Public Health Guidance for Community-Level Preparedness and Response to
Severe Acute Respiratory Syndrome (SARS) Version 2

Supplement I: Infection Control in Healthcare, Home, and Community
Settings

# Contents

I.  Rationale and Goals

II. Lessons Learned

III. Infection Control in Healthcare Facilities

     A.  Preparedness Planning

     B.  Early Recognition and Prevention of Transmission in Outpatient
         Settings

     C.  Early Detection and Isolation of Patients Potentially at Risk
         for SARS-CoV Disease

     D.  Infection Control Precautions for Hospitalized SARS Patients

         1.  Patient placement

         2.  Patient transport

         3.  Visitors

         4.  Hand hygiene

         5.  Personal protective equipment (PPE)

         6.  Medical waste

         7.  Textiles (linen and laundry)

         8.  Dishes and eating utensils

         9.  Patient-care equipment

         10. Environmental cleaning and disinfection

         11. Aerosol-generating procedures

IV. Infection Control for Prehospital Emergency Medical Services (EMS)

    A.  Patient Transport

    B.  Personal Protective Equipment

    C.  Safe Work Practices

    D.  Clinical Specimens

    E.  Post-Transport Management of the Contaminated Vehicle

    F.  Follow-up of EMS Personnel

V.  Infection Control for Care of SARS Patients at Home

    A.  Assessment of the Residence

    B.  Infection Control Precautions for SARS Patients Isolated at Home

    C.  Follow-up of Contacts

VI. Infection Control for Care of SARS Patients in Community Isolation
    Facilities

VII. Infection Control for Public Health and Outreach Workers

VIII. Infection Control for Laboratory and Pathology Procedures

      A.  Specimen Collection and Handling

      B.  Laboratory Procedures

      C.  Postmortem Handling of Human Remains

IX. Occupational Health Issues

    A.  Surveillance and Monitoring of Healthcare Workers

    B.  Management of Exposures and Other Contacts with SARS Patients

Appendix I1: Recommendations for Application of Standard Precautions for
the Care of All Patients in All Healthcare Settings

Appendix I2: Summary of Recommendations for Expanded Precautions

# Infection Control in Healthcare, Home, and Community Settings

# I. Rationale and Goals

Transmission of SARS-CoV appears to occur predominantly through close
interactions with infected persons. Infectious respiratory secretions
are the most likely source of infection, although fecal/oral
transmission may have occurred in some settings. Contact with
contaminated body substances, either directly (e.g., shaking hands) or
indirectly (e.g., touching objects contaminated with respiratory
secretions or stool), can lead to exposure. SARS-CoV may also be
transmitted through close contact with respiratory droplets expelled
when a patient coughs or sneezes. In some instances, however, true
airborne transmission (i.e., via droplet nuclei) cannot be excluded as a
possible mode of SARS-CoV transmission.

SARS-CoV has been transmitted in healthcare settings (e.g., inpatient
settings, emergency departments, nursing homes) to and from patients,
healthcare workers, and visitors. Transmission to healthcare workers has
occurred primarily after close contact with symptomatic persons before
implementation of infection control precautions. During the 2003
outbreaks, multiple hospitals reported cases of SARS-CoV disease among
healthcare workers who were present during aerosol-generating procedures
performed on patients with SARS-CoV disease, suggesting that
aerosol-generating procedures may pose an increased risk of SARS-CoV
transmission. Special precautions during these procedures are
recommended.

Infection control guidance to prevent SARS-CoV transmission is necessary
to help ensure the protection of healthcare workers and healthcare
facilities. In addition, as hospitalization of patients with SARS-CoV
disease is recommended only if medically indicated, patients with less
severe disease will likely be isolated in personal residences and
designated community facilities. Therefore, appropriate infection
control measures will be required to prevent transmission of SARS-CoV in
these facilities. The goals for all settings are to:

-   Ensure early recognition of patients at risk for SARS-CoV disease.

-   Prevent transmission of SARS-CoV by implementing appropriate
    infection control precautions.

# II. Lessons Learned

The following lessons learned from the global experience with SARS-CoV
have been considered in developing this Supplement:

-   Transmission of SARS-CoV appears to occur predominantly through
    close interactions with infected persons.

-   Persons with unrecognized SARS-CoV disease can contribute to the
    initiation or expansion of an outbreak, especially in healthcare
    settings.

-   Transmission of SARS-CoV in a single healthcare facility can have
    far-reaching public health effects.

-   Transmission to healthcare workers has occurred primarily after
    close, unprotected contact with symptomatic persons before
    implementation of infection control precautions.

-   Certain high-risk procedures and events can increase the risk of
    SARS-CoV transmission.

-   Infection control is a primary public health intervention for
    containing the spread of SARS-CoV.

-   Patients with SARS-CoV disease need to be isolated to minimize the
    risk of transmission to others.

-   Patients with mild SARS-CoV disease can be safely isolated in
    locations other than acute-care facilities, such as at home or in
    community facilities designated for isolation of SARS patients.

# III. Infection Control in Healthcare Facilities

## 

## A. Preparedness Planning 

**SARS preparedness planning for healthcare facilities is addressed in
Supplement C.** One component with particular relevance to this
Supplement is the education and training of healthcare workers on
infection control measures**.** Observations of healthcare workers
caring for SARS patients during the 2003 epidemic identified numerous
breaches in infection control, especially in the use of personal
protective equipment (PPE). These can be corrected through complete and
comprehensive training, provision of properly selected PPE, and
monitoring of PPE use. Most important, all healthcare settings need to
re-emphasize the importance of basic infection control measures,
including hand hygiene, for the control of SARS-CoV and other
respiratory pathogens.

> **Objective:** Reinforce basic infection control practices in
> healthcare facilities and among healthcare personnel.
>
> **Activities**

-   Educate staff about the importance of strict adherence to and proper
    use of standard infection control measures, especially hand hygiene
    (i.e., hand washing or use of an alcohol-based hand rub). For
    complete recommendations on hand hygiene, refer to:
    [www.cdc.gov/handhygiene/](http://www.cdc.gov/handhygiene/).

-   Reinforce education on the recommended procedures for Standard,
    Contact, and Airborne Infection Isolation (AII) Precautions (see
    [www.cdc.gov/ncidod/hip/ISOLAT/Isolat.htm](http://www.cdc.gov/ncidod/hip/ISOLAT/Isolat.htm)).

-   Ensure that personnel have access to appropriate PPE, instructions
    and training in PPE use, and respirator fit-testing.

## B. Early Recognition and Prevention of Transmission in Outpatient Settings

> **Objective:** Ensure early recognition and prevention of transmission
> of
>
> SARS-CoV and other respiratory viruses at the initial encounter with a
>
> healthcare setting.
>
> The 2003 outbreaks identified weaknesses in the way infection control
> precautions are implemented at the time symptomatic patients first
> visit a healthcare facility for evaluation. To address this
> deficiency, CDC is *incorporating measures to prevent the transmission
> of all respiratory infections*, beginning at the first point of
> contact with a potentially infected person, as one component of
> Standard Precautions in healthcare settings (see Appendix I1 and
> [www.cdc.gov/ncidod/hip/ISOLAT/Isolat.htm](http://www.cdc.gov/ncidod/hip/ISOLAT/Isolat.htm)).
>
> These simple preventive measures apply in the absence and presence of
> SARS-CoV transmission in the world. Once SARS-CoV transmission is
> detected, efforts to enhance the early detection of patients with
> SARS-CoV disease (described in Section III.C below) should be added to
> these new Standard Precautions measures.
>
> **Activities**
>
> [Visual alerts]{.underline}

-   Post visual alerts (in appropriate languages) at the entrance to
    outpatient facilities (e.g., emergency departments, physicians'
    offices, outpatient clinics) instructing patient and the persons who
    accompany them to: 1) inform healthcare personnel of symptoms of a
    respiratory infection when they first register for care, and 2)
    practice respiratory hygiene/cough etiquette
    [(]{.underline}[www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm](http://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm)[)]{.underline}.
    Sample visual alerts will be posted on CDC's SARS website:
    [www.cdc.gov/ncidod/sars/](http://www.cdc.gov/ncidod/sars/).

> [Respiratory hygiene/cough etiquette]{.underline}
>
> To contain respiratory secretions, all persons with signs and symptoms
> of a respiratory infection, regardless of presumed cause, should be
> instructed to:

-   Cover the nose/mouth when coughing or sneezing.

-   Use tissues to contain respiratory secretions.

-   Dispose of tissues in the nearest waste receptacle after use.

