Public Health Guidance for Community-Level Preparedness and Response to
Severe Acute Respiratory Syndrome (SARS) Version 3

Supplement E: Managing International Travel-Related Transmission Risk

**Contents**

I.  Rationale and Goals

II. Lessons Learned

III. Activities Directed to Inbound Travelers

IV. Activities Directed to Outbound Travelers

V.  Activities Related to SARS on Conveyances

VI. De-escalation of Control Measures

VII. Roles and Responsibilities

VIII. Preparedness Planning

Appendix E1: Travel-Related SARS Response Matrices

# Managing International Travel-Related Transmission Risk

# I. Rationale and Goals

The rapid global spread of SARS-CoV in 2003 was facilitated by
international travel, as illustrated by the initial dissemination of the
SARS outbreak from Hong Kong. Although travelers visiting SARS-affected
areas are potentially at risk of contracting SARS-CoV disease, SARS-CoV
transmission is generally localized and often limited to specific
settings (e.g., hospitals) or households of SARS patients, even in
settings with large outbreaks. Consequently, the overall of risk of
SARS-CoV disease for outbound travelers who are not exposed to these
settings is low. Nevertheless, nearly all U.S. laboratory-confirmed SARS
cases were in travelers to SARS-affected areas. Screening and evaluating
travelers for SARS-like symptoms, educating them about SARS, and
reporting illness should therefore decrease the risk of
travel-associated SARS. Because SARS-CoV can sometimes be transmitted on
conveyances (e.g., airplanes), it is also important to prevent spread
from an ill passenger with a SARS-like illness and to identify and
monitor contacts on the conveyance for SARS-like illness.

Because of the significant impact of travel on the spread of
communicable diseases such as SARS-CoV disease, legal authority exists
at local, state, federal, and international levels to control the
movement of persons with certain communicable diseases within and
between jurisdictions. Measures that might be used to modify the risk of
travel-related SARS-CoV disease range from distribution of health alert
notices and arrival screening to quarantine of new arrivals and
restrictions or prohibitions on nonessential travel. Although the states
have authority for movement restrictions within states, federal laws
govern movement between states and across international borders. Thus,
airports and other ports of entry are sites of multiple overlapping
jurisdictions where the interplay between various authorities must be
clearly understood (See Section VII: Roles and Responsibilities, below).

The overall goals for the management of international travel-related
SARS-CoV transmission risk are to:

-   Prevent the introduction of SARS-CoV (and spread from an
    introduction) into the United States from SARS-affected areas.

-   Prevent exportation of SARS-CoV from the United States if domestic
    transmission presents an increased risk of exportation.

-   Reduce the risk of SARS among outbound travelers to SARS-affected
    areas.

-   Prevent the spread of SARS-CoV to passengers on a conveyance with a
    SARS patient, and evaluate or monitor other passengers to detect
    SARS-like illness and prevent further spread.

# II. Lessons Learned

During the 2003 global response, the control strategy for the United
States included issuing travel notifications,[^1] distributing health
alert notices to travelers arriving from areas with SARS, and conducting
visual inspections of arriving travelers to facilitate early
identification of imported cases and response to reports of ill
passengers. CDC staff met more than 11,000 direct and indirect flights
from SARS-affected areas and distributed more than 2.7 million health
alert notices to arriving passengers as well as to persons arriving at
13 U.S. land border crossings near Toronto and departing passengers
bound for the United States from the Toronto airport. Health alert
notices informed returning travelers of potential exposure to SARS-CoV.
They alerted travelers to the symptoms of SARS-CoV disease and advised
them to promptly seek medical attention if symptoms develop. The notices
also provided information and instructions for physicians.

During the outbreak response, CDC quarantine staff met planes reporting
an ill passenger to facilitate 1) evaluation of the passenger for
possible SARS-CoV disease, 2) collection of locating information on the
other passengers, and 3) coordination with federal and local
authorities. If the ill passenger was determined to be a possible SARS
case, then the locating information was forwarded to state and local
health departments for contact tracing.

