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INFECTION CONTROL MANUAL
Chapter 38
SARS (Severe Acute Respiratory Syndrome)/MERS (Middle
Eastern Respiratory Syndrome) Policy
Version 5
Document Summary
This policy provides guidance for the appropriate actions and responsibilities
for the management of patients with SARS (Severe Acute Respiratory
Syndrome) caused by SARS coronavirus (SARS CoV) or Middle Eastern
Respiratory Syndrome coronavirus (MERS-CoV).
DOCUMENT NUMBER
APPROVING COMMITTEE
DATE APPROVED
DATE IMPLEMENTED
NEXT REVIEW DATE
ACCOUNTABLE DIRECTOR
POLICY AUTHOR
TARGET AUDENCE
KEY WORDS
STHK0039
Patient Safety Council
10 September 2014
1 October 2014
1 October 2017
Sue Redfern, Director of Nursing, Midwifery &
Governance
Karen Allen, Director of Infection Prevention &
Control
All clinical staff
SARS, Severe Acute Respiratory Syndrome,
SARS coronavirus, MERS coronavirus, SARS
CoV, MERS-CoV, MERS, coronavirus.
Important Note:
The Intranet version of this document is the only version that is maintained.
Any printed copies should therefore be viewed as “uncontrolled” and, as such,
may not necessarily contain the latest updates and amendments
Infection Control Manual - Chapter 38- SARS/MERS Policy – Version 6 (clinical)
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St Helens & Knowsley Teaching Hospitals NHS Trust
Document Version History
Date
Version
Summary of key changes
Author
Designation
1
DIPC
2
DIPC
3
DIPC
4
DIPC
5
Format changed.
DIPC
Page 10: References to wards in old
build removed.
Page 14: Spillage of blood: addition of
Haz-Tab rinse.
Page 18: Contact details updated.
Page 19: Reference updated
Format updated.
DIPC
Information on MERS-CoV added.
1st May 2003
1st
December 2004
1st December 2006
1st November 2008
1st
October 2011
6
1st October 2014
1st
October 2017
Review
date
Infection Control Manual - Chapter 38- SARS/MERS Policy – Version 6 (clinical)
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CONTENTS
Item No.
Subject
Page No.
1.
2.
3.
4.
5.
6.
6.1
6.2.
6.3
6.4
6.5
6.6
6.7
6.8
6.9
6.10
Scope
Introduction
Statement of Intent
Definitions
Duties, Accountabilities and Responsibilities
Process
Coronavirus infections
Case definitions for SARS & MERS-CoV
Treatment for SARS & MERS-CoV
Infection Control Precautions for SARS & MERS-CoV
Notification of SARS/MERS-CoV
Diagnosis of SARS & MERS-CoV
Laboratory precautions
In the event of death
Further advice
Glossary
4
4
4
5
5
5
5
6
7
8
14
15
15
16
16
17
7.
8.
8.1.
8.2.
9.
10.
11.
Training
Monitoring compliance
Key Performance Indicators of the Policy
Performance Management of the Policy
References and Bibliography
Related Policies and Procedures
Equality analysis
Appendix A: SARS surveillance reporting forms
Appendix B: SARS information sheet for visitors
Appendix C: Information for contacts of cases of SARS
Appendix D: Staff contact record sheet for SARS & MERS-CoV
Appendix E: SARS coronavirus diagnosis
Appendix F: MERS-CoV case algorithm
Appendix G: Putting on and removing personal protective
equipment
17
17
17
17
18
18
18
19
23
25
26
27
28
29
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1. Scope
This policy applies to all clinical staff within St Helens and Knowsley Teaching
Hospitals NHS Trust and describes the management of patients with serious
coronavirus infections e.g. SARS/MERS-CoV.
2. Introduction
Coronaviruses
Human coronaviruses were first identified in the mid-1960s. They are common
viruses that most people get some time in their life. Human coronaviruses usually
cause mild to moderate upper-respiratory tract illnesses. Coronaviruses are named
for the crown-like spikes (corona) on their surface. The six coronaviruses that can
infect people are:
 alpha coronaviruses 229E and NL63
 beta coronaviruses OC43, HKU1
 SARS-CoV (the coronavirus that causes severe acute respiratory syndrome,
or SARS), and
 MERS-CoV (the coronavirus that causes Middle East Respiratory Syndrome,
or MERS).
This policy applies to the latter 2 coronaviruses which are not common but have the
potential to cause life-threatening disease.
SARS
SARS (Severe Acute Respiratory Syndrome) is a term used to describe a serious
respiratory illness. Its main symptoms are high fever (≥38oC), dry cough and
shortness of breath or difficulty in breathing. Changes in chest X-rays indicative of
pneumonia also occur.
SARS coronavirus was first recognized in China in November 2002. It caused a
worldwide outbreak with 8,098 probable cases including 774 deaths from 2002 to
2003. Since 2004, there have not been any known cases of SARS-CoV infection
reported anywhere in the world.
MERS CoV
MERS-CoV was first reported in Saudi Arabia in 2012. As of September 20, 2013, a
total of 130 cases of MERS-CoV from eight countries have been reported to WHO.
Most people who have been confirmed to have MERS-CoV infection developed
severe acute respiratory illness. Mortality rate is high (approximately 45%). All cases
have been directly or indirectly linked through travel to or residence in four countries:
Saudi Arabia, Qatar, Jordan, and the United Arab Emirates (UAE).
There are some differences between SARS and MERS coronaviruses (CoVs).
MERS-CoV patients have shorter time from illness onset to clinical presentation and
requirement for ventilatory support (median seven days; range 3-11) than SARS-CoV
patients, as well as associated higher respiratory tract viral loads during the first
week of the illness.
See references (section 9) for latest updates from PHE/WHO.
3. Statement of Intent
The objective of the policy is to reduce transmission, to patients and staff, of serious
coronavirus infections with the use of correct isolation precautions.
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4. Definitions
SARS is the acronym for Severe Acute Respiratory Syndrome, a serious respiratory
illness caused by SARS coronavirus.
MERS-CoV is the acronym for Middle East Respiratory Syndrome Coronavirus, the
virus that causes MERS (Middle East Respiratory Syndrome).
5. Duties Accountabilities and Responsibilities
For full details of infection control responsibilities see Infection Control Policy,
Chapter 28B Infection Control Manual.
5.1. Staff
It is the responsibility of all clinical staff to:
 be aware of the current guidelines.
 put these guidelines into practice.
 bring to the attention of the Unit Manager or Infection Prevention and Control
Team any problems in applying these guidelines
Breaches of this policy may lead to disciplinary action being taken against the
individual.