-   Perform hand hygiene after contact with respiratory secretions and
    contaminated objects/materials.

Healthcare facilities should ensure the availability of materials for
adhering to respiratory hygiene/cough etiquette in waiting areas for
patients and visitors:

-   Provide tissues and no-touch receptacles (i.e., waste container with
    pedal-operated lid or uncovered waste container) for used tissue
    disposal.

-   Provide conveniently located dispensers of alcohol-based hand rub.

-   Provide soap and disposable towels for hand washing where sinks are
    available.

[Masking and separation of persons with symptoms of respiratory
infection]{.underline}

-   During periods of increased respiratory infection in the community,
    offer masks to persons who are coughing. Either procedure masks
    (i.e., with ear loops) or surgical masks (i.e., with ties) may be
    used to contain respiratory secretions; respirators are not
    necessary. Encourage coughing persons to sit at least 3 feet away
    from others in common waiting areas. Some facilities may wish to
    institute this recommendation year-round.

[Droplet Precautions]{.underline}

-   Healthcare workers should practice Droplet Precautions (i.e., wear a
    surgical or procedure mask for close contact), in addition to
    Standard Precautions, when examining a patient with symptoms of a
    respiratory infection. Droplet Precautions should be maintained
    until it is determined that they are no longer needed (see
    [www.cdc.gov/ncidod/hip/ISOLAT/Isolat.htm](http://www.cdc.gov/ncidod/hip/ISOLAT/Isolat.htm)).

## C. Early Detection and Isolation of Patients Potentially at Risk for SARS-CoV Disease

Early detection and isolation of patients who may be infected with
SARS-CoV are the most important interventions to prevent the
introduction of SARS-CoV into a healthcare setting. However, because
measures to control SARS-CoV can impose a considerable burden,
especially if multiple patients with respiratory illnesses are being
seen in an outpatient setting or admitted to a hospital for treatment of
pneumonia, the intensity of early detection and control measures should
be based on the level of SARS-CoV transmission in the world. See CDC's
SARS website ([www.cdc.gov/sars/](http://www.cdc.gov/ncidod/sars/)) for
current information on SARS-CoV transmission worldwide.

**Objective 1**: ***In the absence of SARS-CoV transmission in the
world***, implement screening to detect the re-emergence of SARS-CoV,
and ensure appropriate triage and management of patients with possible
SARS-CoV disease.

In the absence of person-to-person SARS-CoV transmission, the likelihood
that a patient being evaluated for fever or lower respiratory illness,
with or without pneumonia, has SARS-CoV disease will be exceedingly low
unless there are both typical clinical findings and some accompanying
epidemiologic evidence that raises the suspicion of exposure to
SARS-CoV. Therefore, patients with respiratory infections should not be
considered as possible cases of SARS-CoV disease unless they have severe
pneumonia (or acute respiratory distress syndrome) of unknown etiology
that requires hospitalization *and* an epidemiologic history that raises
the suspicion of SARS-CoV exposure.

**Activities**

[Screening and triage]{.underline}

-   Only patients requiring hospitalization for radiographically
    confirmed pneumonia (or acute respiratory distress syndrome) of
    unknown etiology should be screened for SARS epidemiologic risk
    factors. The suspicion for SARS-CoV disease is raised if, within 10
    days of symptom onset, the patient:

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-   Has a history of travel to mainland China, Hong Kong, or Taiwan,[^1]
    or close contact[^2] with an ill person with a history of recent
    travel to one of these areas, *OR*

    -   Is employed in an occupation associated with a risk for SARS-CoV
        exposure (e.g., healthcare worker with direct patient contact;
        worker in a laboratory that contains live SARS-CoV), or

    -   Is part of a cluster of cases of atypical pneumonia without an
        alternative diagnosis

Evaluate persons with such a clinical and exposure history according to
Figure 1 in *Clinical Guidance on the Identification and Evaluation of
Possible SARS-CoV Disease among Persons Presenting with
Community-Acquired Illness*
([www.cdc.gov/ncidod/sars/clinicalguidanceframe1.htm](http://www.cdc.gov/ncidod/sars/clinicalguidanceframe1.htm)).

[Outpatient infection control]{.underline}

-   Follow the infection control recommendations for respiratory
    hygiene/cough etiquette and Droplet Precautions outlined in Section
    III.B above.

[Disposition]{.underline}

-   No special infection control measures are recommended following
    discharge from an outpatient setting.

[Hospitalization]{.underline}

-   Patients who require hospitalization for radiographically confirmed
    pneumonia (or acute respiratory distress syndrome) of unknown
    etiology and who have one of the potential SARS risk factors should
    be placed on Droplet Precautions until it is determined that the
    cause of the pneumonia is not contagious. If the health department
    and clinicians *strongly* suspect SARS-CoV disease, then the patient
    should be placed on Contact and Airborne Infection Isolation
    Precautions, in addition to Standard Precautions (See Section C
    below and *Clinical Guidance on the Identification and Evaluation of
    Possible SARS-CoV Disease among Persons Presenting with
    Community-Acquired
    Illness*,[www.cdc.gov/ncidod/sars/clinicalguidance.htm](http://www.cdc.gov/ncidod/sars/clinicalguidance.htm)).

**Objective 2: *In the presence of person-to-person transmission of
SARS-CoV in the world***, ensure the prompt identification and
appropriate management of patients with possible and known SARS-CoV
disease.

**Activities**

[Screening and triage]{.underline}

Once person-to-person SARS-CoV transmission has been documented anywhere
in the world, the probability that a patient presenting with early
clinical symptoms of SARS actually has SARS-CoV disease increases if the
patient has an epidemiologic link to a geographic location in which
SARS-CoV transmission has been documented.

-   Screen all patients with fever or lower respiratory symptoms, with
    or without pneumonia, to determine if, within 10 days of the onset
    of symptoms, they had:

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-   Close contact with a person suspected of having SARS-CoV disease,
    *or*

-   A history of foreign travel (or close contact with an ill person
    with a history of travel) to a location with documented or suspected
    SARS-CoV transmission, *or*

-   Exposure to a domestic or occupational location with documented or
    suspected SARS-CoV (including a laboratory that contains live
    SARS-CoV), or close contact with an ill person with such an exposure
    history

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-   For persons with a high risk of exposure to SARS-CoV (e.g., persons
    previously identified through contact tracing or self-identified as
    close contacts of a laboratory-confirmed case of SARS-CoV disease;
    persons who are epidemiologically linked to a laboratory-confirmed
    case of SARS-CoV disease), the clinical criteria should be expanded
    to include, in addition to fever or respiratory symptoms, the
    presence of any other early symptoms of SARS-CoV disease (subjective
    fever, chills, rigors, myalgia, headache, diarrhea, sore throat,
    rhinorrhea). The more common early symptoms include chills, rigors,
    myalgia, and headache. In some patients, myalgia and headache may
    precede the onset of fever by 12-24 hours. However, diarrhea, sore
    throat, and rhinorrhea may also be early symptoms of SARS-CoV
    disease.

Evaluate persons with an exposure history suggesting possible SARS-CoV
disease according to Figure 2 in *Clinical Guidance on the
Identification and Evaluation of Possible SARS-CoV Disease among Persons
Presenting with Community-Acquired Illness*
([www.cdc.gov/ncidod/sars/clinicalguidanceframe2.htm](http://www.cdc.gov/ncidod/sars/clinicalguidanceframe2.htm)).

-   Patients who require hospitalization for pneumonia and who do not
    have a known epidemiologic link to a setting in which SARS-CoV has
    been documented should be screened for additional risk factors using
    the questions that apply when no SARS-CoV is documented in the world
    (i.e., employment in an occupation at particular risk for SARS-CoV
    exposure; part of a cluster of atypical pneumonias without an
    alternative diagnosis).

-   Healthcare workers who are the first points of contact (e.g., triage
    and reception) should be trained to perform SARS-CoV screening. If
    screening personnel are not available, healthcare providers should
    screen symptomatic patients for SARS-CoV disease risk factors before
    initiating history-taking and physical examination. If SARS symptoms
    and risk factors are present, follow the clinical algorithm for
    patient management
    ([www.cdc.gov/ncidod/sars/clinicalguidanceframe2.htm](http://www.cdc.gov/ncidod/sars/clinicalguidanceframe2.htm)).

[Outpatient infection control]{.underline}

-   Patients with fever or lower respiratory symptoms, with or without
    pneumonia, who have been exposed to SARS-CoV or who have SARS risk
    factors should be suspected of having SARS-CoV disease and isolated
    as soon as possible. Such patients should be given a mask (surgical
    or procedure) to wear and immediately placed in a private
    examination room or cubicle. If available, an AII room (AIIR) should
    be used.

