**GENERAL INTRODUCTION**

The Clinical Center (CC) is instituting a strict category of isolation
for patients with special respiratory disease, including Severe Acute
Respiratory Syndrome (SARS). It is anticipated that emerging infections
or smallpox could be managed with this type of isolation.

The following precautions were developed based on latest recommendations
from the Centers for Disease Control (CDC), the World Health
Organization (WHO), the CC Safety, and the CC Hospital Epidemiology
Service (HES). The CDC estimates that several thousand diagnostic
specimens from patients with SARS have been processed in routine
clinical laboratories and to date there have been no reported clusters
of SARS illness among laboratory workers. As we learn more about these
patients and the best way to handle laboratory specimens, we will likely
change this procedure. The finalized version will become part of the
Safety Manual (2003 version is currently under review). At present, the
only types of samples expected under the new SARS protocol are:

-   Bronchial alveolar lavage (BAL) or other bronchial cytology
    specimen, placed in formalin.

-   Trans-bronchial biopsy placed in formalin.

-   Other, unexpected specimens, as clinically indicated.

-   Potential autopsy.

*Notes:*

1.  *Frozen sections will not be done on these patients, until more is
    learned about how to do them safely.*

2.  *Smears cannot be made at the bedside for Fine Needle Aspirates.*

3.  *Specimens dedicated for tissue exam or cytopathology exam (not
    cultures) must be placed directly in formalin (see below).*

For questions or problems, contact your supervisor. The supervisor may
consult the following resources:

-   CDC website:
    [http://www.cdc.gov/ncidod/sars/index.htm](http://www.cdc.gov/)

-   WHO website: [www.who.int](http://www.who.int/)

-   Hospital Epidemiologist:

    -   Office: 301-496-3515

    -   Cell: 240-602-8375

-   Hospital Epidemiology Service:

    -   Office: 301-496-2209

    -   Evenings/weekends (page): 301-496-1211

-   SARS Investigators:

    -   John Beigal: 301-435-2292

    -   Cliff Lane: 301-496-7196

-   LP, Clinical Lab Manager: Kevin Nellis: 301-594-9532

**NOTIFICATION OF SPECIAL RESPIRATORY ISOLATION (INCLUDING SARS,
SMALLPOX, ETC.**

HES will notify certain LP employees of patients with Special
Respiratory Isolation via secure e-mail. The e-mail notifications will
be printed and stored in a secured notebook in the Histology and
Cytology sections.

**SPECIMEN COLLECTION**

All clinical specimens for LP must be double bagged, hand transported,
and processed in a Biosafety Cabinet (10/2A21) in a Biosafety Level 2
(BL-2) facility, unless deactivated. Deactivated specimens (formalin
fixed, or otherwise inactivated specimens) are handled using universal
precautions and respiratory precautions in a BL-2 laboratory setting.

Samples are labeled with "Special Respiratory Isolation" stickers,
available from HES. Retrieval, transport, and processing of specimens
should be carefully coordinated with laboratory senior staff and study
investigators. All specimen container surfaces are wiped with CC
approved disinfectant before placing in a plastic bag. All specimens are
double-bagged, with the transmittal sheet place in the outer bag pocket.

*Reminder: Document the collection of research specimens using form
NIH-2803-1.*

**[Cytology Specimens:]{.underline}**

-   Obtain 120-ml specimen cups containing 60 ml of 10% neutral buffered
    formalin from the Histology Section (building 10, room 2A28).

*Caution: The solution contains formaldehyde which is a toxin and
chemical hazard. A blank patient label and a "formalin caution" label
are affixed to these containers.*

-   Label the specimen cup with patient name, medical record number,
    date and time of collection, and a "Special Respiratory Isolation"
    sticker.

-   Mix specimen thoroughly (if greater than 40 ml) and add specimen (up
    to 40 ml) directly into the collection vial.

*Note: The cytology lab does not need excess volumes. Do not add more
than 40 ml of specimen. If specimen is greater than 40 ml, mix gently by
inversion before adding to the cup. Discard excess as biohazard waste or
use for research in accord with IRB approved protocol.*

-   Screw the lid tightly onto the container. Double check to make sure
    the lid is secure and the cup does not leak.

