’s isolation status when transfer or investigations
are ordered and patients must be escorted during transport between negative pressure areas to ensure
that appropriate precautions are maintained.
• See Equipment and Cleaning details below for advice on necessary equipment and
environmental surface cleaning and decontamination following procedures on suspected SARS patients.
PPHSN. SARS Guidelines
28/03/2003
3. Emergency Dept. and Ward management details
Isolation room details
• The patient must be isolated in a negative pressure single room – eg. rooms A3 or C7 in the Emergency
Dept. or a room (preferably with attached ensuite bathroom) within the airborne isolation area in Ward 17.
• The isolation room door must be kept closed at all times except when required by entry or exit of
personnel.
• A laminated “STOP” isolation sign (as distributed by the Infection Control Officers) must be placed on
the door or where it will be visible to all who enter the room
• The patient should leave the room only when clinically necessary (see point 2. above).
• Microshield 4 antiseptic handwash should be used for all handwashing within the room and at
adjacent washbasins outside the room (eg. in the anteroom) immediately following removal of protective
clothing on exiting the isolation room.
Handwashing is the most important hygiene measure for preventing the spread of infection.
Gloves are not a substitute for handwashing. Hands must be washed and gloves replaced before and
after significant contact with the patient, after activities involving handling of contaminated items and after
removal of gloves.
• All staff and visitors must put on mask, gowns and gloves as specified before entering the isolation
room.
• On leaving the isolation room, staff and visitors should remove gown, gloves and mask (in that order,
masks should be handled only strings); place them into a yellow Biohazard waste bin and immediately
wash their hands. (In Ward 17 this is done in the ante-room to the isolation rooms; in the Emergency
Dept. this must be done immediately outside the isolation room and then the nearest washbasin must be
used for handwashing.). These are single use items - fresh gowns, gloves and masks must be put on for
any subsequent entry into the isolation room.
• Provide patients with ample supplies of disposable tissues and teach them to cover their mouth and
nose when coughing or sneezing. Tissues must be handled and disposed of as Biohazard waste.
• Patient notes, including medicine and observation charts (and clinical staff’s pens) must not be kept or
taken into the room.
• Patient samples/specimens should be handled in the usual manner (placed in a Biohazard specimen
bag for transport to the laboratory accompanied by a completed request form)
Staff allocation
• The primary focus must be appropriate, skilled response to the clinical needs of the patient
• The nurse allocated to direct patient care on each shift is responsible for directing other health care
workers and visitors on the nature of the precautions required
• The number of staff allocated to the patient should be as small as possible to decrease the possibility of
transmission to other patients within the ward or to other areas of the hospital.
eg. Blood tests are to be taken by the Medical Officer ordering the test rather than being put out for
Phlebotomy service staff
• Whenever possible, care is provided by nurses/staff usually working in the ward
• If care cannot be provided from within the ward, the Coordinator Central Nursing, her deputy or the after
hours manager is contacted for assistance by the nurse in charge and consultation must include the
Clinical Microbiologist/Infectious Diseases physician on call
• A nurse employed by the Casual Resource may look after the patient only if s/he has the skills and
knowledge necessary to care safely and confidently for the patient, and the Central Nursing Coordinator
and the nurse agree to the assignment.
Equipment and supplies
• Disposable equipment should be used wherever possible in the treatment of patients with suspected
SARS.
• A range of sizes of non-sterile gloves must be available inside and at the entrance to the isolation room.
Gloves must be changed as clinically indicated and removed and disposed of in the Biohazard waste
each time personnel leave the isolation room.
• Disposable, impermeable isolation gowns are recommended (eg. Baxter yellow disposable isolation
gowns). Gowns are single use items and may not be kept for reuse – they must be removed and
PPHSN. SARS Guidelines
28/03/2003
disposed of in the Biohazard waste when personnel leave the isolation room and a new gown must be
worn for re-entry.
• Masks:
 Particulate filter respirator (Tb) masks must be available (eg. Tecnol PCM 2000 mask), preferably
the fluid repellent orange version (PCM 2000 reorder number 47707 – available from Supply
Dept.) and in the fluid repellent orange version with attached eyeguard (PCM 2000 reorder
number 47757 – available as a buy-in, 15/box).
 Standard surgical masks (eg. Tecnol Procedure mask 6001 – available from Supply Dept.) must
be available for use by the patient to prevent dispersal of respiratory droplets if the patient must
leave the isolation room.
 Masks are single use items and must be removed and disposed of in the Biohazard waste each
time staff and visitors leave the isolation room and a new mask must be worn for re-entry.
• Equipment and supplies necessary for patient treatment, safety and comfort must be available in the
isolation room but storage of supplies and equipment within the room must be kept to a minimum and be
replenished daily if necessary.