-   Where limited space and examination room capacity preclude these
    measures, the patient should sit as far away as possible from other
    patients in the waiting area.

-   Family members or friends who accompany the patient should be
    considered at risk for SARS-CoV disease and screened for fever and
    lower respiratory symptoms. If either is present, infection control
    measures to prevent SARS-CoV transmission should be applied.

-   Healthcare workers should wear gown, gloves, respiratory protection,
    and eye protection (if needed) as described in Section III.D.5
    below.

> [Disposition]{.underline}

-   Hospital admission or discharge of a possible SARS patient should
    generally be based on the patient's clinical condition and
    healthcare needs. If diagnostic, therapeutic, or supportive regimens
    do not necessitate hospitalization, patients with possible SARS-CoV
    disease should not be hospitalized.

-   Exceptions include persons for whom no other alternative for
    providing safe infection control is available. Such persons include
    travelers, homeless persons, and persons who would be returned to an
    environment where infection control measures are not feasible or
    practical (e.g., crowded dormitories, prisons and jails, detention
    centers, homeless shelters, other multi-person single-room
    dwellings). These persons should be hospitalized and isolated as
    recommended in Section D below. As soon as appropriate arrangements
    can be made for out-of-hospital care, the patient can be discharged.
    Alternatively, the patient may be admitted to a designated
    residential facility for isolation of convalescing SARS-CoV disease
    cases, if one exists.

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-   During transport between locations, patients should wear a mask.
    Public transportation (e.g., bus, train) should be avoided.
    Recommendations for emergency medical transport are provided in
    Section IV below.

[Hospitalization]{.underline}

-   Follow recommended precautions for hospitalization of a patient with
    known or possible SARS-CoV disease as described in Section D below.

## D. Infection Control Precautions for Hospitalized SARS Patients

The following recommendations apply to patients who have laboratory

evidence of SARS-CoV disease or for whom the attending clinicians and
health

department strongly suspect SARS-CoV disease. The level of precautions
described

will rarely be needed in the absence of SARS-CoV transmission in the
world but will

be used increasingly once SARS-CoV transmission is detected.

Contact and AII Precautions, in addition to Standard Precautions, should
be applied when caring for patients with known or possible SARS-CoV
disease. (Droplet Precautions also are required but are subsumed within
AII Precautions.) These precautions should be maintained for the
duration of potential infectivity (see
([www.cdc.gov/ncidod/sars/clinicalguidance.htm](http://www.cdc.gov/ncidod/sars/clinicalguidance.htm))
or until a diagnosis of SARS-CoV disease has been ruled out. See
Appendix I2.

**The objective of all of the following activities is to prevent the
transmission and acquisition of SARS-CoV in the hospital.**

### 1. Patient placement

-   Admit patients with SARS-CoV disease to an AIIR. An AIIR is a
    single-patient room in which environmental conditions are controlled
    to minimize the possibility of airborne transmission of infectious
    agents. These rooms have specific requirements for controlled
    ventilation, including: 1) a specified number of required air
    exchanges per hour (ACH) (i.e., 6 for old buildings; 12 for new
    construction or renovation), 2) monitored negative pressure relative
    to hallways, and 3) air exhausted directly to the outside preferably
    or passed through a high-efficiency purifying air (HEPA) filter if
    recirculated. These requirements are detailed in the *Guideline for
    Environmental Infection Control in Healthcare Facilities, 2003*
    ([www.cdc.gov/ncidod/hip/enviro/guide.htm](http://www.cdc.gov/ncidod/hip/enviro/guide.htm)).

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-   If there is a lack of AIIRs and/or a need to concentrate infection
    control efforts and resources, patients may be cohorted on a floor
    or nursing unit designated for the care of SARS patients only,
    rather than placed in AIIRs throughout the hospital. This strategy
    physically isolates SARS patients and also makes it possible to
    dedicate resources and appropriately trained staff to their care.
    Experience in some settings in Taiwan and Toronto demonstrated that
    cohorting SARS patients, without use of AIIRs, effectively
    interrupted transmission. Thus, although single AIIRs are
    recommended for SARS isolation, other strategies may provide
    effective overall infection control, particularly if air-handling
    systems in existing rooms/units/floors can be modified to allow
    these areas to operate under negative pressure relative to
    surrounding areas.

-   Even if a facility has chosen to cohort SARS patients, properly
    designed and operated AIIRs are preferred for 1) patients who are
    known to have transmitted SARS-CoV to other persons and 2) patients
    in whom the risk of SARS is being assessed.

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-   Designate "clean" and "dirty" areas for isolation materials.
    Maintain a stock of clean patient care and PPE supplies outside the
    patient's room. Decide where contaminated linen and waste will be
    placed. Locate receptacles close to the point of use and separate
    from the clean supplies. Also designate the location where reusable
    PPE (e.g., goggles, face shields) will be placed for cleaning and
    disinfection before reuse.

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-   Limit the amount of patient-care equipment brought into the room to
    that which is medically necessary. Provide each patient with
    patient-dedicated equipment (e.g., thermometer, blood pressure cuff,
    stethoscope).

-   Limit staff to the number sufficient to meet patient-care needs.
    Using staff who have been specially trained to care for patients
    with SARS may reduce opportunities for exposure, increase adherence
    to recommended infection control practices, and promote continuity
    of care.

### 2. Patient transport

-   Limit patient movement and transport outside the AIIR to medically
    necessary purposes. Whenever possible, use portable equipment to
    perform x-rays and other procedures in the patient's room.

-   If transport or movement is necessary, ensure that the patient wears
    a surgical mask, puts on a clean patient gown, and performs hand
    hygiene before leaving the room. If a mask cannot be tolerated
    (e.g., due to the patient's age or deteriorating respiratory
    status), apply the most practical measures to contain respiratory
    secretions.

-   Limit contact between SARS patients and others by using less
    traveled hallways and elevators when possible.

### 3. Visitors

-   Limit visits to patients with known or possible SARS-CoV disease to
    persons who are necessary for the patient's emotional well-being and
    care.

-   Visitors who have been in contact with the patient before and during
    hospitalization are a possible source of SARS-CoV. Therefore,
    schedule and control visits to allow for appropriate screening for
    SARS-CoV disease before entering the hospital and appropriate
    instruction on use of PPE and other precautions (e.g., hand hygiene,
    limiting surfaces touched) while in the patient's room.

### 4. Hand hygiene

> Hand hygiene (i.e., hand washing or use of an alcohol-based hand rub)
> should be performed after contact with a patient on precautions for
> SARS-CoV disease or their environment of care. Current guidelines for
> hand hygiene are provided at:
> [www.cdc.gov/handhygiene/](http://www.cdc.gov/handhygiene/).

###  5. Personal protective equipment (PPE)

> Gloves, gown, respiratory protection, and eye protection (as needed)
> should be donned before entering a SARS patient's room or designated
> SARS patient-care area. This level of protection is required for the
> majority of patient contacts. Additional guidance for performing an
> aerosol-generating procedure on patients with SARS Co-V disease is
> provided in Section III.D.11 below. Instructions on how to safely don,
> use, and remove PPE are being developed and will be provided at
> [www.cdc.gov/ncidod/sars/](http://www.cdc.gov/ncidod/sars/) when
> available. Removal of PPE in a manner that prevents contamination of
> clothing and skin is a priority.

-   [Gown and gloves]{.underline} -- Wear a standard isolation gown and
    pair of nonsterile patient-care gloves for all patient contacts. The
    gown should fully cover the front torso and arms and should tie in
    the back. Gloves should cover the cuffs of the gown.

-   [Respiratory protection]{.underline} -- Wear a NIOSH-certified N-95
    filtering facepiece respirator for entering an AIIR or designated
    SARS patient-care area.[^3] If N-95 or higher level of respiratory
    protection is not available, then wear a snug-fitting surgical mask
    to prevent nose and mouth contact with large respiratory droplets.
    Discard respirators upon leaving the patient room or area.

-   [Eye and face protection]{.underline} \-- It is not yet known
    whether routine eye protection is needed to prevent SARS-CoV
    transmission. Routinely wear eye protection when within 3 feet of a
    patient with SARS-CoV. If splash or spray of respiratory secretions
    or other body fluids is likely, protect the eyes with goggles or a
    face shield, as recommended for Standard Precautions. The face
    shield should fully cover the front and wrap around the side of the
    face. Corrective eyeglasses or contact lenses alone are not
    considered eye protection.