5.2. Unit managers (person in charge of a ward or department) must ensure that
 The policy is readily accessible to all staff.
 The required facilities and equipment are available to enable compliance with
the policies.
 All staff within their area of responsibility have received training in the
appropriate procedures with respect to infection control.
6. Process
6.1 Coronavirus infections
6.1.1 Coronaviruses
Coronaviruses are common viruses that most people get some time in their life.
Human coronaviruses usually cause mild to moderate upper-respiratory tract
illnesses. The six coronaviruses that can infect people are:
 alpha coronaviruses 229E and NL63
 beta coronaviruses OC43, HKU1
 SARS-CoV (the coronavirus that causes severe acute respiratory syndrome,
or SARS), and
 MERS-CoV (the coronavirus that causes Middle East Respiratory Syndrome,
or MERS).
This policy applies to the latter 2 coronaviruses which are not common but have the
potential to cause life-threatening disease.
6.1.2 Transmission
Coronaviruses are mainly transmitted by large respiratory droplets and direct or
indirect contact with infected secretions. They have also been detected in blood,
faeces and urine and, under certain circumstances, airborne transmission is thought
to have occurred from aerosolised respiratory secretions and faecal material.
Meticulous attention to infection control procedures can successfully prevent the
spread of coronaviruses within a healthcare setting. Personal protective equipment
and good infection control can never completely eliminate risk and therefore staff
exposed to coronaviruses should be vigilant for symptoms for ten days after they
were last exposed to a patient with coronavirus infection e.g. SARS/MERS-CoV.
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6.1.3 Incubation period:
The incubation period is around 2-10 days for SARS and 2-14 days for MERS-CoV
6.1.4 What countries are high risk?
6.1.4.1 SARS
Currently, there are no known cases worldwide but the possibility of re-emergence
remains, particularly in whole of mainland China, especially Guangdong Province,
and Hong Kong SAR (Special Administrative Region of China). The World Health
Organisation and Health Protection Agency will issue country alerts as appropriate in
the event of a potential increase in the incidence of cases of SARS.
6.1.4.2 MERS-CoV
Cases of MERS-CoV have originated from Bahrain, Iraq, Israel, Jordan, Kingdom of
Saudi Arabia, Kuwait, Lebanon, Occupied Palestinian territories, Oman, Qatar, Syria,
UAE and Yemen. For an up-to-date list of countries, check the WHO/CDC websites.
6.1.5 Prognosis
SARS mortality is 4-10%.
MERS-CoV mortality may be as high as 30% (based on 2014 figures, Centers for
Disease Control and Prevention, USA).
6.2 Case definitions for SARS & MERS-CoV
6.2.1 SARS case definitions (possible, probable & confirmed)
Possible case
The respiratory illness should be severe enough to warrant hospitalisation and
include:
Fever ≥38°C (documented or reported)
AND
One or more symptoms of lower respiratory tract illness (cough,
difficulty breathing, shortness of breath)
AND
Radiographic evidence of lung infiltrates consistent with pneumonia or
Respiratory Distress Syndrome (RDS) OR autopsy findings consistent
with the pathology of pneumonia or RDS without an identifiable cause.
AND
No alternative diagnosis to fully explain the illness
AND
within ten days of onset of illness, a history of travel to an area classified by
WHO as a potential zone of re-emergence of SARS (This currently includes
the whole of mainland China, especially Guangdong Province, and Hong Kong
SAR).
OR
Within ten days of onset of illness, a history of exposure to laboratories or
institutes which have retained SARS virus isolates and/or diagnostic
specimens from SARS patients.
Probable Case
An individual with symptoms and signs consistent with clinical SARS and with
preliminary laboratory evidence of SARS CoV infection based on the following:
Either
Single positive antibody test for SARS CoV
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Or
Positive PCR for SARS-CoV on a single clinical specimen and assay
Confirmed case
An individual with symptoms and signs consistent with clinical SARS and with
laboratory evidence of SARS-CoV infection based on one or more of the following:
a) PCR positive for SARS-CoV from:
At least two different clinical specimens (e.g. nasopharyngeal and stool) OR
The same clinical specimen collected on two or more occasions during the
course of the illness (e.g. sequential nasopharyngeal aspirates) OR
Two different assays on the original clinical sample on each occasion of
testing.
b) Seroconversion by ELISA or IFA
6.2.2 MERS CoV (see Appendix F)
Possible case
Any person with severe acute respiratory infection requiring admission to hospital:
With symptoms of
Fever (≥ 38⁰C) or history of fever, and cough
AND
With evidence of pulmonary parenchymal disease (e.g. clinical or
radiological evidence of pneumonia or Acute Respiratory Distress
Syndrome (ARDS)
AND
Not explained by any other infection or aetiology
AND AT LEAST ONE OF
History of travel to, or residence in an area where infection with MERS-CoV
could have been acquired in the 14 days before symptom onset (see above
for list of countries).
OR
*Close contact during the 14 days before onset of illness with a confirmed
case of MERS-CoV infection while the case was symptomatic
OR
Healthcare worker based in ICU caring for patients with severe acute
respiratory infection, regardless of history of travel or use of PPE
OR
Part of a cluster of two or more epidemiologically linked cases within a two
week period requiring ICU admission, regardless of history of travel
*Close contact is defined as:
• prolonged face-to-face contact (>15 minutes) with a symptomatic
confirmed case in a household or other closed setting OR
• healthcare or social care worker who provided direct clinical or personal care
or examination of a symptomatic confirmed case ,or within close vicinity of
an aerosol generating procedure AND who was not wearing full PPE(6.4.2) at
the time
6.3 Treatment
There is no specific treatment for SARS or MERS-CoV. Treatment is supportive.
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6.4 Infection control precautions
6.4.1 Patient presenting to Emergency Department
Ideally, patients referred to hospital with probable SARS should be admitted
directly to a single hospital room without going via Emergency Department.
However if a patient presents to Emergency Department:






