1. The WHO announced today that the Travel Warning for Taiwan has now been lifted and there are no restrictions for travel to this area.  June 16, 2003
2. The WHO further reiterates that the only official restriction in place now is Beijing city in China.  June 16, 2003
3. The WHO reports that there have been no new cases in China for the past 5 days.  There needs to be 20 consecutive days of “no new cases” for a travel advisory to be lifted from a city or country.  June 16, 2003
4. The WHO has reported that there will no longer be daily reporting of SARS cases since the epidemic has all but ended.  June 16, 2003

Severe Acute Respiratory Syndrome (SARS)

A set of symptoms labeled “Severe Acute Respiratory Syndrome” or “SARS” was observed in early February 2003, in the Guangdong province of Southern China, bordering Hong Kong.  In the intervening time, SARS cases have rapidly spread around the world, with certain countries including China, Hong Kong, Singapore, Vietnam and Canada being particularly hard hit.

Symptoms

The World Health Organization (WHO) and the U.S. Centers for Disease Control (CDC) have advised that all travelers be aware of the main symptoms of SARS, which include a combination of the following:

Fever: generally over 38C (100.4F) although typically, it is much higher (104 F) and develops quickly.

Cough, respiratory distress, shortness of breath, difficulty breathing.  These symptoms develop rapidly over the course of a few days and progress into full pneumonia.  Other symptoms can include headache, poor appetite, general weakness, sore muscles, and some are reporting some generalized body rashes.  These symptoms can develop, then improve for a couple of days and then return.

Other associated criteria include close contact with a person who has been diagnosed with SARS or having traveled to an area that has been heavily stricken by SARS cases.

Treatment
Supportive therapy seems to be the only method of treatment. Antibiotics and antiviral medications are all being used but there is little effect since the cause has been identified as a virus. 

There is no current recommendation for prophylactic medications.

There is some anecdotal evidence that these treatments may in fact be causing more harm to the patient than good and are being halted in many hospitals in Asia.

A traveler who experiences any of the above symptoms should seek medical attention immediately. 

Initial diagnostic testing for suspected SARS patients should include chest radiograph, pulse oximetry, blood cultures, sputum Gram's stain and culture, and testing for viral respiratory pathogens, notably influenza A and B and respiratory syncytial virus. A specimen for Legionella and pneumococcal urinary antigen testing should also be considered. Clinicians should save any available clinical specimens (respiratory, blood, and serum) for additional testing until a specific diagnosis is made.

Anyone exhibiting symptoms should pay close attention and seek medical attention as soon as possible.  If you are extremely ill you should not hesitate to seek the appropriate medical care, however if you have access to a health care provider who will make a house call this may be preferable to going to a health care facility in a highly infected area and risking additional exposure to the virus or contaminating other people.  You may be asked to wear a mask in public in order to minimize the transmission of water droplets to others.  Good hygiene, including frequent hand-washing, may also prevent the transmission of the virus.

 

Geographic Distribution

The virus, which first appeared in Asia, is traveling with alarming speed around the globe.  Every day the number of reported infections increases, as do the number of deaths.  However, comparing the numbers of “new” cases on a day to day basis, the Department of Health for Hong Kong has found that their numbers are decreasing significantly which could represent a trend suggesting that the extraordinary control measures undertaken by that country are working.

Map of Cumulative Number of Reported Probable Cases

Travel Advisory

Most of the travel advisories have been lifted and the only city that still carries a recommendation of precaution is Beijing.  In an attempt to assist with the reduction of the spread of this illness many companies, particularly those with operations in or travelers to or through SARS-prone areas, are recommending “self quarantining” of any individual who is exhibiting symptoms or has traveled to one of the heavily affected areas.  Generally this should be done for the duration of the incubation period, which is 10 days. 

You should check closely with your corporate policy regarding SARS and any travel restrictions or advise that your corporation may already have in place.