-   Use safe work practices when wearing PPE:

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-   Avoid touching the face with contaminated gloves

-   Avoid unnecessary touching of surfaces and objects with contaminated
    gloves

### 6. Medical waste

> Medical waste has not been implicated in the transmission of SARS-CoV.
> Therefore, no special handling procedures are recommended for
> SARS-CoV-contaminated medical waste.

-   Contain and dispose of SARS-CoV-contaminated medical waste in
    accordance with facility-specific procedures and/or local or state
    regulations for handling and disposal of medical waste, including
    used needles and other sharps.

-   Discard as routine waste used patient-care supplies that are not
    likely to be contaminated (e.g., paper wrappers).

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-   Wear disposable gloves when handling waste. Perform hand hygiene
    after removal of gloves.

### 7. Textiles (linen and laundry)

> Contact with textiles has not been implicated in the transmission of
> SARS-CoV. Therefore, no special handling procedures are recommended
> for linen and laundry that may be contaminated with SARS-CoV.

-   Store clean linen outside patient rooms, taking into the room only
    linen needed for use during the shift.

-   Place soiled linen directly into a laundry bag in the patient's
    room. Contain linen in a manner that prevents the linen bag from
    opening or bursting during transport and while in the soiled linen
    holding area.

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-   Wear gloves and gown when directly handling soiled linen and laundry
    (e.g., bedding, towels, personal clothing) as per Standard and
    Contact Precautions. Do not shake or otherwise handle soiled linen
    and laundry in a manner that might aerosolize infectious particles.

-   Wear gloves for transporting bagged linen and laundry.

-   Perform hand hygiene after removing gloves that have been in contact
    with soiled linen and laundry.

-   Wash and dry linen according to routine standards and procedures
    ([www.cdc.gov/ncidod/hip/enviro/guide.htm](http://www.cdc.gov/ncidod/hip/enviro/guide.htm)).

### 8. Dishes and eating utensils

> Dishes and eating utensils have not been implicated in SARS-CoV
> transmission. Therefore, no special precautions, beyond those for
> Standard Precautions, are recommended for dishes and eating utensils
> used by a patient with known or possible SARS-CoV disease.

-   Wash reusable dishes and utensils in a dishwasher with recommended
    water temperature
    ([www.cdc.gov/ncidod/hip/enviro/guide.htm](http://www.cdc.gov/ncidod/hip/enviro/guide.htm)).

-   Wear gloves when handling patient trays, dishes, and utensils.

### 9. Patient-care equipment

-   Follow standard practices for handling and reprocessing used
    patient-care equipment, including medical devices. Wear gloves when
    handling and transporting used patient-care equipment. Wipe heavily
    soiled equipment with an EPA-approved hospital disinfectant before
    removing it from the patient's room. Follow current recommendations
    for cleaning and disinfection or sterilization of reusable
    patient-care equipment.

-   Wipe external surfaces of portable equipment for performing x-rays
    and other procedures in the patient's room with an EPA-approved
    hospital disinfectant upon removal from the patient's room.

### 10. Environmental cleaning and disinfection

> Cleaning and disinfection of environmental surfaces are important
> components of routine infection control in healthcare facilities.
> Although little is known about the extent of environmental
> contamination in SARS patients' rooms, epidemiologic and laboratory
> evidence suggests that the environment could play a role in
> transmission. Therefore, cleaning and disinfection are critical to the
> control of SARS-CoV transmission. Environmental cleaning and
> disinfection for SARS-CoV follows the same principles generally used
> in healthcare settings.
>
> [Cleaning and disinfection of occupied patient rooms]{.underline}

-   Consider designating specific, well-trained environmental services
    personnel for cleaning and disinfecting of SARS patient rooms/units.
    Fully define the scope of cleaning that will be done each day;
    identify who will be responsible for cleaning and disinfecting the
    surfaces of patient-care equipment (e.g., IV pumps, ventilators).
    Consider using a checklist to promote accountability for cleaning
    responsibilities.

-   Environmental services personnel should wear PPE as described in
    Section III.D.5 above. These staff should be trained in proper
    procedures for PPE use, including removal of PPE, and the importance
    of hand hygiene.

-   Keep cleaning supplies outside the patient room (e.g., in an
    anteroom or storage area).

-   Keep areas around the patient free of unnecessary supplies and
    equipment to facilitate daily cleaning.

-   Use any EPA-registered hospital detergent-disinfectant. Follow
    manufacturer's recommendations for use-dilution (i.e.,
    concentration), contact time, and care in handling.

-   Clean and disinfect SARS patients' rooms at least daily and more
    often when visible soiling/contamination occurs. Give special
    attention to frequently touched surfaces (e.g., bedrails, bedside
    and over-bed tables, TV control, call button, telephone, lavatory
    surfaces including safety/pull-up bars, doorknobs, commodes,
    ventilator surfaces) in addition to floors and other horizontal
    surfaces.

-   Because so little is known about environmental transmission of
    SARS-CoV, placement of patients in rooms that do not have carpeting
    is preferred because non-carpeted floors are easier to clean and
    disinfect. If use of carpeted rooms cannot be avoided, vacuuming
    should be done daily, and personnel should wear the recommended PPE.
    Follow current CDC environmental guidelines for vacuuming and
    shampooing carpeted floors in patient rooms
    ([www.cdc.gov/ncidod/hip/enviro/guide.htm](http://www.cdc.gov/ncidod/hip/enviro/guide.htm)).

-   After an aerosol-generating procedure (e.g., intubation), clean and
    disinfect horizontal surfaces around the patient. Clean and
    disinfect as soon as possible after the procedure.

-   Clean and disinfect spills of blood and body fluids in accordance
    with current recommendations for Standard Precautions
    ([www.cdc.gov/ncidod/hip/ISOLAT/Isolat.htm](http://www.cdc.gov/ncidod/hip/ISOLAT/Isolat.htm)).

> [Cleaning and disinfection after patient discharge or
> transfer]{.underline}
>
> Follow standard facility procedures for terminal cleaning of an
> isolation room.

-   Clean and disinfect all surfaces that were in contact with the
    patient or may have become contaminated during patient care.

-   Wipe down mattresses and headboards with an EPA-approved hospital
    disinfectant.

-   Privacy curtains should be removed, placed in a bag in the room and
    then transported to be laundered.

-   No special treatment is necessary for window curtains, ceilings, and
    walls unless there is evidence of visible soil.

-   Do not spray (i.e., fog) occupied or unoccupied rooms with
    disinfectant. This is a potentially dangerous practice that has no
    proven disease control benefit.

### 11. Aerosol-generating procedures

> Because aerosol-generating procedures may pose a greater risk of
> SARS-CoV transmission, additional precautions are recommended for
> healthcare workers who perform or assist with these procedures.
> Procedures that stimulate coughing and promote the generation of
> aerosols include aerosolized or nebulized medication administration,
> diagnostic sputum induction, bronchoscopy, airway suctioning,
> endotracheal intubation, positive pressure ventilation via face mask
> (e.g., BiPAP, CPAP), and high-frequency oscillatory ventilation.
>
> Healthcare facilities should review their strategies to protect
> healthcare workers during these procedures, including the use of PPE
> and safe work practices. Healthcare workers who perform these
> procedures should be alerted to the fact that there may be an
> increased risk for SARS-CoV transmission when these procedures are
> performed.
>
> [Infection control measures]{.underline}

-   Limit performance of aerosol-generating procedures on SARS patients
    to those that are considered medically necessary. Clinically
    appropriate sedation during intubation and bronchoscopy may minimize
    resistance and coughing during the procedure.

-   Limit the number of healthcare workers in the room during an
    aerosol-generating procedure to those essential for patient care and
    support.

-   Perform aerosol-generating procedures in an AIIR. If an AIIR is not
    available, perform the procedure in a private room, away from other
    patients. If possible, increase air exchanges, create a negative
    pressure relative to the hallway, and avoid recirculation of the
    room air. If recirculation of air from such rooms is unavoidable,
    pass the air through a HEPA filter before recirculation, as
    recommended for *Mycobacterium tuberculosis*
    ([www.cdc.gov/mmwr/preview/mmwrhtml/00035909.htm](http://www.cdc.gov/mmwr/preview/mmwrhtml/00035909.htm)).

-   Air-cleaning devices, such as portable HEPA filtration units, may be
    used to further reduce the concentration of contaminants in the air.
    Keep doors closed except when entering or leaving the room, and
    minimize entry and exit during the procedure.