They should be rapidly diverted by triage nurses to a separate room to
minimise transmission to others.
They should be given a surgical face mask to wear.
Patients should be advised to cough/sneeze into a paper tissue and
dispose of this safely into the toilet, or a plastic bag tied off at the top, prior
to placing it in a bin.
Patients’ hands should be frequently washed, particularly after contact with
body fluids (e.g. respiratory secretions, urine or faeces).
Staff involved in the triage process must wear full protective clothing as
listed below and wash hands before and after contact with any patient,
after activities likely to cause contamination e.g. cleaning of the
environment and after removing gloves.
The room should be decontaminated before being used again.
6.4.2 Personal protective equipment (PPE) must be worn by all staff and visitors
accessing the isolation room. The PPE worn in this situation must include:

A filter mask (FFP3 respirator) must be worn. Ordinary surgical masks are
not effective. Masks are disposable and should not be reused. Care should
be given to face-fit. If an FFP3 respirator is not immediately available, an
FFP2 respirator may be used as an emergency but FFP3 masks must be
sought without delay.
 Single pair of gloves e.g. non-sterile surgical gloves.
 Eye protection e.g. tight-fitting goggles or visor (disposable or wipeable,
not with elastic straps). Prescription glasses do NOT provide adequate
protection.
 Disposable gown (long sleeved fluid-repellent)
 Plastic apron
This equipment is available in Emergency Department (who will supply Emergency
Department, 1B, 1C or OBS) or from the Equipment Pool (for the rest of the hospital).
All respiratory wards must have a supply of FFP3 filter masks.
Gown, goggles/visor and gloves should be placed in yellow (clinical waste) bin inside
the room immediately before leaving. The respirator must be removed outside the
room. Respirator mask should be placed in yellow (clinical waste) bin outside the
room. See Appendix G for full details.
6.4.3 Hand washing is crucial.
Hands should be washed before and after contact with any patient, after activities
likely to cause contamination and after removing gloves. Alcohol hand rub should
only be used on visibly clean hands.
Rings, wrist watches and wrist jewellery must not be worn by staff.
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6.4.4 Isolation
Isolate in lobbied single room with the door kept closed.
Possible SARS/MERS-CoV cases should be isolated in a lobbied single room (with
negative pressure ventilation) while they are symptomatic or until an alternative
diagnosis is made. They must NOT be cared for on an open ward. The door must be
kept closed. An airborne isolation poster must be affixed to the door.
Should the numbers of affected patients be such that lobbied single room isolation is
not possible, patients may be isolated in ordinary side rooms or cohorted together in
a bay. The Infection Prevention and Control Team will assist with a risk assessment.
6.4.5 Staff who care for the patient
 Non-essential staff (including students) should not be allowed into the isolation
room.
 All staff, including ancillary staff should be trained in the infection control
measures required for the care of such a patient.
 A member of staff e.g. Infection Control link nurse, must be identified who will
have the responsibility of observing the practice of others and provide feedback
on Infection Control.
 The use of bank or agency staff should be avoided wherever possible.
 Staff involved in the care of SARS/MERS-CoV cases should avoid working in
other parts of the hospital or in other hospitals until they are past the incubation
period of SARS/MERS-CoV i.e. 10 (SARS) or 14 (MERS-CoV) days following last
contact with a case.
 Staff must comply with all infection control procedures as detailed.
 A record of all staff caring for the patient must be maintained (record sheet at
Appendix D). The record sheet should be placed at the door and all staff entering
must complete this. This record should be sent to the Health, Work and Wellbeing
Department each day.
 All healthcare workers should be vigilant for symptoms of SARS in the ten days
(SARS) or 14 days (MERS-CoV) following last exposure to a case and should not
come to work if they have a fever or cough. Further advice should be sought from
the Infection Prevention and Control team and Health, Work and Wellbeing
Department. Their local Health Protection Team will advise on where they should
be medically assessed. During this period, possibly infected workers should avoid
close contact with persons both in the hospital and in the general community.
 Healthcare workers returning from an affected area should return to work as
normal unless, they are unwell and have symptoms consistent with
SARS/MERS-CoV, in which case they should stay off work and phone their GP
for assessment or they are well, but have been in close contact with a
SARS/MERSCoV case, or worked in a healthcare setting where cases were
being treated. Healthcare staff in this group should avoid contact with patients for
14 days after departure from an affected area, should contact their local Health,
Work and Wellbeing department, and monitor their own health for 14 days,
seeking medical advice if they become unwell.
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6.4.6 Equipment
 Use dedicated equipment inside the isolation room. Stethoscopes and other
equipment have the potential to spread infection. Stethoscope and
sphygmomanometer should be left in the isolation room for the duration of
stay.
 Disposable equipment should be used wherever possible in the treatment and
care of patients with SARS and disposed of as clinical waste inside room. If
devices are to be reused, they should be sterilised in accordance with
manufacturers’ instructions (e.g. 1000ppm hypochlorite).
 Closed system suction should be used.
 Do not use equipment that re-circulates air e.g. fans, hot air warming blankets
as this has the potential to turn a negative pressure room into a positive
pressure room.
 Ventilators should be protected with high efficient filter e.g. BS EN 13328-1
and standard decontamination procedures followed.
6.4.7 Cleaning
 There must be exceptional standards of environmental hygiene (even in areas
e.g. Emergency Department were patients have only been cared for temporarily).
 Domestic staff must be made aware of the need for additional precautions and be
trained in these.
 Daily cleaning should be carried out with 1000ppm available chlorine
(Chlorclean).
 Domestic staff to wear protective clothing as indicated above (6.4.2).
 The isolation area should be cleaned after the rest of the ward area.
 Dedicated or disposable equipment must be used for cleaning.
 Cleaning equipment must be decontaminated with a 1000ppm available chlorine
solution (Chlorclean) following use.
6.4.8 Visitors
Visitors should be kept to a minimum. A list of all visitors should be kept. They should
be issued with personal protective equipment (PPE), same as for staff, and
supervised closely. Provided they are healthy there is no problem with them mixing
with other people on the ward while waiting to visit. Contacts are free to continue with
usual activities unless they become unwell.
Close contacts with either fever or respiratory symptoms should not be allowed onto
the ward to visit. They should be advised to consult their GP by phone. The local
Health Protection Team will co-ordinate follow-up of contacts of SARS patients.
6.4.9 Management of contacts of cases of SARS/MERS-CoV
6.4.9.1 Management of contacts of SARS
Management of close contacts a possible case of SARS
 Give information on SARS to the contact (See Appendices B & C)
 No specific follow-up is needed for contacts of possible cases.
 A close contact who develops symptoms of SARS within ten days of contact
with a possible case should phone their GP and seek medical advice. They
should inform medical staff of their contact with a possible case.
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Management of close contacts of probable cases of SARS
 Generate a list of such contacts and record the date on which they last had
contact with the case
 The clinical team will liaise with the local CCDC / Health Protection team who
will arrange follow-up of contacts as follows:
On day one, the GP or local Health Protection Team will telephone the
contact to assess their health and provide them with information on SARS.
On day ten following last contact with the case the GP or local Health
Protection Team will telephone the contact to assess their health.
If the contact develops symptoms consistent with SARS they should be
assessed at home by their GP rather than in the practice setting. If the patient
meets the clinical case definition for SARS, they should be referred to hospital.
If the contact is mildly unwell, they should be managed at home by their GP.
While at home, the patient should keep contact with others to a minimum until
their symptoms have resolved and they have been afebrile for 48 hours. GPs
should contact the patient regularly during the course of the patient’s illness.
Management of contacts of confirmed cases of SARS
Voluntary home isolation is recommended for a close contact of a confirmed case of
SARS. Such close contact should stay indoors and keep contact with other people to
a minimum for a period of 10 days from the time of last contact with the case. They
should monitor their health for SARS symptoms over this 10 day period, and phone
their GP if they develop any symptoms. In addition, the GP or local health protection
team should telephone the contact daily during 10 day incubation period to assess
their health.
6.4.9.2 Contacts of cases of MERS-CoV
Contacts will be managed as per current PHE advice:
http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1317136270963
6.4.10 Transfer of patients to other departments
 Where possible, all procedures and investigations should be carried out in the
single room. Only a minimal number of staff should be present in room during
any procedures.
 Only if clinical need dictates should patients be transferred to other
departments and the following procedures then apply:
 The department must be informed in advance.
 The patient must be taken straight to and from the
investigation/treatment room, and must not wait in a communal
area.
 Ideally patients should be at the end of a list to allow appropriate
decontamination after any procedure.
 The patient should wear a 'surgical ' mask - this will prevent large
droplets being expelled into the environment by the wearer.
 The trolley/chair should be wiped with a 1000ppm available
chlorine solution (Chlorclean) after use
 Staff carrying out procedures must wear the protective clothing
indicated above (6.4.2).
 The treatment/procedure room and all equipment should be
cleaned with a 1000ppm available chlorine solution (Chlorclean).
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
SARS and MERS-CoV can survive in the environment for at
least 48 hours, so environmental decontamination is vital.
If ambulance transfer is required, they must be informed in advance and will transport
the patient using category 3 containment measures.
6.4.11 Transfer to other institutions
 Transfer of SARS/MERS-CoV cases to another hospital should be avoided
unless it is absolutely necessary for medical care.
 SARS/MERS-CoV patients should not be transferred solely for the purpose of
accommodation in a negative pressure room.
 Transfer of other patients who may have been exposed to SARSMERS-CoV
and could be incubating disease should also be avoided.
 If transfer is essential, the Infection Prevention & Control Team at the
receiving hospital and the ambulance staff must be advised in advance of the
special circumstances of the transfer.
6.4.12 Intensive care
 To reduce the risk of difficult intubation in an emergency situation without
adequate infection control, SARS/MERS-CoV patients should be transferred
early to intensive care if their condition is deteriorating and consideration given
to early planned intubation by an experienced operator.
 All respiratory equipment must be protected with a high efficiency filter e.g. BS
EN 13328-1 that has viral efficiency to 99.99% (FFP3)
 Disposable respiratory equipment should be used wherever possible. Reusable equipment must, at a minimum, be disinfected in accordance with
manufacturer’s instructions.
 The ventilator circuit should not be broken unless absolutely necessary.
 Ventilators must be placed on standby when carrying out bagging.
 Protective clothing as detailed above to be worn (6.4.2).
 The use of non-invasive positive pressure ventilation equipment should be
avoided as it carries increased risk of transmission of infection.
 Water humidification should be avoided and a heat and moisture exchanger
should be used if possible.
 Only essential staff should be in the patient’s room when aerosol generating
procedures e.g. airway management, cough inducing activities or nebulisation
of drugs is being carried out.
6.4.13 Theatres
 Theatres must be informed in advance.
 The patient should be transported directly to the operating theatre and should
wear a surgical mask if it can be tolerated.
 The patient should be anaesthetised and recovered in the theatre.
 Staff should wear protective clothing as detailed above (6.4.2).
 Disposable anaesthetic equipment should be used wherever possible.
 Re-usable anaesthetic equipment should be decontaminated in line with
manufacturer’s instructions.
 The anaesthetic machine must be protected by a filter with viral efficiency to
99.99%.
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