Border and travel-related activities implemented in countries more
seriously affected by SARS included pre-departure temperature and
symptom screening, arrival screening (asking passengers about travel
history and possible exposure to SARS-CoV), "stop lists" (maintaining
lists of persons who were possible SARS cases or contacts to prevent
them from traveling), and quarantine of travelers returning from other
SARS-affected areas.

Lessons learned from this response support the recommendations included
in this Supplement. These lessons included the following:

-   SARS-CoV can spread rapidly on a global scale through international
    travel if control measures are not implemented.

-   SARS-CoV transmission is usually localized and often limited to
    healthcare settings and households; the risk of SARS-CoV disease to
    travelers visiting an affected area is low unless travelers are
    exposed in these settings.

-   Patients with SARS can transmit infection to other passengers on
    conveyances and should postpone travel until they are no longer
    infectious.

-   SARS-CoV transmission can occur within the close confines of
    conveyances. Resulting infections usually represent a failure to
    recognize symptomatic index cases and their high-risk contacts, who
    should have been prevented from traveling.

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-   Active follow-up of passengers on conveyances with SARS cases can
    help prevent further spread by informing passengers of their
    exposure and providing instructions for monitoring their health and
    seeking medical evaluation if they become ill.

# 

# III. Activities Directed to Inbound Travelers

The nature and scope of activities related to travelers entering or in
the United States will differ depending on the extent of SARS-CoV
transmission in the United States and in the country or countries from
which the passenger has traveled (Appendix E1). When SARS-CoV
transmission is absent or limited in the United States, then efforts
will focus on promptly identifying cases imported from SARS-affected
areas and preventing further spread from such cases. Guidelines have
been developed for various groups who might be arriving from areas
affected by SARS-CoV
([www.cdc.gov/ncidod/sars/hostingarrivals.htm](http://www.cdc.gov/ncidod/sars/hostingarrivals.htm);
[www.cdc.gov/ncidod/sars/business_guidelines.htm](http://www.cdc.gov/ncidod/sars/business_guidelines.htm)).
If active transmission of SARS-CoV is occurring in a U.S. city or area,
then it will be important to prevent spread to other areas in the United
States, possibly by limiting or restricting non-essential travel into or
from the affected area.

#  

# Objective: Prevent spread from SARS-CoV-infected travelers entering the United States. 

**Basic Activities**

-   Inform incoming travelers about SARS, and provide guidance on
    monitoring their health and reporting illness to the appropriate
    authorities. This may be accomplished by use of:

    -   Videos or public announcements on the conveyance just before
        arrival

    -   Distribution of health alert notices before or upon arrival
        ([www.cdc.gov/ncidod/sars/travel_alert.htm](http://www.cdc.gov/ncidod/sars/travel_alert.htm))

    -   Posters or public announcements in airports

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-   Evaluate travelers who report SARS-like symptoms (e.g., fever or
    respiratory symptoms) during travel, and collect locating
    information for the other passengers and crew (See Section V:
    Activities Related to SARS on Conveyances).

-   Respond to reports of ill passengers on airplanes or other
    conveyances arriving from areas with SARS-CoV disease.

> **Enhanced Activities**

-   If the level of transmission in another country is high, incoming
    passengers from that country might require enhanced screening and
    evaluation through:

    -   Visual inspection of all travelers as they disembark

    -   Screening of travelers for symptoms of SARS-CoV disease and
        recent high-risk exposures to SARS-CoV (e.g., SARS patients or
        high-risk settings) through a self-administered questionnaire

    -   Temperature screening

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-   Quarantine inspectors at CDC quarantine stations and public health
    workers in locations near other ports of entry may be required to
    meet all airplanes or other conveyances arriving from areas with
    SARS to question crew members about any ill passengers and to
    visually inspect passengers upon disembarkation.

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-   If the level of SARS-CoV transmission in a U.S. area is sufficiently
    high to present a substantial risk to travelers, then non-essential
    travel to this area may be limited, cancelled, or subjected to
    increased surveillance measures.