-   Wipe the outside of specimen container with CC approved disinfectant
    (e.g. Dispatch, 95% EtOH).

-   Change gloves.

-   Place specimen in bag.

-   Clean outside of specimen bag with CC approved disinfectant.

-   Place bagged specimen in secondary bag.

-   Place transmittal sheet in outer pocket of secondary bag.

-   Place specimen in refrigerator outside the Cytopathology Section
    (building 10 room 2A21).

**[Surgical Pathology (tissue exam) Specimens:]{.underline}**

-   Obtain 120-ml specimen cup containing 60 ml of 10% neutral buffered
    formalin (fixative) from the Histology Section (building 10, room
    2A28).

*Caution: The solution contains formaldehyde which is a toxin and
chemical hazard.*

*Note: If specimen is greater than 1/10 th the volume of fixative (e.g.,
larger than about 1x 2 x 3 cm, use a larger container containing
formalin. Containers and formalin and caution stickers are available in
Histology Section or Frozen section lab.*

-   Label the specimen container with patient name, medical record
    number, date and time of collection, and "Special Respiratory
    Isolation" sticker. Place a "formalin caution" sticker on large
    containers if they are not already affixed.

-   Place specimen directly into the collection container.

-   Screw the lid tightly onto the container. Double check to make sure
    the lid is secure and the cup does not leak.

-   Wipe the outside of specimen container with CC approved disinfectant
    (e.g. Dispatch, 95% EtOH).

-   Change gloves.

-   Place specimen in bag.

-   Clean outside of specimen bag with CC approved disinfectant.

-   Place bagged specimen in secondary bag.

-   Place transmittal sheet in outer pocket of secondary bag.

-   Deliver to refrigerator outside the Histology Section (building 10,
    room 2A28) or place is specimen refrigerator in the frozen section
    lab (building 10, room 2C433). Record the specimen information in
    the log book.

**[Ultrastructural (EM) Pathology Specimens (only if clinical
indicated):]{.underline}**

-   Obtain collection vial containing gluteraldehyde from the
    refrigerator outside the Ultrastructural (EM) Section (building 10,
    room 2A10).

*Caution: The solution contains 2.5% gluteraldehyde which is an irritant
chemical hazard, and is labeled as such. Keep collection vial
refrigerated, do not store at room temperature.*

-   Label the vial with patient name, medical record number, date and
    time of collection, and "Special Respiratory Isolation" sticker.

-   Place specimen directly into the collection container.

-   Screw the lid tightly onto the container. Double check to make sure
    the lid is secure and the vial does not leak.

-   Wipe the outside of specimen container with CC approved disinfectant
    (e.g. Dispatch, 95% EtOH).

-   Change gloves.

-   Place specimen in bag.

-   Clean outside of specimen bag with CC approved disinfectant.

-   Place bagged specimen in secondary bag.

-   Place transmittal sheet/EM order sheet in outer pocket of secondary
    bag.

-   Deliver specimen to refrigerator outside room 10/2A10.

**[Autopsy:]{.underline}**

-   Follow special bagging, disinfecting, and transport procedures
    developed by CC nursing and NCI/CCR/LP.

-   Notify Admissions of Special Respiratory Isolation precautions, so
    they can communicate this information to the autopsy staff and
    funeral home.

**[All other Laboratory of Pathology specimens:]{.underline}**

-   Call the section chief of the lab to discuss special arrangements in
    advance of collecting specimen.

-   Obtain proper collection containers specified for the particular
    test desired.

-   Label the container with patient name, medical record number, date
    and time of collection, and "Special Respiratory Isolation" sticker.

-   Place specimen directly into the collection container. Tighten lid
    securely. Double check to make sure it does not leak.

-   Wipe with CC approved disinfectant.

-   Change gloves.

-   Place specimen in bag.

-   Place bagged specimen in secondary bag.

-   Place transmittal sheet in outer pocket of secondary bag.

-   Deliver to appropriate location as communicated by section chief.

**SPECIMEN HANDLING PRECAUTIONS AND PERSONAL PROTECTIVE EQUIPMENT**

[Full Personal Protective Equipment (PPE) to be used when processing
specimens that have not been properly bagged, transported, or
inactivated with fixative, or for autopsy procedures:]{.underline}

-   In addition to the PPE stated below, follow the usual level three
    respiratory isolation precaution procedures, outlined in your safety
    manual and the CC Isolation Guidelines flip chart.