Instruments and devices should be decontaminated in the normal manner.
Instruments must be transported safely.
The theatre should be cleaned using a 1000ppm available chlorine solution
(Chlorclean).
Theatres should not be used for 15 minutes after the patient leaves if
conventionally ventilated, or 5 minutes if ultraclean ventilation is used.
6.4.14 High risk procedures (aerosol-generating procedures)
 Procedures that produce aerosols of respiratory secretions, e.g.
o bronchoscopy,
o induced sputum
o positive-pressure ventilation via a face mask,
o intubation
o extubation
o airway suctioning
o chest physiotherapy
o or any other intervention which may disrupt the respiratory tract or
place the healthcare worker in close proximity to the patient and
potentially infected secretions.
carry an increased risk of transmission.
 Where these procedures are medically necessary, they should be
undertaken in a negative pressure room i.e. lobbied single room. The
minimum number of required staff should be present and all staff present in
the room must wear personal protective equipment (PPE) as described
above (6.4.2) including goggles/visor. Entry and exit from the room should
be minimised during the procedure.
 If a room is used for a procedure it should be left for 20 minutes, cleaned
and is then ready for re-use. This is because the large particles will fall out
within seconds and the small aerosol particles will behave almost as a gas.
Clearance of any aerosol is dependent on the ventilation of the room. In
hospitals this is usually around 12-15 air changes per hour, and so after
about 20 minutes there would be less than 1 per cent of the starting level
(assuming cessation of aerosol generation).
6.4.15 Taking blood
Only trained staff should take blood. Do not re-sheath needles. Dispose of sharps
into a sharps box at the bedside. Do not leave sharps for others to clear away.
Specimens and request forms must be labelled as high risk.
6.4.16 Spillage of blood
Wear gloves and apron. Sprinkle sodium dichloroisocyanurate (10,000 ppm chlorine
releasing) Haz-Tab granules over spillage. Wait for 2 minutes. Wipe clean using a
paper towel. Discard paper towel into yellow clinical waste bag. Rinse disinfected
area thoroughly with Haz-Tab solution 10,000ppm. Wipe dry. (See Chapter 9
Infection Control Manual).
6.4.17 Crockery
Crockery should be treated as normal and washed in central dishwasher.
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6.4.18 Clinical waste
Dispose of all waste as clinical waste; in particular, ensure the appropriate disposal
of faeces and urine.
Clinical waste must be placed in a yellow plastic bag. Bags must only be ¾ filled and
the top securely tied. Bags must be tagged with a label to indicate which
ward/department they are from.
6.4.19 Linen
Linen must be placed in a red water-soluble inner bag at the bedside. This must
then be placed inside a white Sunlight bag. Bags must only be ¾ filled and securely
tied. The laundry must be informed of the high risk nature.
6.4.20 Accidental injury
Puncture wounds and sharps injuries should be encouraged to bleed, thoroughly
washed with soap and water and covered with a waterproof dressing following Trust
policy for needlestick injury (see Chapter 22 of the Infection Control Manual for full
details). Contamination of broken skin, eyes or mouth should also be treated by
washing with copious amounts of water. The victim should attend Health, Work and
Wellbeing (or Emergency Department if out of hours, with attendance at Health,
Work and Wellbeing at the earliest opportunity).
6.5 Notification of SARS/MERS-CoV
6.5.1 SARS
The doctor in charge of the patient is responsible for ensuring that the following
people are informed:
 Consultant Microbiologist (or duty Microbiologist via switchboard out of hours).
The microbiologist will inform:
o The local Consultant in Communicable Disease Control (CCDC) for the
area in which the patient is resident.
o The other members of the Infection Prevention and Control Team
o The Health, Work and Wellbeing Department
o The Chief Executive/deputy
o Consultant Virologist