-   Other activities that may be considered but whose effectiveness is
    unclear (especially given the resources required for implementation)
    include:

    -   Ten-day quarantine of all passengers arriving from SARS-affected
        areas

    -   Collection of locating information on all arriving passengers

# IV. Activities Directed to Outbound Travelers

Activities related to outbound travelers will vary based on the extent
of SARS-CoV transmission in the United States and at the destination
(Appendix E1). If there is little SARS-CoV transmission in the United
States, the goal is to inform travelers about the risk of SARS and
appropriate measures to reduce the risk of acquiring SARS-CoV infection
during travel
([www.cdc.gov/ncidod/sars/travel_advice.htm](http://www.cdc.gov/ncidod/sars/travel_advice.htm)).
If there is extensive SARS-CoV transmission in the United States, then
preventing the exportation of SARS-CoV will be an added objective.

> **Objective**: Minimize outbound travelers' risk for exposure to
> SARS-CoV during travel or the risk of spreading SARS-CoV to other
> localities.

**Basic Activities**

-   Issue travel notifications (see Box).

-   Provide educational materials to travelers on measures to reduce the
    risk of SARS-CoV disease.

**Enhanced Activities**

-   If there are locations with extensive SARS-CoV transmission where
    control measures do not appear to be effective, further travel
    restrictions (e.g., cancellation of flights) to those locations may
    be considered (see Section VII: Roles and Responsibilities).

-   If the level of SARS-CoV transmission in the United States presents
    an increased risk for exportation, then some or all of the following
    might be implemented:

    -   Pre-departure screening (e.g., temperature screening, visual
        screening) of outbound travelers

    -   Health certifications, i.e., requiring travelers to have a
        medical examination before departure, with a doctor's statement
        that they are free of SARS-CoV symptoms and have not had close
        contact to a SARS-CoV patient in the past 10 days

    -   Stop lists, i.e., maintaining lists of SARS cases and close
        contacts at ports of departure against which travelers' names
        can be checked to prevent them from traveling

+-----------------------------------------------------------------------+
| **TRAVEL NOTICE DEFINITIONS**                                         |
+-----------------------------------------------------------------------+
| CDC issues different types of notices for international travelers. On |
| May 20, 2004, these definitions were refined to make the              |
| announcements more easily understood by travelers, healthcare         |
| providers, and the general public                                     |
| <http://www.cdc.gov/travel/outbreaks.htm#noticekey>. The definitions  |
| provided below describe both the levels of risk for the traveler and  |
| the recommended preventive measures for each level of risk.           |
+-----------------------------------------------------------------------+
| ![](media/image1.png){width="4.1666666666666664e-2in"                 |
| height="4.1666666666666664e-2in"}                                     |
|                                                                       |
| **Notice Scope^1^ Risk for travelers^2^ Preventive measures^3^**      |
+-----------------------------------------------------------------------+
|   -                                                                   |
| ------------- ------------- -------------------- -------------------- |
|   **In the       Reports of    No increased risk    Keep travelers    |
|   News**         sporadic      over baseline for    informed, and     |
|                                                                       |
|                 cases         travelers observing  reinforce standard |
|                                standard             prevention        |
|                                recommendations      recommendations   |
|                                                                       |
|   **Outbreak     Outbreak in a Increased but        Remind travelers  |
|                                                                       |
|  Notice**       limited       definable risk that  about standard and |
|                  geographic    is limited to        enhanced          |
|                                                                       |
|                area or       specific settings    recommendations for |
|                  setting                            the region        |
|                                                                       |
|   **Travel       Outbreak of   Increased risk in    Inform travelers  |
|   Health         greater scope some settings, along about specific    |
|   Precaution**   affecting a   with risk for spread precautions to    |
|                                                                       |
|                 larger        to other areas       reduce risk during |
|                                                                       |
|               geographic                         the stay and what to |
|                                                                       |
|                area                               do before and after |
|                                                     travel            |
|                                                                       |
|                                                                       |
|  **Travel       Evidence that Increased risk       In addition to the |
|   H                                                                   |
| ealth         outbreak is   because of evidence  specific precautions |
|   Warning**      expanding     of transmission      cited above,      |
|                  outside the   outside defined      **postpone        |
|                  area or       settings and/or      nonessential      |
|                  populations   inadequate           travel**          |
|                  initially     containment measures                   |
|                  affected                                             |
|   -                                                                   |
| ------------- ------------- -------------------- -------------------- |
+-----------------------------------------------------------------------+
| ![](media/image1.png){width="4.1666666666666664e-2in"                 |
| height="7.291666666666667e-2in"}                                      |
+-----------------------------------------------------------------------+
| ^1^The term "scope" incorporates the size, magnitude, and rapidity of |
| spread of an outbreak.\                                               |
| \                                                                     |
| ^2^Risk for travelers is dependent on patterns of transmission, as    |
| well as severity of illness.\                                         |
| \                                                                     |
| 3Preventive measures other than the standard advice for the region    |
| may be recommended depending on the circumstances (e.g., travelers    |
| may be requested to monitor their health for a certain period after   |
| their return, or arriving passengers may be screened at ports of      |
| entry).                                                               |
+-----------------------------------------------------------------------+