-   Refer to procedure for donning/removing PPE (Appendix A).

-   Double Gloves. For autopsy procedures, use interposed layer of cut
    resistant gloves between rubber gloves.

-   Impervious disposable gown, coverall, and/or apron, as appropriate.

-   Disposable surgical cap and shoe covers.

-   All employees must be re-trained to wear the PAPR and be fit tested
    for the N-95 respirator mask prior to handling unfixed specimens
    from Special Respiratory Specimens.

-   A full face shield must be worn with an N-95 mask, but not required
    when using a PAPR.

-   Autopsy down draft table (autopsy procedures only) in negative
    pressure autopsy suite. See room preparation for autopsy procedure
    (below).

-   The biosafety cabinet (BSC) located in the Cytology Section
    (10/2A21) may be used to process specimens, if needed, while wearing
    full PPE.

-   It is acceptable to wear the N-95 respirator while working at the
    BSC, but a PAPR should be worn when handling unfixed specimens
    outside of the BSC (e.g., Autopsy procedure in the negative pressure
    autopsy suite).

*Notes:*

1.  *DO NOT add fixative to active specimens delivered to the LP, in the
    grossing hood or down draft table. Use the BSC for this purpose.*

2.  *ALL EMPLOYEES MUST BE RE-TRAINED TO WEAR THE PAPR AND FIT TESTED
    FOR THE N95 RESPIRATOR PRIOR TO HANDLING SPECIAL RESPIRATORY
    ISOLATION SPECIMENS THAT ARE NOT FIXED. Contact CC Safety at
    extension (301) 496-5281 to arrange for an N-95 mask fit test and/or
    PAPR training in advance of performing the procedures.*

3.  *Personnel who cannot wear fitted N-95 face mask must wear a PAPR.*

4.  *Pay careful attention to procedures for hand hygiene, disposable
    waste, particulate aerosols, and environmental cleaning (see below,
    for more details)*

[Personal Protective Equipment (PPE) to be used when processing formalin
fixed, or otherwise inactivated specimens.]{.underline}

-   Follow universal precautions when handling the specimen throughout
    the remainder of the testing.

-   Wear gloves and lab coat.

-   Employees may wear additional PPE and a PAPR or N-95 mask if
    desired, but these are not necessary for inactivated specimens.

[Cytology Specimens/Surgical Pathology Specimens/Ultrastructural (EM)
Pathology Specimens:]{.underline}

-   Verify specimen was collected, transported, and labeled properly. If
    not, do the following:

    1.  Notify your supervisor immediately and complete an ORS report.

    2.  The supervisor will notify HES and contact the Hot Seat or
        Autopsy Resident to assist with placing the sample on fixative
        in the BSC located in the Cytology Section (10/2A21), while
        wearing full PPE.

    3.  Transfer the specimen directly into a properly labeled container
        containing 10% neutral buffered formalin, or add the fixative to
        the specimen. Tighten lid securely. Double check to make sure it
        does not leak.

    4.  Wipe with CC approved disinfectant (Dispatch or 95% EtOH).

    5.  Change gloves.

    6.  Place specimen in bag.

    7.  Place bagged specimen in secondary bag.

    8.  Dispose of gloves, gowns, shoe covers, empty specimen container,
        and any other biomedical waste as instructed below.

-   All specimens must be fixed for at least 24 hours prior to
    additional handling. A longer time period is required if the
    specimen is greater than 3 mm thick. Larger specimens should be
    sectioned as thin as possible by the resident wearing full personal
    protection equipment (see above), under the biological safety
    cabinet (BSC) in room Cytology (10/2A21), and placed in 20 volumes
    of 10% neutral buffered formalin.

-   All cytology specimens will be processed as a cell block.

**[All other Laboratory of Pathology specimens:]{.underline}**

-   Collection, retrieval, transport, and processing of specimens should
    be carefully coordinated with Section Chief and study investigators.

**[Autopsy:]{.underline}**

*IMPORTANT: STRICT PROCEDURES MUST BE ADHERED TO BY ALL STAFF
PATICIPATING IN THE AUTOPSY.*

-   Before starting the autopsy, refer to the CDC website for the latest
    recommendations. Prepare autopsy suite by clearing unneeded items
    from countertops and draping desks and unneeded equipment. Verify
    air pressure differential is not in alarm status.