• All non-disposable equipment (eg. blood pressure cuffs, stethoscopes, tympanic membrane
thermometers and including mobile units such as X-ray machines, IV pumps etc.) that is taken into the
room must be decontaminated immediately after removal from the isolation room and before it may be
reused in the care of other patients. At a minimum, items will require cleaning by surface wiping with a
disposable cloth, detergent and water (or specialist products if these are normally used) and usual
disinfection and sterilisation processes should be used for items normally reprocessed by these methods.
• It is recommended that some dedicated items of non-disposable equipment (eg. blood pressure cuffs)
are left in the room for the duration of the patient’s isolation so that discharge/terminal cleaning only is
likely to be required.
• Bedpans and urinals should be emptied and reprocessed (immediately after use ie. Should not be left
unprocessed on communal dirty benches in utility rooms) by the usual method in ward sanitisers. The
isolation nurse may need assistance from other nursing staff outside the isolation room to facilitate this
(these staff should use gloves, disposable aprons and facial protection when handling used toilet items
and plan the transfer of items so that minimal contamination of environmental surfaces occurs).
• Metal surgical instruments requiring sterilisation in the Sterile Production Centre can be placed in a clear
plastic bag, the opening secured and then returned in the usual container to SPC for routine
decontamination (full body and facial protective equipment is worn routinely in the SPC decontamination
area).
• A designated sharps container must be available in the room plus phlebotomy equipment if required
(tourniquet, vacutainer collection system, A.N.D. disposal unit for vacutainer needles, etc).
• The wash bowl is kept in the room for the duration of the isolation. It is cleaned with hot soapy water
after use, dried, then stored, inverted, off the floor. Bowls used to clean patients after incontinence
episodes are to be emptied in the sluice room, rinsed and wiped over with 1% Chlorine solution then
sanitised in the usual manner.
Food service
• Usual meal trays, plates and cutlery may be used. Menus and trays do not need special marking or
bagging as isolation items.
• After use, waste food should be disposed of within the isolation room and the trays and utensils should
be returned directly (with assistance from staff working outside the isolation area) to the Food Services
trolley for return to the kitchen for reprocessing. Staff in this area routinely wear protective clothing and
the usual machine dishwashing process is adequate to decontaminate the trays and utensils.
Linen and waste handling
• A linen skip (with a cloth linen bag lined with a hot water soluble alginate liner) and a Biohazard yellow
waste bag must be present in the isolation room.
• All waste (except sharps which must go into the sharps container) produced in the room must go into
the Biohazard waste bag.
• Care should be taken not to shake or flap the bedlinen. Change the bedlinen completely each morning
shift and carefully scoop and fold used linen to place it in the used linen container.
• Linen and waste bags are to be replaced at least daily and when two thirds full.
• Nursing staff are responsible for the closure and replacement of bags. Double bagging and labelling are
not required.
PPHSN. SARS Guidelines
28/03/2003
Visitors
• Visitors other than close family members should be discouraged as the causative organism and
infectivity of SARS is not yet clear and specific treatments have not yet been identified.
• Request visitors not to visit other patients in hospital if they are visiting patients with suspected SARS.
• All visitors must wear full protective clothing (gown, gloves and mask) to enter the isolation room. (See
procedures detailed for staff).
• Nursing staff are responsible for ensuring that visitors comply with isolation procedures and should
explain and assist as necessary.
Daily cleaning
• The isolation room must be cleaned daily.
• Under the direction of the Team Leader, Clinical Coordinator or deputy, the cleaner must be directed
and shown how to use full protective clothing (gown, gloves and mask).
• The room (and ensuite) must be cleaned last of all the rooms on the ward. Disposable cleaning cloths
must be used.
• The cleaner must dust to a height of 6 feet the door, bed frame, bed light, window sills and furniture,
shelves and ledges, trolleys and equipment. Dust must not be shaken out of cleaning cloths but must be
contained by folding inwards.
• Locker tops, washbasins, taps and door handles must be cleaned with clean cloths, fresh hot water and
detergent.
• The floor must be wet mopped with clean hot water and detergent.
• Isolation bathroom areas must be cleaned following the isolation room, using the same precautions.
• Dispose of all cleaning cloths in the Biohazard bag in the isolation room. The mop head must be placed
in an alginate liner bag before being sent to the Laundry for routine laundering – special labelling is not
required.
• The bucket is to be washed thoroughly with hot water and detergent and turned upside down to dry.
• The cleaner must be shown how and where to take off protective clothing in a safe manner, dispose of it
into a Biohazard container and instructed to wash their hands immediately.
Terminal cleaning (on patient discharge)
• Infection Control advice must be sought for the decontamination complex equipment.