# 

#  

# V. Activities Related to SARS on Conveyances

A SARS patient on a conveyance presents a risk of transmission to other
passengers and crew and to non-passengers on arrival and a risk of
further spread from passengers who become infected. Many of the
activities listed below are performed by CDC staff at the eight current
quarantine stations and by public health workers in locations near other
ports of entry with assistance by CDC quarantine station staff from that
region.

> **Objective:** Protect co-passengers and crew members from
> SARS-CoV-infected passengers and from transmission associated with
> passengers exposed to the index case.

**Activities**

[Management of a potential SARS patient on a conveyance]{.underline}

-   Separate the potential SARS patient as completely as possible from
    other passengers and the crew. The ill passenger should wear a
    surgical mask.

-   Ensure that persons caring for the ill passenger follow infection
    control measures recommended for cases of SARS (See Supplement I and
    <http://www.cdc.gov/ncidod/sars/airpersonnel.htm>).

-   If possible, designate a separate toilet for the exclusive use of
    the ill passenger.

-   Notify the airport or land port authorities at the destination so
    that health authorities are informed and prepared to meet the
    conveyance upon arrival, to manage the ill passenger, and to
    evaluate other passengers.

[Management on arrival]{.underline}

-   Separate the ill passenger from exposed, well co-passengers at the
    soonest moment both in transit and after arrival.

-   Place the ill passenger in an isolation facility (if available), and
    assess.

-   Assess other passengers for illness, types of exposures to the ill
    passenger, and other potential SARS-CoV exposures. EMS personnel and
    local emergency department staff can perform these evaluations using
    appropriate precautions (See Supplement I and
    <http://www.cdc.gov/ncidod/sars/airpersonnel.htm>).

-   Transfer the ill passenger to a local healthcare facility for
    further evaluation if needed. Protocols and memoranda of agreement
    with ambulance services and hospitals with appropriate infection
    control measures in place should be established in advance (see
    Section VIII: Preparedness Planning.)

[Management of passengers and crew on the same conveyance]{.underline}

-   Collect locating information for all passengers and crew. This
    information should be obtained directly from passengers, if
    possible. If a potential SARS case on a conveyance is not detected
    until after arrival, this information can be obtained from passenger
    manifests, staff lists, and/or customs forms.

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-   Inform all passengers on board about SARS, and advise them to seek
    immediate medical attention if fever or respiratory symptoms develop
    within 10 days of the flight. Pay particular attention to close
    contacts of the case.

-   Consider temporary detention of the plane and arrangements for
    monitoring and quarantine of all passengers and crew in some
    circumstances (e.g., if the ill passenger had contact with a
    laboratory-confirmed SARS case and had significant respiratory
    symptoms during a prolonged flight). Home quarantine may be used for
    persons who live in or near the port of arrival; a designated
    facility should be arranged for the others (See Supplement D).

# VI. De-escalation of Control Measures

**Objective 1:** Downgrade or remove travel notifications as
appropriate.

> **Activities**

-   CDC will downgrade a travel health warning to a travel health
    precaution when there is:

    -   Adequate and regularly updated reporting of surveillance data
        from the area

    -   No evidence of ongoing transmission outside defined settings for
        for 20 days (two incubation periods) after date of onset of
        symptoms for the last confirmed case without an epidemiologic
        link, as reported by public health authorities.