If you MUST travel to a SARS infected area: (From the CDC)

Before you leave:

• Assemble a travel health kit containing basic first aid and medical supplies. Be sure to include a thermometer, household disinfectant, a supply of surgical masks and disposable gloves (for use if you or someone you are traveling with becomes ill with SARS), and alcohol-based hand rubs for hand hygiene.
• Inform yourself and others who may be traveling with you about SARS. For information about this illness, see CDC's SARS Web site.
• Be sure you are up to date with all your shots, and see your health-care provider at least 4 to 6 weeks before travel to get any additional shots or information you may need. For information on CDC health recommendations for international travel, see CDC's Travelers' Health site.
• You may wish to check your health insurance plan or get additional insurance that covers medical evacuation in the event of illness. Information about medical evacuation services can be found at this U.S. Department of State page.
• Identify in-country health-care resources in advance of your trip.

While you are in an area with SARS:

Risk Management
MedAire follows the CDC and WHO guidelines and recommends for those individuals who are located in one of the primary affected areas the following guidelines:

• Avoiding the mass population if at all possible.
• Avoid using mass transit systems unless absolutely necessary
• Get plenty of fresh air.  Avoid over-crowded or confined rooms and buildings
• Cover your mouth when you cough or sneeze and avoid people who are coughing or sneezing without covering themselves
• Good hand washing cannot be stressed enough.  This can be done with soap and water or using any brand of alcohol based cleansing solution.  It should be done regularly throughout the day.
• Be aware of your environment and be careful what you touch.  Keep in mind that doorknobs, handles, windows, elevator buttons, handrailings, computer keyboards and household items may be contaminated with the virus, remember to wash your hands carefully and regularly before putting fingers anywhere near your face.  If possible, use a sanitizing alcohol solution to clean surfaces of telephones.
• Do not share utensils, towels, and personal hygiene items.  If you work in an office you should do daily cleaning of the telephone sets.
• If you are surrounded by someone who has symptoms encourage them to wear a mask so as not to spread the virus.  Likewise, if you are exhibiting symptoms then you should wear a mask.
• Some people are wearing a mask anyway if they are out in public in some of the heavily affected cities
• If you begin to exhibit any symptoms, however, you should immediately seek medical attention because the severe symptoms develop rapidly.  The sooner the medical care begins the better the outcome.
• The death rate with SARS is thought to be somewhere between 10-50% depending on age. It is difficult to pinpoint this exactly because there are still many people still in the hospital where it is not known if they will survive or not. The higher age groups, older than 50 have the highest death rate.  Early diagnosis and treatment seem to be the key to managing the disease.  

Medical Aircraft Cleaning & Decontamination

The CDC has issued new guidelines for cleaning aircraft that have transported SARS passengers or patients.  These guidelines take into consideration that the virus is believed to be transmitted via several modes of transmission - respiratory, airborne and contaminated surfaces.  Each company may have their own policy for aircraft cleaning, however these are the most up to date recommendations from the CDC.  

• After transporting a SARS patient or a passenger with SARS symptoms, all exits and doors should be opened and the entire interior of the aircraft should be aired out with the air conditioning running at maximum capacity for a specified time based on aircraft – specific engineering guidelines.
• All personnel boarding the aircraft must wear N-95 respirators until the airing out is completed.
• No cleaning should be done while the aircraft is airing out.
• Do not use compressed air that might re-aerosolize infectious materials.
• All cleaning personnel should wear non-sterile gloves, disposable gowns and face shields while cleaning passenger/patient areas and while cleaning equipment.
• Clean all surfaces in the passenger/patient area with an EPA-registered hospital disinfectant in accordance with aircraft manufacturer’s recommendations.  The virus can live on surfaces (door knobs, flooring, walls, control panels, galleys etc)
• Spills of body fluids during transport should be cleaned by placing absorbent material on the spill and disposing of it in a biohazard bag.  The spill area should be cleaned with the EPA- registered hospital disinfectant.
• Any contaminated seat cushions or web seats should be placed in a biohazard bag for cleaning or disposal.

Aeromedical Transport of SARS Patients

Corporate or commercial aircraft may be asked to transport SARS patients from one hospital to another or to repatriate the patient to their home country.  All SARS patient movement involving US citizens should be coordinated with appropriate state and federal health authorities including the Centers for Disease Control and Prevention (CDC) (24 hour response number (770) 488-7100) and the Department of State BEFORE the transport begins.

International movement of SARS patients may require special approvals by countries that will be over flown, aircraft servicing locations, patient rest stops hospitals and/or final destinations.