Communicable Disease Surveillance Centre (CDSC), Colindale. Telephone
the duty doctor on 020 8200 6868 and complete a standard report form using
the reporting form available at:
www.hpa.org.uk/infectiions/topics_az/SARS/repform.pdf
Send the completed form to CDSC by email: [email protected].
Alternatively, the form is also attached as Appendix A to this document and
can be faxed to 020 8200 7868.
6.5.2 MERS-CoV
The doctor in charge of the patient is responsible for ensuring that the following
people are informed:
 Consultant Microbiologist (or duty Microbiologist via switchboard out of hours).
 local PHE Health Protection Team
Within hours: 9am – 5pm Monday to Friday 0344 225 1295
Out of hours: via RLBGUH (Royal Liverpool and Broadgreen University Hospitals
NHS Trust) Switchboard on 0151 706 3134/2000.
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6.6 Diagnosis
6.6.1 SARS
SARS remains a clinical diagnosis. The gold standard laboratory test is serology
(acute and convalescent antibodies). PCR tests are improving but may not be as
sensitive as required. See Appendix E for samples collected at different stages of
illness.
A patient who fulfils the possible case definition for SARS (fever, cough or dyspnoea,
an abnormal Chest X-ray and epidemiological link) should have the following
samples taken:
 Respiratory samples:
o Sputum/tracheal aspirate/bronchoalveolar lavage fluid.
o Nose and throat swabs should be sent in viral transport medium.
 Blood:
o Acute and convalescent blood (20mls clotted whole blood) and
o 20mls EDTA blood (for PCR).
 Urine: 20mls
 Stool sample
All samples should be sent to the Microbiology Department.
6.6.2 MERS-CoV
Required samples (send to Microbiology)
 Sputum
 Duplicate set of nose and throat swabs in viral transport media
o One set for MERS-CoV specific upE assay
o One set for respiratory viral screen
 Acute serum (5mls clotted blood)
*testing of a lower respiratory tract sample (i.e. sputum or BAL) is necessary
for formal exclusion of MERS-CoV diagnosis).
All specimens must be treated as biohazard:
 Label with biohazard label
 Mark request form accordingly
 Double bag
For confirmed cases all specimens will be handled at Containment Level 3.
6.7 Laboratory precautions
6.7.1 Non-microbiology clinical samples e.g. haematology and biochemistry
Samples can be processed in the local laboratory. Samples from PROBABLE OR
SUSPECT cases should be treated as “high risk”. Blood should be handled with
precautions appropriate for HIV/hepatitis or other blood borne virus transmission.
6.7.2 Microbiology specimens
It is suggested that samples taken from hospitalised cases of POSSIBLE
SARS/MERS-CoV are handled at Containment Level 3.
If cerebrospinal fluid, pleural fluid, pericardial fluid, or any other specimens are taken
as part of the clinical diagnostic work-up, culture as routine. Reserve a portion of the
sample at -70ºC or lowest temperature available.
Transportation of samples between laboratories should be by enhanced category B
(category A packaging and category B courier).
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6.8 In the event of patient death
 Carry out last offices using full PPE (6.4.2)
 A body bag must be used.
 Once in the hospital mortuary it would be acceptable to open the body bag in
order to view the body.
 Washing or preparing the body is acceptable if those carrying out the task
wear long-sleeved gowns and gloves which should then be discarded. Facial
protection may be considered against splashing and should be guided by a
local risk assessment.
 Embalming is not recommended because of the potential presence of virus in
blood.
 Mortuary staff and funeral directors must be advised of the biohazard risk.
Post mortem examination
 If a post mortem is required then it needs to be undertaken using safe working
techniques (e.g. manual rather than power tools) and wearing full PPE, as per
pandemic influenza, in the event that power tools are used. High security post
mortem suites are available if needed.
 Personal protective equipment (PPE) i.e. surgical scrub suit, surgical cap,
impervious gown or apron with full sleeve coverage, face shield, shoe covers
and double surgical gloves with an interposed layer of cut-proof synthetic
mesh gloves.
 Respiratory protection: A respirator equipped with a high efficiency particulate
air (HEPA) filter must be worn.
Safety procedures should include:
 Prevention of percutaneous injury.
 Removing protective outer garments when leaving the immediate autopsy
area and discarded in appropriate laundry or waste receptacles immediately
inside the entrance if an antechamber is not available.
 Hand washing upon glove removal.
6.9 Further advice
For further advice please contact:
Lead Nurse, Infection Prevention and Control
Ext. 1193
Clinical Nurse Specialists, Infection Prevention and Control
Ext. 2452/1384
Consultant Microbiologists: 1834/1836/1622 or duty microbiologist via switchboard
out of hours
CCDC for St Helens and Knowsley:
Cheshire & Merseyside Health Protection Unit, 5th Floor, Rail House, Lord Nelson
Street, Liverpool L1 1JF
Telephone 0344 225 1295
Fax 0151 708 8417
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Infectious Diseases Physicians for Mersey Region:
Regional Infectious Diseases Unit
Royal Liverpool University Hospital
Contact via Ward 3Y (0151 706 2436)
6.10 Glossary
CDSC:
Communicable Disease Surveillance Centre
CoV:
Coronavirus
DIPC:
Director of Infection Prevention & Control
ELISA:
Enzyme-Linked ImmunoSorbent Assay
IFA:
Immunofluorescent Antibody
PCR:
Polymerase chain reaction
PHE:
Public Health England
PPE:
Personal Protective Equipment
RDS:
Respiratory Distress Syndrome
SARS:
Severe Acute Respiratory Syndrome
WHO:
World Health Organisation
7. Training
Training required to fulfil this policy will be provided in accordance with the Trust’s
Induction Mandatory and Risk Management Training Policy - Training Needs
Analysis.
8. Monitoring compliance with this document
8.1 Key performance Indicators of the Policy
Describe Key Performance Frequency
Indicators (KPIs)
Review
of Lead
None specific to this policy (see
related Infection Control Manual
chapters) referenced in section
10.
8.2 Performance Management of the Policy
Aspect
of Monitoring Individual
Frequency
compliance
method
responsible of
the
or
for
the monitoring
effectiveness
monitoring activity
being
monitored
N/A
N/A
N/A
N/A
Group
/
committee
which will
