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Information for crew on international transport from areas affected by severe acute respiratory syndrome (SARS)

17 April, 2003

Preface

The World Health Organization International Health Regulations (IHR) contain provisions regarding routine point of entry control activities and specific measures for some diseases.  In addition, the IHR reference technical guides for both ships and aircraft.  The SARS outbreak, like other international disease outbreaks that occur around the world from time to time, requires that crew have a basic understanding of the disease, the risks and the public health precautions necessary for both passenger and crew protection.  The information below, like the Guide to Hygiene and Sanitation in Aircraft and the Guide to Ship Sanitation, is provided as a technical reference for the development of operating procedures by international passenger transport companies.   Although this information is provided for use by international ship and aircraft operators, it can apply, as appropriate, to other means of travel.

Background on SARS

From the information available at this time, SARS is a respiratory disease, spread by droplets from persons in the symptomatic stage of SARS. The incubation period of SARS is 2-10 days.  Although serious illness and some deaths have resulted from SARS infection, the vast majority of SARS cases to date (96%) recover.  Recent information suggests that SARS may also be spread for a short period of time by contact with surfaces contaminated by droplets or hands, and this is being investigated. Although the mode of transmission is similar, SARS is not spread as easily as influenza (flu), for example.   Frequent handwashing is considered a useful preventive measure for SARS, as it would be for colds, flu and other common illnesses.

Remember that there is a good chance that an ill passenger does not have SARS, even though he or she has come from an affected area.  Precaution is the best way to proceed, however, and the following advice is provided for  reference.

Symptoms

All passengers and crew should be aware of the main symptoms and signs of SARS, which include:

  • High fever (>38o C, 100.4 degrees Fahrenheit) and one or more respiratory symptoms including cough or difficulty in breathing and

  • Either close contact with a person who has been diagnosed with SARS or a recent history of travel to areas reporting cases of SARS.

Management of possible SARS cases1 on board

Please note that this applies only to aircraft/ships carrying a passenger who meets the SARS symptoms listed above.

If a passenger on a flight from an area where SARS transmission is occurring becomes noticeably ill with fever and respiratory symptoms, the following action is recommended for the cabin crew attending to the ill passenger.  Other cabin crew do not require personal protection, but must wash hands before and after: eating, handling materials that could have been contaminated by the ill passenger, using areas of the aircraft where the ill passenger moved about:

1. Isolation

The passenger should be, as far as possible, isolated from other passengers and the crew, and should be asked to wear a protective mask.2

2. Crew and passenger protection

  • Those caring for the ill passenger should follow infection control measures (see below) recommended for cases of SARS, including handwashing after contact with the ill passenger or with any materials that the passenger may have contacted

The other protective measures are:

  • Provide the ill passenger with a mask (see below) to help ensure that droplet spread is contained.

  • Keep contact with the ill passenger to a minimum, and avoid being close to the face of the passenger if possible.

  • Wear a suitable mask and follow the manufacturer's instructions to ensure that the mask fits properly. If, for any reason the attending crew member needs to remove his/her mask, then a new mask should be used.  The mask (s) and other materials used by the ill passenger should be left on the adjacent seat, for disposal as a potential biohazard.  The cleaning crew must be informed of the possibly contaminated materials (e.g. gloves required) and the need to thoroughly disinfect the seating area where the ill passenger was isolated, and the washroom areas in particular.

  • Wear durable disposable gloves, remembering that  hands should be washed before the gloves are removed, then again after removal, and that touching the face while wearing gloves provides the same risk of infection as when using bare hands.

  • Although the risk of virus entry from droplets or hand contact to the eye is low,  goggles that fit tightly to the face, with a soft sealing surface should be worn by the crew member attending to the ill passenger.  Goggles should be washed before re-use, according to the manufacturer's instructions.

  • A separate toilet should be made available for the exclusive use of the ill passenger.

  • Disposable masks, gloves and other material in contact with the ill passenger must be bagged and sealed and treated as biohazard waste.

  • As a general precaution, all passengers on a flight or voyage where a possible SARS case is carried should be advised to wash their hands before and after using the toilets on board.

Aircraft/ship operators should ensure that flights/sailings from affected areas are provided with sufficient gloves, face masks, goggles and disinfectant, and that a seat or berth in an isolated area can be made available when needed.