-   Submicron filters on exhalation valves of mechanical ventilators may
    prevent contaminated aerosols from entering the environment.
    Although the effectiveness of this measure in reducing the risk of
    SARS-CoV transmission is unknown, the use of such filters is prudent
    during high-frequency oscillatory ventilation of patients with
    SARS-CoV disease.

> [PPE for aerosol-generating procedures]{.underline}
>
> The optimal combination of PPE for preventing SARS-CoV transmission
> during aerosol-generating procedures has not been determined. Wearing
> PPE during these procedures protects the respiratory tract from
> inhalation of droplet nuclei and the mucous membranes, skin, and
> clothing from contact with infectious respiratory secretions. PPE
> should cover the torso, arms, and hands as well as the eyes, nose, and
> mouth. PPE must be compatible with the needs of healthcare worker
> protection and patient care. The following PPE is recommended:

-   Disposable isolation gown, preferably with fluid-resistant
    properties, to protect the body and exposed areas of the arms. A
    disposable full-body isolation suit is an option and may provide
    greater protection of the skin, especially around the neck. Surgical
    hoods, which fully cover the head, neck, and face, (with the
    addition of an N-95 or higher-level disposable particulate
    respirator), have been used in some settings. It is unknown whether
    covering exposed areas of skin or hair on the head will further
    reduce the risk of transmission.

-   Pair of disposable gloves that fit snuggly over the gown cuff.

-   Eye protection (i.e., goggles) to protect the eyes from respiratory
    splash or spray. Goggles should fit snuggly (but comfortably) around
    the eyes. A face shield may be worn over goggles to protect exposed
    areas of the face but should not be worn as a primary form of eye
    protection for these procedures.

-   Respiratory protection \-- During aerosol-generating procedures,
    there must be minimal respirator face-seal leakage to fully protect
    the worker from exposure to aerosolized infectious droplets. The
    following respiratory protection options should be considered:

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-   Disposable particulate respirators (e.g., N-95, N-99, or N-100) are
    sufficient for routine respiratory protection for Airborne Infection
    Isolation and are the minimum level of respiratory protection
    required for healthcare workers who are performing
    aerosol-generating procedures. To ensure adequate protection,
    healthcare workers must be fit-tested to the respirator model that
    they will wear
    ([www.cdc.gov/niosh/99-143.html](http://www.cdc.gov/niosh/99-143.html))
    and also know how to check the face-piece seal. A fit-check should
    be performed each time a respirator is put on, before entering the
    patient room. Workers who cannot wear a disposable particulate
    respirator because of facial hair or other fit limitations should
    wear a loose-fitting (i.e., helmeted or hooded) PAPR.

-   Healthcare facilities in some SARS-affected areas routinely used
    higher levels of respiratory protection for performing
    aerosol-generating procedures on patients with SARS-CoV disease. It
    is unknown whether these higher levels of protection will further
    reduce transmission. Factors that should be considered in choosing
    respirators in this setting include availability, impact on
    mobility, impact on patient care, potential for exposure to higher
    levels of aerosolized respiratory secretions, and potential for
    reusable respirators to serve as fomites for transmission. Higher
    levels of respiratory protection include:

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```
-   PAPR with loose-fitting face piece that forms a partial seal with
    the face

-   PAPR with hood that completely covers the head and neck and may also
    cover portions of the shoulder and torso

-   PAPR with tight-fitting face piece (half and full face-piece)

-   Full face-piece elsastomeric negative-pressure (non-powered)
    respirators with N, R, or P-100 filters.

# IV. Infection Control for Prehospital Emergency Medical Services (EMS)

Effective communication among clinicians requesting emergency transport
of a patient with possible or known SARS-CoV disease, EMS personnel, and
receiving facilities is necessary to ensure the appropriate protection
of healthcare workers. Prehospital care personnel should follow the
updated Standard Precautions recommendations to prevent the spread of
respiratory infections described in III.B above. These include promoting
respiratory hygiene/cough etiquette
([www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm](http://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm))
and using Droplet Precautions
([www.cdc.gov/ncidod/hip/ISOLAT/Isolat.htm](http://www.cdc.gov/ncidod/hip/ISOLAT/Isolat.htm)),
in addition to Standard Precautions, for all patients with symptoms of a
respiratory infection. When SARS is suspected in a patient needing
emergency transport, ***prehospital care providers and healthcare
facilities should be notified in advance that they may be transporting
or receiving a patient who may have SARS-CoV disease.***

## A. Patient Transport

> **Objective:** Safely transport patients with known or possible
> SARS-CoV disease.

**Activities**

> Patients who may have SARS-CoV disease may be safely transported in
> any emergency vehicle with the proper precautions.

-   Involve the fewest EMS personnel required to minimize possible
    exposures.

-   Family members and other contacts of SARS patients should not ride
    in the ambulance if possible. If necessary, they should be evaluated
    for fever and lower respiratory symptoms and, if either is present,
    asked to wear a surgical or procedure mask when riding in the
    vehicle.

-   When possible, use vehicles that have separate driver and patient
    compartments that can provide separate ventilation to each area.
    Close the door/window between these compartments before bringing the
    patient on board. Set the vehicle's ventilation system to the
    non-recirculating mode to maximize the volume of outside air brought
    into the vehicle. If the vehicle has a rear exhaust fan, use it to
    draw air away from the cab, toward the patient-care area, and out
    the back end of the vehicle. Some vehicles are equipped with a
    supplemental recirculating ventilation unit that passes air through
    HEPA filters before returning it to the vehicle. Such a unit can be
    used to increase the number of ACH (NIOSH HETA report 95-0031-2601
    \[[www.cdc.gov/niosh/hhe/reports/pdfs/1995-0031-2601.pdf](http://www.cdc.gov/niosh/hhe/reports/pdfs/1995-0031-2601.pdf)\]).

-   If a vehicle without separate compartments and ventilation must be
    used, open the outside air vents in the driver area and turn on the
    rear exhaust ventilation fans to the highest setting. This will
    create a negative pressure gradient in the patient area.

-   If possible, place a surgical mask on the patient to contain
    droplets expelled during coughing. If this is not possible (i.e.,
    would further compromise respiratory status, difficult for the
    patient to wear), have the patient cover the mouth/nose with tissue
    when coughing.

-   Oxygen delivery with a non-rebreather face mask may be used to
    provide oxygen support during transport. If needed,
    positive-pressure ventilation should be performed using a
    resuscitation bag-valve mask, preferably one equipped to provide
    HEPA or equivalent filtration of expired air.

-   If a patient has been mechanically ventilated before transport, HEPA
    or equivalent filtration of airflow exhaust should be available.
    (EMS organizations should consult their ventilator equipment
    manufacturer to confirm appropriate filtration capability and the
    effect of filtration on positive-pressure ventilation.)

-   Cough-generating procedures (e.g., mechanical ventilation, nebulizer
    treatment) should be avoided during prehospital care.

## B. Personal Protective Equipment

> **Objective:** Ensure the safety of prehospital care providers who
> transport patients with known or possible SARS-CoV disease.

**Activities**

-   Prehospital care providers who directly handle a patient with
    SARS-CoV disease or who are in the compartment with the patient
    should wear PPE as recommended for Standard, Contact, and AII
    Precautions
    ([www.cdc.gov/ncidod/hip/ISOLAT/isopart2.htm](http://www.cdc.gov/ncidod/hip/ISOLAT/isopart2.htm)).
    These include the following:

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```
-   Disposable isolation gown, pair of disposable patient examination
    gloves, eye protection (i.e., goggles or face shield).

-   Respiratory protection (i.e., N-95 or higher-level respirator)

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```
-   Personnel in the driver's compartment who will have no direct
    patient contact should wear an N-95 or higher-level respirator
    during transport. Drivers who also provide direct patient care
    (e.g., moving patients on stretchers) should wear the recommended
    PPE for patient contact. This PPE, with the exception of the
    respirator, should be removed and hand hygiene performed after
    completing patient care and before entering driver's compartment to
    avoid contaminating the compartment. Instructions on how to safely
    don, use, and remove PPE is being developed and will be provided
    when available on CDC's SARS website:
    [www.cdc.gov/ncidod/sars/](http://www.cdc.gov/ncidod/sars/).

## C. Safe Work Practices

> **Objective:** Ensure safe work practices among EMS personnel to
> prevent transmission of SARS-CoV.

**Activities**

-   Avoid touching one's face with contaminated gloves.

-   Avoid unnecessary touching of surfaces in the ambulance vehicle.