receive the
findings /
monitoring
report
N/A
Group
/
committee /
individual
responsible
for
ensuring
that
the
actions are
completed
N/A
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9. References/ bibliography
9.1. INFECTION CONTROL ADVICE: Middle East respiratory syndrome coronavirus
(MERS-CoV), Public Health England. 2013
http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1317136232722
9.2 PHE website
Up-to-date information can be obtained from the following website:
http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/SevereAcuteRespirato
rySyndrome/
9.3. WHO
This WHO website carries up-to-date information on affected areas, travel advice and
symptoms for
SARS:
www.who.int/csr/sars/en/
MERS-CoV:
http://www.who.int/csr/disease/coronavirus_infections/update_20130620/en/
10. Related trust policy/procedures
Associated Infection Control Manual chapters:
Chapter 21
Hand decontamination policy
Chapter 5:
Personal protective equipment
Chapter 9:
Disinfection Policy
Chapter 22
Safe use and disposal of sharps
Chapter 15
Waste disposal
Chapter 4
Care of the isolated patient
11. Equality analysis
Please refer to the overarching document which covers all chapters of the Infection
Control Manual.
http://nww.sthk.nhs.uk/MANAGE/library/documents/EqualityAnalysisforICM.pdf
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Appendix A: SARS Surveillance forms Reporting of a possible case of SARS
A patient who fits the surveillance case definition of possible SARS, available at
http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/SevereAcuteRespirato
rySyndrome/GeneralInformation/sarsCasedefinitionandguidanceonreporting/
should be reported to the Health Protection Agency, Communicable Disease
Surveillance Centre (CDSC) duty doctor by telephone on 020 8200 6868.
In addition, this reporting form which is also available on line at:
http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1194947355893
should be completed and sent to:
1. CDSC by fax (020 8200 7868) or email ([email protected]), and
2. The local Consultant in Communicable Disease Control (CCDC).
The patient will require investigating for the SARS coronavirus in addition to other
possible respiratory pathogens. Clinicians should liaise with their local microbiological
laboratory and the Central Public Health Laboratory in Colindale on appropriate
samples.
Patient details
Surname: _ _ _ _ _ _ _ _ _ _ _ _ _ First name _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date of birth: _ _/ _ _/ _ _
Female
Country of
Sex:
residence: _ _ _ _ _ _ _ _ Contact tel nos: _ _ _ _ _ _ _ _ _ _ _ _ _
Male
(If not in the UK)
Occupation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
UK address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ City/town _ _ _ _ _ _ _ _ _ _ Postcode: _ _ _ _ _
GP contact details
Name: _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ City/town_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Contact tel nos. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Fax no. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Reporter details
Name of reporter: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Report date: _ _ / _ _ /__ __ _ _
Organisation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Contact tel nos. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Clinical details
Date of onset of illness _ _ / _ _ / _ _ _ _
Pneumonia
Yes
No
Cough
Yes
No
Myalgia
Yes
Shortness of breath/ difficulty breathing
Diarrhoea
Yes
No
Clinical
diagnosis:
ARDS
Other_________
Not very ill
Moderately ill
Yes
No
Severely ill
Died
Date of death _ _ _ / _ _ / _ _
No
Severity of
illness on
presentation:
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Hospital admission
Date of admission _ _ / _ _ / __ _ Hospital _ _ _ _ _ _ _ _ _ _Ward name: _ _ _ _ _ _ _ _
Date of transfer _ _ / _ _ / __ _
Hospital _ _ _ _ _ _ _ _ _ _Date of discharge_ _ / _ _ / _ _
Tests performed and laboratory results
Chest X-ray
Yes
Results:
Normal
No
Date of the
X ray: _ _ / _ _/ _ _ _ _
Abnormal:
Specify _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Other results: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
What is the likely diagnosis? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Contact with other ill persons
In the 10 days prior to onset of illness, has the patient been in contact with other
person(s) with severe unexplained respiratory illness?
Yes
No
If yes:
Country of contact: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Place of contact: (e.g.: hospital (incl name), household, community) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Source of contact: (e.g. hospital staff/patient, family member etc) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Type of contact: (e.g. close contact (<2m), high risk procedure, contact with secretions)
Provide Details _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
____________________________________________________
Travel history
Has the patient travelled outside the UK since the 1st August 2003?
Yes
No
If yes
Country/city visited
Length of stay
From
To
1________________________
__/__/____
__/__/____
2________________________
__/__/____
Date of return to the UK: _ _ / _ _ / _ _ _ _
Airport: _ _ _ _ _ _ _
Was the patient symptomatic on the flight?
Yes
__/__/____
No
If yes: give flight details _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _
Additional Comments
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HPA CDSC: Follow Up Form for Possible and Probable Cases of SARS
This form should be completed:
- 48 hours following initial report,
- ten days following initial report and (if not recovered)
- weekly thereafter until recovery (afebrile for 48 hours and resolving symptoms)
Please fax this form
1. to the CDSC SARS Team (020 8200 7868) or send by email ([email protected])
AND
2. to your local Consultant in Communicable Disease Control (CCDC).
Reporter details
Name of person completing form: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Date of follow up: _ _ / _ _ /_ _ _ _
Name of reporter: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Position: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Institution/Organisation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Contact tel: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Patient details
Forename: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Sex:
Female