-   Set up a specimen cart by placing absorbent pads on each shelf.

-   Before transporting the body to the autopsy suite, drape all benches
    within 10 feet from the table with linen drapes.

-   Deactivate door, so people can not push button for entrance.

-   Place signs in front of door

    1.  Hexagon magnetic stop sign: "STOP DO NOT ENTER, SPECIAL
        RESPIRATORY ISOLATION AUTOPSY IS IN PROGRESS THANKS"

    2.  Hang banner across the doors to the suite to prevent entrance.
        This banner states "STOP DO NOT ENTER, SPECIAL RESPIRATORY
        ISOLATION AUTOPSY IS IN PROGRESS."

-   Only the section chief, the resident, and the autopsy assistant will
    be present to perform the autopsy. No others will be permitted in
    the suite without prior discussion with the section chief.

-   Use the same protocol used for multi drug resistance tuberculosis
    (MDR TB) protocol.

-   Don all PPE (see above) before opening the body bag. Save the outer
    bag, but discard the inner bag into biohazard waste.

-   The extent of the autopsy and the approach used in dissection will
    be limited based on the autopsy permission and the discretion of the
    section chief.

-   Use an autopsy head drape (under evaluation) to contain particulate
    matter. The drape is easily adjusted for use over the head or torso.
    Entry ports are available on all four sides with cover flaps.
    Minimize the number of ports entered at one time. If possible, enter
    only one port at a time.

-   Use the bone dust collector attachment with HEPA filter on the
    Stryker saw.

-   Do not cut rib cage with clippers. Use the Stryker with bone dust
    collector to cut rub cage.

-   Specimen collection

    1.  Collect clinical autopsy specimens directly into containers of
        formalin.

    2.  Collect specimens for the CDC (check website for details). At
        the time of this writing, the CDC recommends collection of the
        following specimens for the evaluation of potential cases of
        SARS.

        a.  [Fixed tissue:]{.underline} all major organs (e.g. lung,
            heart, spleen, liver, brain, kidney, adrenals).

        b.  [Frozen tissue:]{.underline} lung and upper airway (e.g.
            trachea, bronchus)

        c.  [Upper Respiratory:]{.underline} nasopharyngeal aspirate;
            nasopharyngeal and oropharyngeal swabs.

        d.  [Lower Respiratory:]{.underline} Broncheoalveolar lavage
            (BAL), tracheal aspirate or pleural tap.

        e.  [Blood:]{.underline} Serum, whole blood.

        f.  [Stool.]{.underline}

    3.  Collect research tissue for NIAID, as specified, if requested.

    4.  If tissue cannot be fixed, carefully coordinate collection
        requirements, bagging, and transportation between the Principle
        Investigator, CC/DLM, and/or CDC. Wipe with a CC approved
        disinfectant (Dispatch or 95% EtOH). Change gloves. Place
        specimen in bag. Place bagged specimen in secondary bag. Arrange
        for transportation of the samples.

    5.  Wipe down all formalin fixed tissue containers with a CC
        approved disinfectant (Dispatch or 95% EtOH). Place in double
        bags if possible. Place all large containers on the cart covered
        with absorbent pads, and cover with clear plastic. Allow samples
        to fix for 24 hours before further processing.

-   After the autopsy is complete, prepare the body for transportation
    according to the latest CDC recommendations for handling remains of
    SARS patients. After placing the body back into the body bag,
    disinfect outer surface with Dispatch disinfectant. Place the
    shrouded body in a new (clean) secondary body bag, before
    transporting back to the morgue. Place a "Special Respiratory
    Isolation" sticker on the outside of the new body bag.

-   Disinfect all work surfaces and instruments with disinfectant
    (Dispatch, 95% EtOH, TB Quat2) using a two step cleaning method.