-   Arrange for the receiving facility staff to meet the patient at the
    ambulance door to limit the need for EMS personnel to enter the
    emergency department in contaminated PPE. (It may not be practical
    to change PPE before patient transfer into the facility.) Remove and
    discard PPE after transferring the patient at the receiving facility
    and perform hand hygiene. Treat used disposable PPE as medical
    waste.

## D. Clinical Specimens

> **Objective:** Safely collect clinical specimens from SARS patients
> during transport.

**Activities**

-   Handle clinical specimens that must be collected during transport
    (e.g., blood gas) in accordance with standard operating procedures.

## E. Post-Transport Management of the Contaminated Vehicle

> **Objective:** Safely clean vehicles used for transport of SARS
> patients to prevent SARS-CoV transmission.

**Activities**

-   Follow standard operating procedures for the containment and
    disposal of regulated medical waste.

-   Follow standard operating procedures for containing and reprocessing
    used linen. Wear appropriate PPE when removing soiled linen from the
    vehicle. Avoid shaking the linen.

-   Clean and disinfect the vehicle in accordance with standard
    operating procedures. Personnel performing the cleaning should wear
    a disposable gown and gloves (a respirator should not be needed)
    during the clean-up process; the PPE should be discarded after use.
    All surfaces that may have come in contact with the patient or
    materials contaminated during patient care (e.g., stretcher, rails,
    control panels, floors, walls, work surfaces) should be thoroughly
    cleaned and disinfected using an EPA-registered hospital
    disinfectant in accordance with manufacturer's recommendations.

-   Clean and disinfect reusable patient-care equipment according to
    manufacturer's instructions.

## F. Follow-up of EMS Personnel 

> **Objective:** Ensure appropriate follow-up and care of EMS personnel
> who transport SARS patients.
>
> **Activities**

-   Manage EMS personnel who transport SARS patients as recommended for
    hospital personnel (see Section IX).

# V. Infection Control for Care of SARS Patients at Home

Patients with SARS-CoV disease who do not require hospitalization for
medical indications may be isolated at home.

##  A. Assessment of the Residence

> **Objective:** Ensure that the residential setting is suitable and
> appropriate for isolation of a SARS patient.

**Activities**

-   Before a SARS patient occupies a residence for home isolation, there
    should be an assessment (by phone or direct observation) to ensure
    that the residence has the features necessary for provision of
    appropriate care and infection control precautions. Because of the
    variability of household settings, professional judgment is needed
    in determining whether a home is an appropriate location for a
    patient with SARS-CoV disease.

-   There should be a bathroom in the home for use by the patient and
    household members only. If there are multiple bathrooms, one should
    be designated solely for the patient's use, especially if the
    patient has diarrhea.

-   The patient should have a bed and preferably a private room for
    sleeping.

-   If the home is a multiple family dwelling (e.g., apartment
    building), the area in which the patient will be housed should have
    a separate air-handling system (if one is present).

-   Basic amenities, such as heat, electricity, potable and hot water,
    sewer, and telephone access, should be available.

-   There should be a primary caregiver to assist the patient with basic
    needs in the home and social service support for obtaining
    groceries, prescriptions, and other personal needs.

## B. Infection Control Precautions for SARS Patients Isolated at Home

> **Objective:** Ensure the use of proper infection control precautions
> in the home setting to minimize the potential for SARS-CoV
> transmission.
>
> Infection control principles used in healthcare settings also apply in
> the home care setting. However, due to practical limitations, there
> are some differences between what can be done in the home and the
> healthcare setting. For example, AII Precautions cannot be practiced
> completely outside of fully controlled settings such as healthcare
> facilities. Since SARS-CoV is most likely transmitted through contact
> and droplet spread, the use of modified precautions that focus on
> preventing droplet and contact spread are recommended for isolation in
> the household setting.
>
> **Activities**
>
> [Duration of infection control measures]{.underline}

-   Continue the infection control precautions outlined below until 10
    days following resolution of fever (given respiratory symptoms are
    absent or resolving) or until the health department has determined
    that home isolation precautions can be safely discontinued (e.g.,
    diagnosis of SARS-CoV disease is ruled out).

[Home isolation precautions]{.underline}

-   Patients should not leave the home for the duration of the isolation
    period, except as necessary for follow-up medical care. When
    movement outside the home is necessary, the patient should wear a
    mask, if tolerated, and should not use public transportation.

-   Separate the patient from other persons in the household to the
    extent possible. Use a separate room and bathroom if available.

-   Limit the number of persons in the household to those who are
    essential for patient support. Other household members should either
    be relocated or minimize contact with the patient in the home. This
    is particularly important for persons at risk of serious SARS-CoV
    disease complications (e.g., persons with underlying heart or lung
    disease, diabetes mellitus, older age).

-   Unexposed persons who do not have an essential need to be in the
    home should not visit.

> [Infection control measures in the home]{.underline}

-   [Hand hygiene]{.underline} \-- All persons in the household should
    carefully follow recommendations for hand hygiene (i.e., hand
    washing with soap and water or use of an alcohol-based hand rub)
    after touching body fluids (e.g., respiratory secretions, stool,
    urine, vomitus) and potentially contaminated surfaces and materials
    (e.g., linen). Hand hygiene supplies (soap/water, alcohol-based hand
    rub, disposable towels) should be available and replenished as
    needed. (See
    [www.cdc.gov/handhygiene/](http://www.cdc.gov/handhygiene/).)

-   [Source control]{.underline} \-- Patients should cover the
    nose/mouth when coughing and dispose of tissues in a lined waste
    container. If possible, the patient should wear a surgical mask when
    others are present. If the patient cannot wear a mask, persons in
    close contact with the patient should wear a mask. Masks should fit
    snugly around the face and should not be touched or handled during
    use. If masks will be reused by persons in the home, procedures for
    identifying each person's mask and containing it between uses should
    be in place. A supply of masks should be available based on the
    volume needed each day.

-   [Gloves and other protective attire]{.underline} \-- Use of
    disposable gloves should be considered for any direct contact with
    the body fluids of a patient with possible or known SARS-CoV
    disease. ***However, gloves are not intended to replace proper hand
    hygiene.*** Immediately after gloves are removed, they should be
    discarded and hand hygiene should be performed. Gloves must never be
    washed or reused.

-   [Laundry (e.g., bedding, towels and clothing]{.underline}) \--
    Towels and bedding should not be shared. Laundry may be washed in a
    standard washing machine with warm water and detergent; bleach may
    be added but is not necessary. Gloves should be worn when handling
    soiled laundry, and care should be used when handling soiled laundry
    to avoid direct contact of skin and/or clothing with contaminated
    material. Soiled laundry should not be shaken or otherwise handled
    in a manner that may aerosolize infectious particles.

-   [Dishes and other eating utensils]{.underline} \-- Objects used for
    eating should not be shared, but separation of eating utensils for
    use by the SARS patient is not necessary. Soiled dishes and eating
    utensils should be washed either in a dishwasher or by hand with
    warm water and soap.

-   [Household waste]{.underline} \-- Gloves, tissues, and other waste
    generated in the care of a SARS patient should be bagged and placed
    in another container for disposal with other household waste.

-   [Cleaning and disinfection of environmental surfaces]{.underline}
    \-- Environmental surfaces that are frequently touched by the
    patient or are soiled with body fluids should be cleaned and
    disinfected with a household disinfectant. The bathroom used by the
    patient should be cleaned daily, if possible. Household utility
    gloves should be worn during the cleaning process.

## C. Follow-up of Contacts

> **Objective:** Ensure appropriate follow-up and care of exposed close
> contacts of SARS patients in home isolation.

**Activities**

-   Household members and other close contacts of SARS patients should
    be vigilant for fever (i.e., measure temperature at least daily)
    and/or respiratory symptoms.

-   If household contacts develop fever or respiratory symptoms,
    arrangements should be made immediately for a medical evaluation***.
    In advance of the evaluation, healthcare providers should be
    informed that the person (and those who may accompany him or her) is
    a close contact of a SARS patient so arrangements can be made, to
    prevent transmission to others in the healthcare setting.***

-   Symptomatic household or other close contacts should follow the same
    precautions recommended for the SARS patient.

-   In the absence of fever or respiratory symptoms, household contacts
    need not limit their activities outside the home, unless otherwise
    required by quarantine regulations.

# VI. Infection Control for Care of SARS Patients in Community Isolation Facilities

If a surge in patients overwhelms existing healthcare capacity or if
home isolation is not feasible for individual patients, jurisdictions
might need to use alternative facilities in the community for the
isolation of SARS patient. In most situations, community isolation
facilities will house and care for patients with milder cases of
SARS-CoV disease These patients can be expected to care for themselves
and are not expected to have significant healthcare needs. The specific
precautions that will be required will depend in part of the type of
facility designated for community isolation (e.g., motel, hotel,
hospital). The same infection control principles that apply to home
isolation apply to community isolation facilities. However, in community
settings, personnel who are in the facility should be trained and
fit-tested for an N-95 respirator.