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-   CDC will remove a travel health precaution when there is:

    -   Adequate and regularly updated reporting of surveillance data
        from the area

    -   No evidence of new cases for 30 days (three incubation periods)
        after the date of onset of symptoms for the last case, as
        reported by public health authorities.

    -   Limited or no recent instances of exported cases from the area.
        An *exported case* is an ill person who meets the definition for
        a probable or confirmed case of SARS-CoV disease and who
        acquired SARS-CoV infection in the area in question and then
        traveled outside the affected area to another region and was
        diagnosed there (i.e., the person was not identified as a part
        of contact tracing activities, and travel was not restricted).
        This criterion excludes intentional or planned evacuations.

> **Objective 2:** Reduce measures used for inbound travelers as
> appropriate.
>
> **Activities**
>
> [For all passengers arriving from areas with SARS-CoV
> transmission]{.underline}:

-   Continue general education for passengers from a particular area
    until the travel health precaution has been lifted (30 days after
    the onset of symptoms for the last case in that area). Because
    travel patterns may make it difficult to determine passengers'
    points of origin, it may be more practical to continue general
    education until travel health precautions have been lifted for all
    areas.

-   Continue evaluating travelers who report symptoms of SARS during
    travel until the travel health precaution for that area has been
    lifted (30 days after the onset of symptoms for the last case from
    that area).

[For passengers arriving from areas under a travel health
warning]{.underline}:

-   Continue the use of screening questionnaires until the area of
    origin is downgraded from a travel health warning to a travel health
    precaution.

-   Continue meeting conveyances from SARS-affected areas and visually
    inspecting passengers until the area of origin is downgraded from a
    travel health warning to a travel health precaution.

**Objective 3**: Reduce other measures used for outbound travelers as
appropriate.

> **Activities**

-   Continue pre-departure fever and symptom screening for passengers
    departing from areas with ongoing unlinked transmission, but
    consider discontinuing these activities 20 days after the onset of
    symptoms for the last unlinked case.

-   Continue stop lists until there are no longer any cases under
    isolation or contacts under quarantine.

**Objective 4**: Reduce measures for management of passengers with
SARS-CoV

disease on conveyances as appropriate.

**Activities**

-   Continue meeting any flight with an ill passenger on board who has
    SARS-like symptoms. If the passenger is seriously ill, evaluate and
    follow-up according to established protocols.

-   Continue to collect locating information as long as the passenger
    has symptoms compatible with SARS-CoV disease and has traveled from
    an area with ongoing unlinked transmission (under a travel
    advisory). For areas that have been downgraded to a travel health
    precaution, locating information may not be needed unless the ill
    passenger meets the epidemiologic criteria for [likely]{.underline}
    exposure to SARS-CoV (See Supplement B, Appendix B1).

-   The need for monitoring and quarantine of contacts of a passenger
    from an area on a travel health precaution should be determined
    after the ill passenger has been fully evaluated.

# VII. Roles and Responsibilities

Because jurisdictions and authorities at airports and other ports of
entry overlap, it is important that local, state, and federal staff
establish protocols and outline roles and responsibilities in advance of
a public health emergency.

Currently, eight of the international airports have permanent federal
quarantine staff
([www.cdc.gov/ncidod/dq/quarantine_stations.htm](http://www.cdc.gov/ncidod/dq/quarantine_stations.htm)).
These federal quarantine staff have primary responsibility for handling
the quarantine-related travel activities described above. State and
local public health staff may provide assistance. At other airports and
ports, local and state public health staff or other deployed persons
will have primary responsibility, under the coordination of regional
quarantine personnel. The local health jurisdiction will have primary
responsibility for follow-up and management of passengers who may have
been exposed to a SARS case on a conveyance.

Most local and state jurisdictions have adequate quarantine authority to
require a person with a possible communicable disease, such as SARS-CoV
disease, or their contacts to be detained for evaluation. Federal
authority can be used if necessary. Public health officials should work
closely with local, state, and federal law enforcement officials to
enforce quarantine authority for persons who do not cooperate
voluntarily.