There are specific guidelines for the Air Medical Transport for SARS patients, which have been issued by the CDC.  Considerations include the following:

• General Guidelines for the Air Transport of SARS Patients

• Aircraft Selection and Cabin Airflow Requirements/Considerations

• Patient Placement in the Aircraft

• Infection Control Procedures

• Mechanically Ventilated Patients

• Clinical Specimens

• Waste Disposal

• Cleaning & Disinfections

• Logistical Planning and Post-Mission Follow-Up

•  Ground/In-Flight Emergency Procedures.

Reference: Click here for more information from the CDC website.

Commercial Air Transport Advisory

Many airlines are instituting policies to try to contain or slow the spread of this disease.  One of the measures is “gate screening”.  If someone presents with SARS symptoms at the departure gate they will be denied boarding.  This action is taken in order to prevent further spread of the disease both to other passengers and to individuals in the destination country.  On  April 1, 2003, an airline was quarantined in California while 5 people exhibiting symptoms were removed from the aircraft. These passengers were seen at the local hospital and released when it was determined that they did not have SARS.

CDC Guidelines for Ground Crews:

• For personnel who are screening passengers for security purposes the CDC does not recommend protective measures beyond those already in use (wearing gloves and hand washing). 

• Good handwashing is the first line of defense against any infectious illness.

• CDC recommends that if you encounter a passenger who appears to have a respiratory illness and who may have traveled from one of the affected areas try to keep them separated from the other passengers as much as is possible. 

• Immediately contact the airline and Emergency Medical Services. Provide the passenger with a surgical mask, if not available, then provide them with a tissue and ask them to cover their mouth and nose when coughing.                                                 

• The CDC does NOT recommend the routine use of masks for TSA, Customs, Border Protections staff, or for healthy passengers.

CDC Guidelines for Flight Crews:

• We are working with our airline partners to assist with passenger gate screening as well as in-flight medical consultation so that proper care can be provided to anyone who requires attention while traveling. 

• For individuals suspected of having SARS in-flight, a mask and isolation is recommended. 

• Some airlines are sectioning off several rows of seats in the rear of the aircraft to place anyone developing symptoms in-flight.

• Masks are given to the passenger exhibiting the symptoms and is generally offered to those sitting around them in the event that the plane is full.                                           

• There is no indication that the Flight Attendant crew need to be wearing masks when near the passengers exhibiting symptoms, provided that the passenger is wearing a mask.  However, as always, practice good hand washing when coming in to contact with the passenger or items that they may have touched.                                                    

• The Captain may be required by the laws of some countries to notify the local Quarantine station via their operations center before landing.

• Your airline may have policies in place that supercede these guidelines and should be followed.

CDC Guidelines for Flight Crews who layover in affected areas:

• To minimize the possibility of infection, you may wish to avoid large crowds as much as possible.     

• Consider staying within your hotel environment

• CDC does not recommend the routine use of masks

• Wash your hands frequently with soap and water or alcohol-based handrub

• Ask your employer about healthcare options

• Do not travel while sick and limit your contact with others as much as possible to help prevent the spread of any infectious illness you may have.

• If you have been ill during your trip or you return home ill, contact your health care provider as soon as possible and discuss your symptoms and your travel itinerary.

• The CDC is handing out travel alert cards to people returning from areas affected by SARS.  If you are not ill and did not become ill while traveling but may have been exposed to someone with SARS, you will be advised to monitor your health for the next 10 days.

• Your airline may have policies in place that supercede these guidelines and should be followed.

 CDC Guidelines for Airline Clean-up Crew Members:

• It is not necessary for clean up crews to wear mask or gowns to protect themselves.

• Safety measures such as washing your hands, wearing gloves while working with cleaning fluids in lavatories should be enough.

• Crews cleaning up after a flight with a suspected SARS passenger should wear disposable gloves.

• Your specific airline may have guidelines that supercede these CDC guidelines and should be followed.

There are no indications currently to restrict onward travel of well-appearing passengers or crew.  However, they will be informed about any suspected cases on the flight and given information sheets about what symptoms to look for and how to seek medical attention.

Airline crews should follow established protocols and policies of your respective airline as MedAire is closely working with all of our client airlines to support their policies.  

Aircraft should be disinfected following WHO guidelines for aviation sanitation.

Links

Center for Disease Control and Prevention (CDC)

World Health Organization (WHO)