-   Community isolation facilities should have rooms with private
    bathrooms.

-   Personnel who enter the room should wear an N-95 respirator. If
    there will be direct contact with the patient or the patient's
    environment, a disposable isolation gown and gloves should be worn.

-   Receptacles for soiled linen/laundry and contaminated waste should
    be placed in designated locations. Follow home care guidelines above
    for handling these materials.

# VII. Infection Control for Public Health and Outreach Workers

> **Objective:** Ensure the safety of public health and outreach workers
> who meet with SARS patients or their contacts in the home or a
> community isolation facility.

**Activities**

-   Public health workers and other personnel who work in the field and
    may be visiting patients in home or community isolation facilities
    should wear PPE that is commensurate with the degree of patient
    contact. These personnel should be trained and fit-tested in N-95
    respirator use. Personnel who enter the home or room of a SARS
    patient should wear an N-95 respirator.

-   If there will be direct contact with the patient or the patient's
    environment, a disposable isolation gown and gloves should be worn.

-   PPE should be removed outside the home or facility and bagged for
    disposal; hand hygiene should be performed.

# VIII. Infection Control for Laboratory and Pathology Procedures

Despite the processing of several thousand diagnostic specimens from
patients with SARS-CoV disease in routine clinical laboratories around
the world, to date there have been no reported clusters of SARS-CoV
disease among laboratory workers. To date, the only confirmed episode of
SARS-CoV transmission to a laboratory worker occurred in a research
laboratory. The risk of transmission to laboratory personnel is most
likely during specimen processing and handling of virus cultures.

## A. Specimen Collection and Handling

> **Objective:** Safely collect and handle specimens from SARS patients
> to prevent transmission of SARS-CoV.
>
> **Activities**

-   Healthcare workers who collect specimens from SARS patients should
    wear PPE as appropriate for Standard, Contact, and AII Precautions.

-   Standard facility procedures for specimen collection and transport
    to the clinical laboratory should be followed.

-   All specimens should be appropriately contained (bagged if
    necessary) and have a completed laboratory requisition slip
    attached. Information on the requisition slip should indicate that
    the patient is or could be infected with SARS-CoV. Laboratory
    personnel should be alerted to the possibility of SARS-CoV to ensure
    safe handling procedures.

## B. Laboratory Procedures

**Objective:** Safely process SARS-CoV specimens to prevent
transmission.

**Activities**

-   Biosafety levels 2 and 3, according to specimen type, are
    recommended for processing SARS-CoV specimens. The specifics of
    these recommendations are provided in Supplement F.

## C. Postmortem Handling of Human Remains

> **Objective:** Safely handle human remains during autopsy procedures
> to prevent transmission of SARS-CoV.

**Activities**

> In general, safety procedures for human remains infected with SARS-CoV
> should be consistent with those used for any autopsy procedure.
> However, additional respiratory protection is needed during an autopsy
> procedure that generates aerosols (e.g., use of oscillating saws).
>
> [Personal protective equipment (PPE)]{.underline}

-   Wear standard autopsy PPE, including a scrub suit worn under an
    impervious gown or apron, eye protection (i.e., goggle, face
    shield), double surgical gloves with an interposed layer of
    cut-proof synthetic mesh gloves, surgical mask or respirator, and
    shoe covers.

-   Add respiratory protection if aerosols might be generated. This
    includes N-95 or N-100 disposable particulate respirators or PAPR.
    Autopsy personnel who cannot wear a disposable particulate
    respirator because of facial hair or other fit limitations should
    wear a loose-fitting (i.e., helmeted or hooded) PAPR.

-   Remove PPE before leaving the autopsy suite and disposed in
    accordance with facility policies and procedures.

> [Engineering controls]{.underline}

-   Whenever possible, perform autopsies on human remains infected with
    SARS-CoV in autopsy settings that have adequate air-handling system.
    This includes a minimum of 6 (old construction) to 12 (new
    construction) ACH, negative pressure relative to adjacent areas as
    per recommendations for AIIRs, and direct exhaust of air to the
    outside or passed through a HEPA filter if air is recirculated.
    Exhaust systems around the autopsy table should direct air (and
    aerosols) away from healthcare workers performing the procedure
    (e.g., exhaust downward).

-   Use containment devices whenever possible. Use biosafety cabinets
    for the handling and examination of smaller specimens. When
    available, use vacuum shrouds for oscillating saws to contain
    aerosols and reduce the volume released into the ambient air
    environment.

> [Prevention of percutaneous injuries]{.underline}

-   Follow standard safety procedures for preventing percutaneous
    injuries during autopsy.

# IX. Occupational Health Issues 

## A. Surveillance and Monitoring of Healthcare Workers

> **Objective:** Establish/adapt a healthcare personnel surveillance
> system to ensure that workers who may have had exposure to SARS-CoV
> are identified and monitored and that those who develop illness
> receive appropriate care.
>
> **Activities**

-   Establish a process to identify personnel who enter the rooms or
    units where SARS patients are provided cared. Possible mechanisms
    include self-reports, sign-in sheets, or logs.

-   Instruct personnel who have unprotected contact with patients with
    SARS-CoV disease or who have early symptoms of SARS-CoV disease to
    immediately notify occupational health, infection control, or a
    designee.

-   Develop a system to identify healthcare personnel who provided care
    to a patient who was later identified as having SARS-CoV disease.

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-   See Supplement F, Appendix F6 for guidance on medical surveillance
    of exposed laboratory workers.

## B. Management of Exposures and Other Contacts with SARS Patients

> **Objective:** Ensure appropriate management and follow-up monitoring
> of healthcare workers who have had exposures and other contacts with
> SARS patients.
>
> **Activities**
>
> Clinical judgment should be used in deciding when a worker has been
> exposed and needs follow-up monitoring.
>
> [Management of asymptomatic healthcare workers with unprotected
> high-risk exposures]{.underline}
>
> An unprotected high-risk exposure occurs when a healthcare worker is
> in a room with a SARS patient during an aerosol-generating procedure
> or event *and* the recommended infection control precautions are
> either absent or breached. If a healthcare worker has an unprotected
> high-risk exposure but has no symptoms of SARS-CoV disease, the
> worker:

-   Should be excluded from duty (e.g., administrative leave) for 10
    days after the date of the last high-risk exposure.

-   Should be vigilant for the development of fever and/or respiratory
    symptoms.

-   Should be actively monitored for the development of fever and/or
    respiratory symptoms for 10 days after the date of the last
    high-risk exposure.

> Decisions regarding activity restrictions, (e.g., quarantine home/work
> restrictions) outside the facility should be discussed with the health
> department, in accordance with the recommendations in Supplement D.
>
> The combination of close monitoring for symptoms and exclusion from
> duty protects the hospital and community without imposing unnecessary
> restrictions on a healthcare worker.
>
> [Management of asymptomatic healthcare workers with unprotected
> exposures that are not high risk]{.underline}
>
> Unprotected exposures that are not high risk occur when a healthcare
> worker is in a room or patient-care area with a SARS patient (not
> during a high-risk procedure) and the recommended infection control
> precautions are either absent or breached. If a healthcare worker has
> an unprotected, non-high-risk exposure and has no symptoms of SARS-CoV
> disease, the healthcare worker:

-   Need not be excluded from duty.

-   Should be vigilant for the development of fever and/or respiratory
    symptoms (i.e., measure and record body temperature twice daily for
    10 days following the date of last unprotected exposure, and
    immediately notify the healthcare facility if symptoms develop.)

-   Should be actively monitored for the development of fever and lower
    respiratory symptoms before reporting to duty.

> Decisions regarding activity restrictions, (e.g., quarantine home/work
> restrictions) outside the facility should be discussed with the health
> department, in accordance with the recommendations in Supplement D.
>
> [Surveillance of asymptomatic healthcare workers who have
> cared]{.underline}
>
> [for SARS patient(s) but have no known unprotected
> exposures]{.underline}

-   Instruct workers to be vigilant for the development of fever and/or
    respiratory symptoms, measure and record body temperature twice
    daily throughout the 10-day period following the date of last
    protected contact with a SARS patient, and immediately notify the
    healthcare facility if symptoms develop.

-   Implement active follow-up surveillance of these workers for 10 days
    following the last protected exposure.