# VIII. Preparedness Planning

**A. Legal authority for restricting movement**

In advance of the possible reappearance of SARS-CoV, public health
officials should:

-   Work closely with their legal counterparts to ensure that the legal
    authority for movement restrictions at the local, state, and federal
    levels is known and understood and to establish boundaries of
    authority and processes to address multi-jurisdictional issues (See
    Supplement A).

-   Develop plans for making decisions on movement restrictions, such
    as: 1) requirements for pre-departure screening, 2) requirements for
    arrival screening and/or quarantine, 3) travel prohibitions on cases
    and contacts, 4) restrictions related to use of mass transit
    systems, and 5) cancellation of non-essential travel.

-   Work closely with local, state, and federal law enforcement to
    develop plans for enforcement of these restrictions.

**B. Engagement of key partners**

In advance of the possible reappearance of SARS-CoV, public health
officials should:

-   Begin preparedness planning by identifying key partners
    representing: 1) law enforcement (local, state, federal), 2) legal
    community, 3) emergency medical services (for evaluation of ill
    arriving passengers and transportation to the hospital), 4) hospital
    personnel, 5) transportation industry personnel, and 6) other
    emergency management personnel. The partners should be involved in
    the planning process.

-   Develop plans for the training, mobilization, and deployment of
    pertinent public health and other staff.

-   Conduct training programs and drills.

-   Provide respirator fit-testing and training in use of PPE for
    persons at risk for exposure to possible SARS cases.

-   Plan for the diversion of conveyances carrying supplies for
    maintenance of critical infrastructure around key transportation
    hubs that may be affected by SARS-CoV.

**C. Protocols for management of ill arriving passengers**

> Public health officials and CDC quarantine staff, in collaboration
> with legal and law enforcement authorities, should develop protocols
> for the management of ill arriving passengers at ports of entry,
> including provisions for:

-   Meeting flights with a reported ill passenger

-   Establishing notification procedures and communications links

-   Separating the ill passenger during assessment

-   Assessing the ill passenger and referring for evaluation and care

-   Transporting the ill passenger to a designated healthcare facility
    (see Supplement D.)

-   Collecting locating information on other passengers and crew

-   Collecting the flight manifest, customs declarations, and other
    information for contact tracing

-   Identifying any other ill passengers and separating them from well
    passengers

-   Quarantining contacts if necessary, including transportation to a
    quarantine facility

-   Providing enforcement for uncooperative ill passengers or contacts

See Supplement A.

D.  **Memoranda of agreement (MOA) with healthcare facilities, transport
    services, emergency medical systems, and physicians**

-   State and local public health officials should work with federal
    quarantine staff to develop MOAs with hospitals near ports of entry;
    these facilities must be equipped to isolate, evaluate, and manage
    possible SARS patients (see Supplement C).

-   Agreements should include arrangements with a designated emergency
    medical service for on-site assessment of ill passengers and
    transportation to a hospital for evaluation.

See Supplement A.

**E. Designation of quarantine facility**

> State and local public health officials should identify a facility for
> travelers who are designated as contacts and who require quarantine
> but cannot be quarantined at home.

**F. Roles and responsibilities**

> Roles and responsibilities should be outlined for the various partners
> and the various levels of jurisdiction (local, state, and federal) for
> each component of the response.

For additional information and material on prevention of SARS
travel-related risks,

see
[www.cdc.gov/ncidod/sars/travel.htm](http://www.cdc.gov/ncidod/sars/travel.htm).