Male

Surname: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Date of birth: _ _ / _ _ /_ _ _ _
Postcode: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Patient current status
Hospital
Current status
Severity of illness
at follow-up
Comments

YNever hospitalised

YRemains in hospital

YDischarged - date: _ _ / _ _ /_ _ _ _

Recovered (no fever for 48
Y
hours and resolving symptoms)

YRecovering

YStable

YGetting worse

YDead - date of death: _ _ / _ _ /_ _ _ _

YNot very ill

YModerately ill

YSeverely ill
Comments
Comments
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Chest X-ray
Chest X-ray

performed
Chest X-ray
result

Yes - date: _ _ / _ _ /_ _ _ _

Normal

No
Abnormal - details: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Other tests performed and laboratory results
Cell blood
count
Date
Blood culture
Date
Urine culture
Date
Sputum
culture
Date
Other
culture:
_ _ / _ _ /_ _

Normal

Thrombocytopenic
_ _ / _ _ /_ _

Negative

Positive: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ / _ _ /_ _

Negative

Positive: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ / _ _ /_ _

Negative

Positive: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_________________

Negative

Positive: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
(If performed)
(If performed)
(If performed)
(If performed)

Leucocytopenic
SARS serology
Acute sample taken
Convalescent
sample taken
(21 days or later)
Comments