*NOTE: DO NOT USE BLEACH PRODUCTS. AS A PRECAUTION, ADHERE TO THE
MANUFACTURER'S RECOMMENDATIONS FOR THE LONGER CONTACT TIME (USUALLY
THREE MINUTES).*

1.  Clean surfaces with disinfectant and allow disinfectant to remain on
    surfaces for at least three (3) minutes, or the longest contact time
    recommended by the disinfectant man

2.  Change gloves and repeat.

-   Housekeeping after autopsy is critical because of the potential
    fomite transmission. Notify housekeeping (5-3075) to send staff
    which have been specifically trained in Special Respiratory
    Isolation procedures to clean floors and walls and pick-up MPW waste
    (see below), wearing full personal protective gear.

-   An LP employee will transport samples. Patient Escort Services will
    not transport these specimens. Package samples for the CDC in accord
    with the CDC website.

-   The Admissions Office should inform the funeral home that this is a
    special respiratory isolation case. Please remind them to notify the
    funeral home that the patient has a specific disease (SARS,
    smallpox, etc).

**HAND HYGIENE**

Careful attention should be given to hand hygiene after removal of
gloves and especially before touching the eyes or mucosal surfaces.

All healthcare workers shall practice good hand hygiene to reduce the
risk of transmission of organisms to patients, themselves, and
coworkers. General hand hygiene practices are listed in the Infection
Control Policy of this notebook. See previous section.

**DISPOSABLE WASTE**

All waste will be placed in a double autoclave bags, LOOSELY sealed with
autoclave tape and labeled with the date, location and isolation
category. Wipe the secondary bag with disinfectant (Dispatch or 95%
EtOH). Allow disinfectant to remain in contact with outer bag for at
least three (3) minutes. Change gloves. Wipe the bag again. Place
"Special Respiratory Isolation" stickers (available through HES) on the
outer bags. Contact housekeeping (5-3075) to send staff which have been
specifically trained in Special Respiratory Isolation procedures to
pick-up the waste and transfer it to CC/DLM where it will be autoclaved
before it is transported off campus for incineration.

**PARTICULATE AEROSOLS**

Any procedure with the potential to generate fine particulate aerosols
(e.g., vortexing or sonication of specimens in open tube) should be
performed in a biological safety cabinet (BSC). Close and seal all tubes
before spinning in a centrifuge. The use of sealed centrifuge rotors or
sample cups, if available, should be employed for centrifugation.
Ideally, these rotors or cups should be unloaded in a BSC.

**ENVIRONMENTAL CLEANING**

Work surfaces and equipment must be disinfected; using a CC approved
disinfectant, after infectious specimens are processed. Disinfectants
need to be mycobactericidal and effective against lipid-enveloped
viruses (e.g., Dispatch, 95% EtOH, TB Quat2).

Use the two step cleaning method.

-   Clean surfaces with disinfectant and allow disinfectant to remain on
    surfaces for at least three (3) minutes, or the longest contact time
    recommended by the manufacturer.

-   Change gloves and repeat.

*NOTE: DO NOT USE BLEACH PRODUCTS. AS A PRECAUTION, ADHERE TO THE
MANUFACTURER'S RECOMMENDATIONS FOR THE LONGER CONTACT TIME (USUALLY
THREE MINUTES).*

**REFERENCES**

-   Beigal, J., Lane, C., et. al. Evaluation and Management of Persons
    with Severe Acute Respiratory Syndrome (SARS). Draft NIAID & CC
    protocol, April 25, 2003.

-   CDC. Interim Laboratory Biosafety Guidelines for Handling and
    Processing Specimens Associated with Sever Acute Respiratory
    Syndrome (SARS). June 8, 2003.
    <http://www.cdc.gov/ncidod/sars/sarslabguide.htm>

-   CDC. Safe Handling of Human Remains of Severe Acute Respiratory
    Syndrome (SARS) Patients: Interim Domestic Guidance. May 15, 2003.
    <http://www.cdc.gov/ncidod/sars/pdf/sarsautopsy.pdf>

-   Evans, M. Conversations regarding housekeeping and disinfection
    procedures. June 17, 2003.

-   Michelin, A. Interim Isolation Specifications for Patients who have
    Severe Acute Respiratory Syndrome (SARS). Draft June 4, 2003.

-   Peterson, Anne. CC Nursing (conversations regarding morgue transport
    of SARS cases). May 2003.

-   Wanless, Ian. E-mail Communication regarding 2 hour fixation time
    for tissues collected from SARS patients. University of Toronto ,
    Pathology Department. June 12, 2003.