Severe Acute Respiratory Syndrome (SARS)–Informational Bulletin for Emergency Responders from the IAFF

Severe Acute Respiratory Syndrome (SARS) is thought to be to be a viral illness, spread person to person through close contact with respiratory secretions. The severity of illness is highly variable, from mild illness to death. The following information is provided by the IAFF to assist firefighters in identifying people who may transmit SARS and to advise all those with potential SARS exposure to use infection control precautions to protect their own health and that of the public.

What is the Cause for Concern About SARS?
On March 16,2003 the World Health Organization issued a Global Alert regarding the SARS epidemic. The Alert was issued because this disease was not previously recognized, it caused great risk to exposed health care workers, and it began to spread internationally. As of April 2, there were 2,223 cases, including 48 deaths reported. This represents a case fatality rate of 3.5%.

In Canada, 11 firefighters and 208 paramedics have been quarantined, as well as 40 social workers and four library workers. Three Canadian paramedics and three hospital workers have SARS. The disease has also been transmitted to airline passengers in close proximity to persons with active SARS. As of April 1, thirteen countries have been affected. Of these, four countries imported cases with no documented local transmission. Fortunately, the Global Alert appears to have prevented spread in countries where the disease was imported. There is no indication that SARS is linked to bioterrorism.

When Should I Suspect a Case of SARS?
There are two situations in which you should suspect SARS:

  1. You should suspect that a person may have SARS if the following conditions apply:
    • Measured temperature > 100.5º F (>38ºC) AND
    • One or more observable findings of respiratory illness (cough, shortness of breath, difficulty breathing, hypoxia, or X-ray finding of pneumonia) AND
    • The person has traveled, within 10 days of their illness, to an area with documented or suspected cases of SARS. This includes all of mainland China, Hanoi, Vietnam, Singapore and the Special Administrative Region of Hong Kong.
    OR
  2. You should suspect SARS in a person who was in close contact with a person having SARS, or a person with a respiratory illness who traveled to a SARS area. Close contact is defined as having cared for, having lived with, or having direct contact with respiratory secretions and/or body fluids of a patient suspected of having SARS. The close contact should have occurred within 10 days of symptom onset.

Note: Do not rely on a history of foreign travel/contact with foreign travelers in order to don protective gear

How Does the Illness Progress?
The illness usually begins with fever (> 100.5º F), sometimes with chills or other, nonspecific symptoms (headache, muscle aches). Typically, rash and neurologic or gastrointestinal findings are absent; however, some patients have reported diarrhea during the fever phase.

After 3-10 days, a lower respiratory phase begins, with a dry cough or shortness of breath, which may be associated with diminished blood oxygen level. In 10-20% of cases, the respiratory illness is severe enough to require intubation and mechanical assistance with breathing. The case-fatality rate among persons meeting the above definition of SARS is 3-4%. Of the persons who died, many had a pre-existing condition, such as diabetes, that weakened their immune systems and made them susceptible to complications of an infection.

Some close contacts of SARS patients have reported a mild illness with fever, without respiratory signs, suggesting the illness does not always progress to the respiratory phase.

Ninety per cent of people who have contracted SARS have improved and were in a recovery phase at day seven after disease.

How Can I Protect Myself?
The best protection against SARS is strict adherence to infection control procedures.

Follow universal precautions, including respiratory precautions when SARS is suspected. Additionally, fire department should have an Infection Control program that meets the minimum requirements of NFPA 1581, Standard on Fire Department Infection Control Program.

In situations where the patient has a high fever and any respiratory signs:

  • Don a P-100 respirator (either disposable model or a full or half facepiece air purifying respirator with a HEPA filter/canister) as a minimum respiratory protection. A respirator with a higher level of respiratory protection, e.g. Powered Air-Purifying Respirator with a HEPA filter, may be used.
  • When a patient requires rescue breathing, use a bag-valve-mask–NEVER use direct mouth-to mouth or mouth-to-mask resuscitation.
  • Don disposable gloves prior to making any patient contact.
  • Don protective eyewear in situations where bodily fluids may be splashed.
  • Use of disposable gloves should be considered for any direct contact with body fluids of a SARS patient. However, gloves are not intended to replace proper hand hygiene. Immediately after activities involving contact with body fluids, gloves should be removed and discarded and hands should be cleaned. Gloves must never be washed or reused.
  • Apply a disposable surgical mask (or disposable respirator if surgical mask is not available) to all suspected SARS cases not requiring oxygen therapy.
  • Each patient with suspected SARS should be advised to cover his or her mouth and nose with a facial tissue when coughing or sneezing. If possible, a SARS patient should wear a surgical mask during close contact with uninfected persons to prevent spread of infectious droplets. When a SARS patient is unable to wear a surgical mask, household members should wear surgical masks when in close contact with the patient.
  • When transporting persons suspected of having SARS, do not allow air to recirculate within the vehicle, especially do not use the recirculation (Maximum) control on the vehicles heating/air conditioning system. When possible open windows/vents for improved ventilation.
  • As stated above, the use of gloves does not eliminate the need for hand hygiene. Likewise, the use of hand hygiene does not eliminate the need for gloves. Gloves reduce hand contamination by 70 percent to 80 percent, prevent cross-contamination and protect patients and health care personnel from infection. Antiseptic handwashes should be used before and after each patient just as gloves should be changed before and after each patient.
    When using an alcohol-based handwashes, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry. Note that the volume needed to reduce the number of bacteria on hands varies by product. Personnel should avoid wearing artificial nails and keep natural nails less than one quarter of an inch long, particularly if they come in contact with patients at high risk of acquiring infections.
  • Upon completion of all patient care procedures, remove gloves and cleanse hands with alcohol-based cleanser. Avoid touching hands to face until a thorough washing of hands takes place. As soon as possible following completion of patient care, thoroughly wash hands with soap and water.

How Do I Decontaminate Equipment?

  • Dispose of disposable respirator, respirator filters, gloves and other disposable equipment/supplies used at the scene as bio-hazardous waste. If the turnout gear is visibly contaminated by bodily fluid, it should be placed in a biohazard bag at the scene and washed following prescribed laundry procedures. Chlorinated beach shall not be used with any firefighter protective clothing. Non-disposable respirators shall be cleaned and disinfected in accordance with manufacture’s recommendation.
  • For decontamination of non-disposable equipment, follow manufacturer and departmental standard operating procedures. Vehicles used to transport persons suspected of having SARS should be cleaned by staff wearing protective equipment, using a disinfectant cleanser.

What Advice is Given to Contacts of a Suspected SARS Patient?

  • When possible, in advance of the evaluation, healthcare providers should be informed that the individual is a close contact of a SARS patient. Patients presenting to health care facilities who require assessment for SARS should be diverted to a room designated for respiratory isolation.
  • Sharing of eating utensils, towels, and bedding between SARS patients and others should be avoided, although these items can be used by others after routine cleaning (e.g., washing with soap and hot water). Environmental surfaces soiled by body fluids should be cleaned with a household disinfectant according to manufacturer’s instructions; gloves should be worn during this activity.
  • Household members or other close contacts of SARS patients who develop fever or respiratory symptoms should seek healthcare evaluation.
  • At this time, in the absence of fever or respiratory symptoms, household members or other close contacts of SARS patients need not limit their activities outside the home. Within an affected household, facial tissues and other waste from SARS patients may be discarded as normal household waste.

How Contagious is SARS?
Although the infectivity and definite cause of SARS are currently unknown, transmission to healthcare workers appears to have occurred after close contact with SARS patients before recommended infection control precautions were implemented (hand hygiene, gloves, respirator, eye protection, gown). SARS is not highly contagious when protective measures are used. SARS is not thought to be spread through building ventilation systems.

SARS appears to be less infectious than influenza. The incubation period is usually from 2-7 days, with 3-5 days being most common. Contact with aerosolized respiratory secretions from an infected person appears to be important. It is unknown whether other body fluids are infectious, therefore, all body secretions from suspected SARS patients should be handled only while wearing appropriate protection.

Is a Respirator Effective Against SARS Transmission?
When properly fitted, maintained and used, a P100 respirator (or a full or half face air purifying respirator with a HEPA filter) provides excellent protection from inhalation of infectious airborne droplets. However, there are NO safe exposure levels (i.e. the amount you can inhale without adverse health effects) for biological aerosols. Respirators can reduce inhalation exposures but cannot eliminate the risk of contracting infection, illness, or disease. Additionally, the type of respirator facepiece and filter class required does vary depending activities and risk of exposure. Many have suggested that N95 respirators be used for protection from this disease for public and hospital use. The IAFF does not believe that this type of respirator will afford firefighter and emergency medical personnel proper protection. Accordingly, the IAFF recommends for emergency response, as a minimum, a P100 respirator be used.

One of the easiest ways of transmitting a viral infection from one person to another is through a hand shake that transfers virus from the hand of one person who may have rubbed his nose to another person’s hand. The second individual then touches his/her nose or mouth, then develops an infection. A respirator is not a guarantee of protection against any disease. However, if a high-filtration respirator is worn with eye protection and gloves, a high degree of protection is conferred.

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