# Appendix E1

# Travel-Related SARS Response Matrices

### Matrix 1: Suggested Activities for Inbound Travelers

+----------------------+-----------------------------------------------+
| **Level of SARS-CoV  | **Suggested actions, by situation in          |
| transmission         | originating location**                        |
| activity in the      |                                               |
| United States**      |                                               |
+----------------------+-----------------------------------------------+
| No known SARS-CoV    | ## Imported case                              |
| transmission         | s; limited transmission in location of origin |
| worldwide **or**     |                                               |
| known SARS-CoV       | ## Dis                                        |
| activity but only    | tribute health alert notices to all arrivals. |
| imported cases       |                                               |
|                      | -   Implement passive monitoring of all       |
|                      |     arriving passengers for development of    |
|                      |     fever or respiratory symptoms.            |
|                      |                                               |
|                      | -   Advise persons who develop symptoms to    |
|                      |     self-report before presentation to        |
|                      |     healthcare provider.                      |
|                      |                                               |
|                      | -   Follow quarantine officer protocol for    |
|                      |     arriving ill passengers                   |
|                      |                                               |
|                      |     -   Follow procedures for ill contacts    |
|                      |                                               |
|                      |     -   Collect 30-day contact information    |
|                      |         for passengers on conveyances with    |
|                      |         ill passenger                         |
|                      |                                               |
|                      | -   Consider enhanced surveillance for ill    |
|                      |     passengers.                               |
|                      |                                               |
|                      | #### *Exten                                   |
|                      | sive transmission/effective control measures* |
|                      |                                               |
|                      | -   Implement active surveillance for ill     |
|                      |     passengers.                               |
|                      |                                               |
|                      | -   Implement symptom screening for all       |
|                      |     arriving passengers.                      |
|                      |                                               |
|                      | -   Medically evaluate all passengers with    |
|                      |     symptoms.                                 |
|                      |                                               |
|                      | -   Consider 10-day quarantine for            |
|                      |     asymptomatic arrivals.                    |
|                      |                                               |
|                      | -   Collect contact information on all        |
|                      |     arriving passengers.                      |
|                      |                                               |
|                      | ## Extens                                     |
|                      | ive transmission/ineffective control measures |
|                      |                                               |
|                      | -   Prohibit all non-essential arrivals.      |
|                      |                                               |
|                      | -   Conduct medical screening upon arrival.   |
|                      |                                               |
|                      | -   Implement mandatory 10-day quarantine for |
|                      |     all asymptomatic arrivals.                |
|                      |                                               |
|                      | -   Collect contact information on all        |
|                      |     arriving passengers.                      |
+----------------------+-----------------------------------------------+
| Extensive SARS-CoV   | ## Imported case                              |
| transmission in      | s; limited transmission in location of origin |
| United States and    |                                               |
| community, with      | -   Minimize non-essential travel.            |
| effective control    |                                               |
| measures             | -   Consider restricting travel within        |
|                      |     jurisdictions.                            |
|                      |                                               |
|                      | -   Advise arrivals to follow procedures      |
|                      |     based on situation in location of origin. |
|                      |                                               |
|                      | ***Extensive transmission/effective control   |
|                      | measures***                                   |
|                      |                                               |
|                      | -   Minimize non-essential travel.            |
|                      |                                               |
|                      | -   Consider restricting travel within        |
|                      |     jurisdictions.                            |
|                      |                                               |
|                      | -   Advise arrivals to follow procedures      |
|                      |     based on situation in location of origin. |
|                      |                                               |
|                      | ## Extens                                     |
|                      | ive transmission/ineffective control measures |
|                      |                                               |
|                      | -   Prohibit all non-essential arrivals.      |
|                      |                                               |
|                      | -   Conduct medical screening upon arrival.   |
|                      |                                               |
|                      | -   Implement mandatory 10-day quarantine for |
|                      |     all asymptomatic arrivals.                |
|                      |                                               |
|                      | -   Collect contact information on all        |
|                      |     arriving passengers.                      |
+----------------------+-----------------------------------------------+
| Extensive SARS-CoV   | ## Imported case                              |
| transmission in      | s; limited transmission in location of origin |
| United States and    |                                               |
| community, with      | -   Prohibit all non-essential arrivals.      |
| ineffective control  |                                               |
| measures             | -   Advise arrivals to follow procedures      |
|                      |     based on situation in location of origin. |
|                      |                                               |
|                      | ***Extensive transmission/effective control   |
|                      | measures***                                   |
|                      |                                               |
|                      | -   Prohibit all non-essential arrivals.      |
|                      |                                               |
|                      | -   Advise arrivals to follow procedures      |
|                      |     based on situation in location of origin. |
|                      |                                               |
|                      | ***Extensive transmission/ineffective control |
|                      | measures***                                   |
|                      |                                               |
|                      | -   Prohibit all non-essential arrivals.      |
|                      |                                               |
|                      | -   Conduct medical screening upon arrival.   |
|                      |                                               |
|                      | -   Implement mandatory 10-day quarantine for |
|                      |     all asymptomatic persons.                 |
|                      |                                               |
|                      | -   Collect contact information on all        |
|                      |     arriving passengers.                      |
+----------------------+-----------------------------------------------+