Yes

No

Yes - date: _ _ / _ _ /_ _ _ _
_____________________
_____________________

No
Comments
_____________________
_____________________
Comments
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Appendix B: Frequently asked questions about Severe Acute Respiratory
Syndrome
General information on SARS
Q What is Severe Acute Respiratory Syndrome (SARS)?
A SARS is the term being used to describe a serious respiratory illness. The first
global outbreak occurred between March and July 2003, with over 4,300 cases and
813 deaths. China, south east Asia, and Toronto, Canada were the most affected
Countries.
Q What are the main symptoms of SARS?
A The main symptoms of SARS are high fever (≥38oC), dry cough, shortness of
breath, or breathing difficulties. Other symptoms can include myalgia, headache and
diarrhoea. Symptoms should be severe enough to warrant hospitalisation and chest
X-ray changes show pneumonia or respiratory distress syndrome.
Q How contagious is SARS?
A Reports from countries most affected by SARS show that close contact with a
symptomatic person poses the highest risk of the virus spreading from one person to
another. The majority of cases occurred among hospital workers who have cared for
SARS patients and the close family members of these patients.
Q What is the cause of this infection?
A The cause of SARS is known to be a new member of the coronavirus family. The
SARS coronavirus (SARS CoV) has been isolated and further research is underway.
Q What is the treatment for SARS?
A There is a wide clinical spectrum in SARS. Most patients have recovered with
minimal treatment, but for the severely ill, reports from affected countries suggest
that anti-viral drugs are probably not beneficial, however other research suggests
that interferon maybe helpful. In addition, steroids may be effective in some, research
into this area is continuing. At present, there is no specific treatment.
Q How fast does SARS spread?
A SARS appears to be less infectious than influenza. The incubation period is
believed to be short, around two to seven days (maximum 10 days).
Q Is there a vaccine for this?
A No a vaccine is not available.
Q How many cases of SARS have been reported to date?
A Between March and July 2003, 8,437 probable cases of SARS were reported in 32
countries During the global outbreak, the UK had four probable imported cases.
Q Could this result from bioterrorism?
A There is no indication that SARS is linked to bioterrorism.
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Q What should I do if I am planning to travel, and am worried about SARS?
A During the first global outbreak of SARS, WHO has issued travel
recommendations, for travellers to postpone travel to areas with local transmission in
a bid to interrupt the transmission of the virus internationally. From 5 July 2003, there
are no countries on WHO’s list of areas with recent local transmission. The latest
information and advice is available at <http://www.who.int/en/>.
Q Has SARS gone for good?
A There are currently sporadic cases of SARS in the world and public health systems
are continuing to be vigilant and prepared for the possible global re-emergence of
SARS. We are confident that we have strong surveillance systems in place in the UK
to identify new cases of SARS. We have good infection control measures in place in
hospitals in this country and have issued advice for health care professionals on the
management of SARS case and their contacts to minimise any potential spread of
this illness. The latest information worldwide is available at<http://www.who.int/en/>.
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Appendix C: information for contacts of cases of Severe Acute Respiratory
Syndrome (SARS)
TO THE CONTACT
You have been given this leaflet because you may have had contact with a possible
case of severe acute respiratory syndrome (SARS).
Most cases of SARS have occurred after close contact with a patient with SARS
(close contact includes having cared for, having lived with, or having had direct
contact with respiratory secretions and/or body fluids of a person with SARS). As a
precaution, it is recommended that you monitor your health for ten days.
If you become unwell with a flu-like illness including
 high fever and cough
 shortness of breath or
 difficulty breathing,
 you should seek medical attention.
If you are in the UK see your GP.
Please save this leaflet and give it to your doctor if you become ill and inform him or
her of your contact with a case of SARS
TO THE DOCTOR
The patient presenting this leaflet may have been in contact with a case of severe
acute respiratory syndrome (SARS).
Please notify your local Consultant in Communicable Disease Control immediately if
your patient has the following symptoms:
 high fever (≥38°C)
 one or more respiratory symptoms including
 cough
 shortness of breath or
 difficulty in breathing
The causative organism had not been confirmed to date.
Information about the identification, management and reporting of suspected SARS
in the UK, is available from the website of the former Public Health Laboratory
Service at www.hpa.org.uk.
Alternatively, global updates on the SARS situation are available from the World
Health Organisation website at www.who.int/csr/don/en/
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Appendix D: Staff contact record sheet
Name of index patient ……………………………………………………
Date of record ……………………………………………………………
PLEASE RECORD YOUR NAME IF YOU ENTER THE ROOM
Surname
Forename
Date of birth
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Appendix E: SARS coronavirus diagnosis
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Appendix F: MERS-CoV case algorithm
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Appendix G: Putting on and removing personal protective equipment
Putting on PPE
Put on in the following order:
1. Gown.
2. FFP3 respirator.
3. Eye protection, i.e. goggles or face shield.
4. Disposable gloves.
The order given above is practical but the order for putting on is less critical than the
order of removal given below.
Removal of PPE
PPE should be removed in an order that minimises the potential for crosscontamination. Before leaving the side room gloves, gown and eye protection should
be removed (in that order, where worn) and disposed of as clinical (also known as
infectious) waste. After leaving the area, the respirator can be removed and disposed
of as clinical waste. Guidance on the order of removal of PPE is as follows:
1. Gloves
 Grasp the outside of the glove with the opposite gloved hand; peel off.
 Hold the removed glove in gloved hand.
 Slide the fingers of the ungloved hand under the remaining glove at the wrist.
 Peel the second glove off over the first glove and discard appropriately.
2. Gown
 Unfasten or break ties.
 Pull gown away from the neck and shoulders, touching the inside of the gown
only.
 Turn the gown inside out, fold or roll into a bundle and discard.
3. Eye protection
 To remove, handle by headband or earpieces and discard appropriately.
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4. Respirator
Untie or break bottom ties, followed by top ties or elastic, and remove by handling
ties only and discard appropriately.
To minimise cross-contamination, the order outlined above should be applied even if
not all items of PPE have been used.
5. Wash hands
Clean hands thoroughly immediately after removing all PPE.
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