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-   Decisions regarding activity restrictions, (e.g., quarantine
    home/work restrictions) outside the facility should be discussed
    with the health department, in accordance with the recommendations
    in Supplement D.

> [Management of symptomatic healthcare workers]{.underline}

-   Any healthcare worker who has cared for or been exposed to a SARS
    patient and who develops fever and/or respiratory symptom(s) within
    10 days after exposure or patient care should:

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-   Immediately contact infection control, occupational health or
    designee in each facility where s/he works; and

-   Report to the predetermined location for clinical evaluation.
    (During periods of increased SARS activity in the healthcare
    facility and/or community, this recommendation extends to all
    symptomatic personnel working in the facility, regardless of whether
    they have had contact with a SARS patient.)

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-   Any healthcare worker who develops symptoms or fever while at work
    should immediately put on a surgical mask and notify the appropriate
    facility contact (e.g., occupational health, infection control, or
    other designee) and then report to the designated location for
    clinical evaluation.

-   Symptomatic healthcare personnel should be managed in accordance
    with the recommendations in *Clinical Guidance on the Identification
    and Evaluation of Possible SARS-CoV Disease among Persons Presenting
    with Community-Acquired Illness*
    ([www.cdc.gov/ncidod/sars/clinicalguidance.htm](http://www.cdc.gov/ncidod/sars/clinicalguidance.htm)).
    Decisions on return to work should be guided by policies or
    regulation defined by the facility or health department.

# Appendix I1

# Recommendations for Application of Standard Precautions

# for the Care of All Patients in All Healthcare Settings

+------------------------------+---------------------------------------+
| ## Component                 | ### Recommendations                   |
+------------------------------+---------------------------------------+
| Hand hygiene                 | After touching blood, body fluids,    |
|                              | secretions, excretions, contaminated  |
|                              | items; immediately after removing     |
|                              | gloves; between patient contacts      |
+------------------------------+---------------------------------------+
| Personal protective          |                                       |
| equipment (PPE)              |                                       |
+------------------------------+---------------------------------------+
| Gloves                       | For touching blood, body fluids,      |
|                              | secretions, excretions, contaminated  |
|                              | items; for touching mucous membranes  |
|                              | and nonintact skin                    |
+------------------------------+---------------------------------------+
| Mask, eye protection, face   | During procedures and patient-care    |
| shield                       | activities likely to generate         |
|                              | splashes or sprays of blood, body     |
|                              | fluids, secretions                    |
+------------------------------+---------------------------------------+
| Gown                         | During procedures and patient-care    |
|                              | activities when contact of            |
|                              | clothing/exposed skin with blood/body |
|                              | fluids, secretions, and excretions is |
|                              | anticipated                           |
+------------------------------+---------------------------------------+
| Soiled patient-care          | Handle in a manner that prevents      |
| equipment                    | transfer of microorganisms to others  |
|                              | and to the environment; wear gloves   |
|                              | if visibly contaminated; perform hand |
|                              | hygiene                               |
+------------------------------+---------------------------------------+
| Environmental control        | Develop procedures for routine care,  |
|                              | cleaning, and disinfection of         |
|                              | environmental surfaces, especially    |
|                              | frequently touched surfaces in        |
|                              | patient-care areas                    |
+------------------------------+---------------------------------------+
| Textiles (linen and laundry) | Handle in a manner that prevents      |
|                              | transfer of microorganisms to others  |
|                              | and to the environment                |
+------------------------------+---------------------------------------+
| Needles and other sharps     | Do not recap, bend, break, or         |
|                              | hand-manipulate used needles; use     |
|                              | safety features when available; place |
|                              | used sharps in puncture-resistant     |
|                              | container                             |
+------------------------------+---------------------------------------+
| Patient resuscitation        | Use mouthpiece, resuscitation bag,    |
|                              | other ventilation devices to prevent  |
|                              | mouth contact                         |
+------------------------------+---------------------------------------+
| Patient placement            | Prioritize for single patient room if |
|                              | patient is at increased risk of       |
|                              | transmission, is likely to            |
|                              | contaminate the environment or does   |
|                              | not maintain appropriate hygiene, or  |
|                              | is at increased risk of acquiring     |
|                              | infection or developing adverse       |
|                              | outcome following infection           |
+------------------------------+---------------------------------------+
| Respiratory hygiene/cough    | Instruct symptomatic persons to cover |
| etiquette                    | mouth/nose when sneezing/coughing;    |
|                              | use tissues and dispose in no-touch   |
| (source containment of       | receptacle; observe hand hygiene      |
| infectious respiratory       | after soiling of hands with           |
| secretions in symptomatic    | respiratory secretions; wear surgical |
| patients, beginning at       | mask if tolerated or maintain spatial |
| initial point of encounter)  | separation, \> 3 feet if possible     |
+------------------------------+---------------------------------------+

# Appendix I2

# Summary of Recommendations for Expanded Precautions

+----------------------------+-----------------------------------------+
| **Category**               | **Elements**                            |
+----------------------------+-----------------------------------------+
| Contact Precautions        | -   Single patient room (preferred)     |
|                            |                                         |
|                            | -   Gloves for all contact with patient |
|                            |     and environment of care             |
|                            |                                         |
|                            | -   Isolation gown for all patient      |
|                            |     contact                             |
+----------------------------+-----------------------------------------+
| Droplet Precautions        | -   Single patient room (preferred)     |
|                            |                                         |
|                            | -   Surgical mask within 3 feet of      |
|                            |     patient                             |
|                            |                                         |
|                            | -   Eye protection within 3 feet of     |
|                            |     patient with SARS --CoV             |
+----------------------------+-----------------------------------------+
| Airborne Infection         | -   Private room with monitored         |
| Isolation                  |     negative air pressure relative to   |
|                            |     surrounding areas and 6-12 air      |
|                            |     exchanges per hour                  |
|                            |                                         |
|                            | -   Appropriate discharge of the air to |
|                            |     the outdoors or monitored           |
|                            |     high-efficiency filtration of room  |
|                            |     air before recirculation            |
|                            |                                         |
|                            | -   Doors closed except as needed for   |
|                            |     entry and exit                      |
|                            |                                         |
|                            | -   NIOSH-approved respiratory          |
|                            |     protection (e.g., N-95 respirator)  |
|                            |     for entry to rooms of patients with |
|                            |     infectious pulmonary or laryngeal   |
|                            |     *M. tuberculosis*, draining skin    |
|                            |     lesions with *M. tuberculosis,*     |
|                            |     SARS-CoV disease, smallpox, and     |
|                            |     viral hemorrhagic fevers            |
+----------------------------+-----------------------------------------+

For more detailed information about infection control precautions,
please see
[www.cdc.gov/ncidod/hip/isolat/isolat.htm](http://www.cdc.gov/ncidod/hip/isolat/isolat.htm).

For more information, visit
[www.cdc.gov/ncidod/sars](http://www.cdc.gov/ncidod/sars/) or call the
CDC public response hotline\
at (888) 246-2675 (English), (888) 246-2857 (Español), or (866) 874-2646
(TTY)

[^1]: The 2003 SARS-CoV outbreak likely originated in mainland China,
    and neighboring areas such as Taiwan and Hong Kong are thought to be
    at higher risk due to the large volume of travelers from mainland
    China. Although less likely, SARS-CoV may also reappear from other
    previously affected areas. Therefore, clinicians should obtain a
    complete travel history. If clinicians have concerns about the
    possibility of SARS-CoV disease in a patient with a history of
    travel to other previously affected areas (e.g., while traveling
    abroad, had close contact with another person with pneumonia of
    unknown etiology or spent time in a hospital in which patients with
    acute respiratory disease were treated), they should contact the
    local or state health department.

[^2]: Close contact: A person who has cared for or lived with a person
    with SARS-CoV disease or had a high likelihood of direct contact
    with respiratory secretions and/or body fluids of a person with
    SARS-CoV disease. Examples of close contact include kissing or
    hugging, sharing eating or drinking utensils, talking within 3 feet,
    and direct touching. Close contact does not include activities such
    as walking by a person or briefly sitting across a waiting room or
    office.

[^3]: Respirators should be used in the context of a complete
    respiratory protection program as required by the Occupational
    Safety and Health Administration (OSHA). This includes training,
    fit-testing, and fit-checking to ensure appropriate respirator
    selection and use. To be effective, respirators must provide a
    proper sealing surface on the wearer's face. Detailed information on
    a respiratory protection program is provided at
    [www.osha.gov/SLTC/etools/respiratory/](http://www.osha.gov/SLTC/etools/respiratory/).