### Matrix 2: Suggested Activities for Outbound Travelers

+----------------------+-----------------------------------------------+
| # Level of S         | # Suggested actions                           |
| ARS-CoV transmission |                                               |
+----------------------+-----------------------------------------------+
| No known SARS-CoV    | -   No special activities                     |
| transmission         |                                               |
| worldwide            |                                               |
+----------------------+-----------------------------------------------+
| SARS activity in     | -   Issue travel health precautions and       |
| United States and    |     warnings for destinations based on        |
| community, but only  |     setting and transmission pattern.         |
| imported cases       |                                               |
|                      | -   Prohibit non-essential travel to          |
|                      |     countries where control measures are      |
|                      |     inadequate.                               |
|                      |                                               |
|                      | -   Consider:                                 |
|                      |                                               |
|                      |     -   Medical screening at all exit points  |
|                      |                                               |
|                      |     -   Travel prohibition for all persons    |
|                      |         meeting case definition with          |
|                      |         epidemiologic link to transmission    |
|                      |         setting                               |
|                      |                                               |
|                      |     -   Medical assessment for all with       |
|                      |         signs/symptoms without epidemiologic  |
|                      |         link                                  |
|                      |                                               |
|                      | -   Prohibit travel for persons under         |
|                      |     quarantine.                               |
+----------------------+-----------------------------------------------+
| Extensive SARS-CoV   | -   Issue international travel notifications  |
| transmission in      |     as above.                                 |
| United States and    |                                               |
| community, with      | -   Issue travel health precautions/warnings  |
| effective control    |     for domestic destinations based on        |
| measures             |     setting and transmission pattern.         |
|                      |                                               |
|                      | -   Initiate medical screening of departing   |
|                      |     passengers at all exit points.            |
|                      |                                               |
|                      | -   Prohibit travel for all persons meeting   |
|                      |     case definition.                          |
|                      |                                               |
|                      | -   Prohibit travel for all persons under     |
|                      |     quarantine.                               |
|                      |                                               |
|                      | -   Require health certificate for exit.      |
+----------------------+-----------------------------------------------+
| Extensive SARS-CoV   | -   Issue international travel notifications  |
| transmission in      |     as above.                                 |
| United States and    |                                               |
| community, with      | -   Issue domestic travel health              |
| ineffective control  |     precautions/warnings as above.            |
| measures             |                                               |
|                      | -   Prohibit nonessential outbound travel.    |
|                      |                                               |
|                      | -   Require health certificate for essential  |
|                      |     travel.                                   |
|                      |                                               |
|                      | -   Implement medical screening at all exit   |
|                      |     points.                                   |
|                      |                                               |
|                      | -   Prohibit travel for all persons meeting   |
|                      |     case definition.                          |
|                      |                                               |
|                      | -   Prohibit travel for all persons under     |
|                      |     quarantine.                               |
+----------------------+-----------------------------------------------+

For more information, visit
[www.cdc.gov/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]: During the 2003 SARS outbreak, CDC issued two types of travel
    notifications about disease occurrences in specific geographic
    areas. A ***travel alert***, a lower-level notice, provided
    information about the disease outbreak and informed travelers about
    how to reduce their risk of acquiring the infection. When the health
    risk for travelers was thought to be high, CDC issued a ***travel
    advisory*** recommending against nonessential travel to the area.
    Travel advisories were intended to reduce the number of travelers to
    high-risk areas and the risk for spreading disease to other areas.
    The levels of notification have since been revised to include four
    types of travel notices: **In the News**, **Outbreak Notice**,
    **Travel** **Health Precaution**, and **Travel Health Warning**
    [www.cdc.gov/travel/outbreaks.htm#noticekey](http://www.cdc.gov/travel/outbreaks.htm#noticekey).