• Nursing staff are responsible for supervising the safe stripping and cleaning of the isolation room and
bathroom including instructing and supervising the cleaner in putting on protective clothing.
• Strip the bed of linen. Check for breaks in the impervious covering of the pillow and mattress.
Only when breaks are detected - dispose of these items as Biohazard waste (pillows can be placed in a
Biohazard waste bag; if mattresses are to be disposed of they must be contained within clean large
plastic bags, clearly labelled as intended for Biohazard waste and Orderlies should be contacted to collect
and place them directly into a large yellow Biohazard waste bin for transport to the Infectious Waste
room.)
• Dispose of disposable equipment (used or unused stock) and other waste into the Biohazard waste bag.
• Leave the waste and linen bags to be tied off by the cleaner once cleaning is completed so that cleaning
cloths and protective clothing can be discarded safely.
• The cleaner must clean all the surfaces including isolation bathrooms and floors as listed in the daily
cleaning requirements with clean disposable cloths, clean hot water and detergent.
• All cleaning cloths must be disposed of into the Biohazard waste bag. Mop heads must go to the
Laundry as detailed above in Daily cleaning and the bucket must be cleaned as above.
• Curtains:
 In the Emergency Department, ask the cleaner to check the curtains for soiling; if present, ask for
the curtains to be changed.
 In the ward or unit setting, ask the cleaner to change the curtains. (New curtains must not be put
up until the room has been fully cleaned and aired for 1 hour following completion of cleaning).
• The cleaner must be shown how and where to take off protective clothing in a safe manner, dispose of it
into a Biohazard container and instructed to wash their hands immediately.
• The rooms should be left with the door closed for 1 hour before the bed is remade, curtains are rehung
and the room is re-occupied. This is to allow for sufficient air changes to occur to ensure removal all
possibly contaminated air.
PPHSN. SARS Guidelines
28/03/2003
This information is subject to change and updating as further information and direction comes to
hand from WHO, CDC and the NZ Ministry of Health.
For further infection control advice
• Please contact an Infection Control Officer (Clo Taylor on ext/page 5925 or Viv McEnnis on ext/page
6514).
References
1. Garner JS, Hospital Infection Control Practices Advisory Committee “Guidelines for Isolation
Precautions in Hospitals” Infection Control & Hospital Epidemiology 1996; 17: 53-80.
2. US Centers for Disease Control and Prevention information – Severe Acute Respiratory Syndrome
“Interim Information and Recommendations for Health Care Providers” 15 March 2003.
3. NZ Ministry of Health – information distributed electronically on 18 March 2003 and sourced from WHO
and CDC.
PPHSN. SARS Guidelines
28/03/2003
ANNEX 9
Assessment of Risk and Capacities to Respond to a Multi-country outbreak of
Severe Acute Respiratory Syndrome
The following information has been prepared to assist WHO WRs and CLOs when liasing with
national health authorities (NHA) regarding public health response to the current outbreak of
Severe Acute Respiratory Syndrome (SARS). PPHSN thinks that this information should also be
obtained from countries without WHO offices so that arrangements can be made to enhance our
preparedness. PPHSN has already circulated interim guidance about SARS which will be updated
continuously and circulated, as knowledge about this disease increases.
(1) WPRO has provisionally categorized member countries based on 3 levels of risk and 3 levels
of capability to respond to the outbreak.
Risk Categories
R1
countries where cases have been reported
R2
where traffic risks exist between these and R1 countries
R3
all other WPR countries
Capability to Respond Categories
C1
countries needing the most assistance from WHO in terms of
emergency supplies, enhanced surveillance and technical
assistance
C2
countries with limited national resources and requiring
some emergency assistance
C3
countries not requiring much assistance except for technical
advice and international network coordination
Category R1
C1
Vietnam
C2
China
C3
Singapore
R2
Cambodia
Lao PDR
Northern Mariana Islands
Malaysia
Philippines
Macao SAR
Republic of Korea
Brunei Darussalaam
Guam
Australia
Japan
New Zealand
R3
PNG
Mongolia
All other PICs
Fiji
New Caledonia
* This assessment is current as of 20 March 2003. Revisions may be necessary as the SARS
epidemic evolves, and will be included as necessary in subsequent updates.
A kit of supplies developed to address initial requirements for management of an outbreak of SARS
in select countries will be dispatched this week to Laos, Mongolia, Cambodia, Papua New Guinea
and Fiji (2 kits). A list of contents is attached.
Attachments
WPRO SARS Preparedness Kit contents list.
PPHSN. SARS Guidelines
28/03/2003
Check list for National Health Authorities
PPHSN requests that EpiNET focal points please liase with their health authorities
to complete the following information about preparedness to deal with cases of
SARS.
WHO / National SARS Preparedness Checklist
(attach additional pages if necessary) .