3. Communication and hand-off to airport/port health authorities

  • The pilot/shipmaster should radio ahead to the airport /port of destination so that airport/port management can alert the health authorities.

  • On arrival, the public health authorities should take the ill passenger directly from the aircraft or ship by the exit closest to where the passenger is seated, and avoid passing through the airport or port.  The ill passenger should then be placed in isolation and assessed as quickly as possible by a health authority physician.  Anyone waiting for the passenger should be notified of the delay by airline/ship staff. Other agencies, such as immigration, will need to know that a passenger has by-passed normal airport/port arrival procedures.

4. Management of contacts3 of the ill passenger and of other passengers on board

The pilot/shipmaster should determine prior to landing/disembarking whether  local public health authorities are available to obtain 14 day contact information from the passengers and crew. If it is determined that public health authorities are not available, the crew should hand out forms to obtain the following information:

  1. Seat and row number on flight

  2. Full name, home address and telephone number

  3. Address and contact number (if different) for the period above

  4. information on further travel, including organized tours or cruises

The completed contact forms should be given to the health authorities at the airport/port and a copy of the passenger manifest should be kept by the aircraft or ship operator for 14 days.  The manifests and passenger information forms may be destroyed, in a privacy secured manner, after 14 days.

  • Passengers, including crew members, should immediately seek medical guidance should symptoms occur within 14 days of travel, by calling either their own physician or a toll-free public health number, if one is locally or nationally available. It is important that passengers provide information about any possible contact with SARS, including travel to affected areas or visits to a hospital or health care workers and their families in areas where SARS transmission is occurring.  Any passenger/crew member who develops the above symptoms is advised not to undertake further travel until he or she has been examined and cleared by a physician or has recovered.

  • Contacts and other passengers should be allowed to continue travel as long as they do not have symptoms compatible with SARS.

5. Disinfection of aircraft

see WHO Guide to Hygiene and Sanitation in Aviation (http://www.who.int/csr/ihr/guide.pdf).

References:

WHO, 15 March 2003: World Health Organization issues emergency travel advisory

WHO, 27 March 2003: Update 11 – WHO recommends new measures to prevent travel-related spread of SARS

 
 

End Notes

1 Suspect case

 1.   A person presenting after 1 November 2002 (1) with history of:

-  high fever (>38 °C)

AND

-   cough or breathing difficulty

AND one or more of the following exposures during the 10 days prior to onset of symptoms:

-  close contact (2) with a person who is a suspect or probable case of SARS;

-  history of travel, to an affected area  (3)

-  residing in an affected area (3)

 (1)   The surveillance period begins on 1 November 2002 to capture cases of atypical pneumonia in China now recognized as SARS. International transmission of SARS was first reported in March 2003 for cases with onset in February 2003.

 (2)   Close contact: having cared for, lived with, or had direct contact with respiratory secretions or body fluids of a suspect or probable case of SARS.

 (3)   Affected area: an area in which local chain(s) of transmission of SARS is/are occurring as reported by the national public health authorities.

2 Respiratory protection should be provided at HEPA Filter or  *P100(NIOSH) or *FFP3 (EN149:2001) filter (99.97% efficiency) level. *N95 filters (95% efficiency) and above *(N,R,P 99 or FFP2) also provide high  levels of protection and should be worn where no acceptable  alternatives of a higher level of protection are available. Ideally, the  masks used should be fit tested using an appropriate "fit test kit" in  accordance with the manufacturing instructions. Disposable masks should not  be reused.

*N/R/P 95/99/100 or FFP 2/3 or an equivalent national manufacturing standard.

STANDARDS: Please, refer to  EU guidelines and NIOSH guidelines. Prior to purchasing filter  masks DOH/MOH procurement departments should ensure that they procure products  that are certified to either NIOSH (N,R,P 95,99,100) or European EN149:2001(FFP 2,3) and EN143:2000 (P2) standards or comparable  national/regional standards applicable to the country of  manufacture.

3 For the purposes of air travel, a contact is defined as:

·     Passengers sitting in the same seat row or within at least 2 rows in front or behind the ill passenger

·     All flight attendants on board

·     Anyone having intimate contact, providing care or otherwise having contact with respiratory secretions of the ill passenger

·     Anyone on the flight living in the same household as the ill passenger

·     If it is a flight attendant that is considered to be a SARS case, all passengers are considered to be contacts.

 

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