Action.
Details.
Status / contact details (tel/fax
–office and after hours), email
WHO Country Focal
Point
National Focal Point
Point of first contact for national
and WPRO SARS
MOH/DOH designated SARS focal
point / coordinator
Hospital with isolation (preferably
intensive care) facilities designated
by MOH /DOH for SARS
admissions
Laboratory with appropriate
infection control capability
designated by MOH /DOH for
SARS specimen processing and/or
trans-shipment. Consider P3 / Polio
Reference Laboratory if available,
or measles reference lab, in close
proximity to isolation centre
WR or CLO in countries where
present
Designated SARS
Isolation Facility (s)
Designated SARS
laboratory
Institute Pasteur
Alain Berlioz-Arthaud,
Laboratoire de Biologie Medicale,
Institut PASTEUR de Nouvelle Caledonie,
BP 61, 98845 Noumea, New Caledonia.
Tel : +(687) 27.02.85
Fax :
+(687) 27.33.90
Email : [email protected]
WHO Collaborating Centre for
Reference and Research on
Influenza, Australia
Ian Barr
WHO Collaborating Centre for Reference
and Research on Influenza
45 Poplar Road, Parkville.
Victoria, Australia 3052
Tel
+(61) 3 9389 1761
Fax
+ (61) 3 9389 1881
Email [email protected]
National SARS
preparedness
stockpile
Immediately
identifiable
requirements from
WHO.
Other national SARS
preparedness
activities.
Readily available barrier nursing
and pathology equipment secured
by DOH/MOH, (available, and
planned. See attached WPRO
SARS Preparedness Kit list for
guidance.
Refer to attached WPRO SARS
Preparedness Kit list.
Action taken so far by national
health authorities.
PPHSN. SARS Guidelines
28/03/2003
Daily Updates
Please advise whether you can access the WHO daily epidemiologic update via the
[ ] internet (http://www.who.int/csr/sars/)
or would you like a copy sent by:
[ ] fax
[ ] email as attachment
After completion
Please return completed form by email or fax to:
PPHSN-CB Focal Point
Dr Tom Kiedrzynski
Epidemiologist (Ag)
Secretariat of the Pacific Community, PPHSN-CB Focal Point
SPC PO Box D5
98848 Noumea cedex
New Caledonia
Tel: +(687) 26 20 00 or 01 43
Fax: +(687) 26 38 18
Out of hours +(687) 259236
E-mail: [email protected]
WHO South Pacific
Dr Kevin Carroll
MO/Epidemiologist
WHO South Pacific
PO Box 113
Suva, Fiji
Tel
+(679) 3304 600
Fax
+(679) 3300 462
Out of hours +(679) 99202971
Email [email protected]
PPHSN. SARS Guidelines
28/03/2003
ANNEX 10
WPRO SARS Preparedness Kit contents list.
The list below is designed to provide essential equipment for barrier nursing and pathology
collection for suspected SARS cases. It is based on estimated needs for maximum 50 health
workers per day for 3-4 days, and high-level protection for 6-8 procedural / laboratory workers for a
similar period.
INFECTION CONTROL EQUIPMENT
Coveralls
Disposable Aprons (yellow)
Shoe covers
Hair cover (bouffant)
Safety glasses
Non-fog goggles
UVEX goggles
Hepa Mask
N95 particulate mask
Disposable gloves
Surgical gloves
Anti-microbial waterless
hand-wash
Anti-microbial waterless
hand-wash refills
Absorbent laboratory mat
Aprons: impermeable
Rubber boots
30
200
200 pair
200
30
50
10
30
200
500 pair
150
10
bottles
10
bottles
2 rolls
200
10 pairs
10 large, 10 medium, 10 small (includes hood) polypropylene
Biohazard disposal bags
100
autoclavable
Polypropylene
2-lens
Can be worn with glasses/spectacles
100 large, 200 medium, 200 small
> 60% alcohol, with emollient ('Sterillium 1000ml) dispensor
(Sterillium 1000 ml)
3 x 50ft
2 L, 4 M, 4 S
LABORATORY EQUIPMENT
Sterile cotton swab sticks
Vacutainer 5 ml EDTA
Vacutainer 5ml plain
Vacutainer needles
Vacutainer adapters
Syringe 5ml
Butterfly needles
Sterile screw-top plastic
specimen containers
1 box
1 box
1 box
200
200
100
50
25 ml
(1000)
(50)
(100)
100
SPECIMEN SHIPPING
Bio-bottles 0.5L shipping
containers
Cryogenic vials 5ml
Cooler, large capacity
Ice packs
Ziplock bags
PPHSN. SARS Guidelines
28/03/2003
2
100
1
12
200
For transport of field specimens