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Centers for Disease Control and Prevention
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The current outbreak of Severe Acute Respiratory Syndrome (SARS) has included reports of cases in southeast Asia, North America and Europe, and required urgent air evacuation of patients with severe illness. This guidance is intended to assist air medical transport (AMT) service providers using specialized aircraft to transport SARS patients while ensuring the safety of patients and transport personnel. It should not be generalized to commercial passenger aircraft. These interim recommendations are based on standard infection control practices, AMT standards, and epidemiologic information from ongoing investigations of SARS, including experience from transport of two patients during this outbreak.
Currently recommended infection control measures for hospital patients with SARS include Standard Precautions (with eye protection to prevent droplet exposure), plus Contact and Airborne Precautions. Respiratory protection using respirators providing at least 95% filtering efficiency (e.g., N--95) with appropriate fit-testing is recommended.
I. Air Transport of SARS Patients, General Considerations
- SARS patients should be transported on a dedicated AMT mission minimizing crew size. There should not be any patients or passengers who do not have SARS on board.
- If possible, a single caregiver should be assigned to the SARS patient.
- All SARS patient movement involving U.S. citizens should be coordinated with appropriate state and federal health authorities, including the Centers for Disease Control and Prevention (CDC) (24 hour response number: (770) 488-7100) and the Department of State, before movement begins. International movement of SARS patients may require special approvals by countries that will be over-flown, aircraft servicing locations, patient rest stop hospitals, and/or final destinations.
II. Airframe Selection and Cabin Airflow
- AMT service providers should consult manufacturer(s) of their aircraft to identify cabin airflow characteristics, including: HEPA filtration and directional airflow capabilities, air outlet location, presence or absence of air mixing between cockpit and patient-care cabin during flight, and the time and aircraft configuration required to perform a post-mission airing-out of the aircraft.
- Aircraft with forward-to-aft cabin airflow and a separate cockpit cabin are recommended for transport of SARS patients. The flight deck/cockpit crew in aircraft with forward-to-aft cabin airflow and separate patient-care compartment are not required to wear respirators unless they enter the patient-care compartment.
- Aft-to-forward cabin airflow may create a significant risk of airborne transmission to both cabin and flight deck personnel. If an aircraft with aft-to-forward airflow must be used, all personnel on board must wear fit-tested N-95 respirators throughout the flight.
- Aircraft that re-circulate cabin and flight deck air without HEPA filtration should not be selected for SARS patient transport.
- Aircraft ventilation should remain on at all times during transport of SARS patients, including during ground delays.
- Aircraft that provide separate upwind cabin space for crew members to perform necessary personal activities (eating, drinking, handling contact lenses, etc.) should be selected for flights likely to exceed 4 hours.
III. Patient Placement
The in-flight environment may preclude the creation of a true negative pressure room; however, some aircraft designs permit a downwind zone of relative airflow isolation. The airflow of each aircraft should form the basis for litter and seat assignments. In general:
- SARS patients should be positioned as far downwind with regard to cabin airflow as possible.
- If the AMT aircraft uses vertical litter tiers, SARS litter patients should be placed in the lowest position in the tier.
- Ambulatory SARS patients should be seated next to the cabin sidewall.
- If a non-SARS patient must be transported simultaneously with SARS patient(s), the non-SARS patient must wear an N-95 respirator during transport and should not be positioned downwind from, or within 3 feet of, the SARS patient.
- If several SARS patients are transported, they may be moved as a group (cohorted) in an aircraft that provides appropriate airflow and filtration characteristics as described above.
IV. Infection Control
Protective equipment and procedures:
- Personnel should not wear leather or other "flight" gloves while providing patient care.
- Eating, drinking, application of cosmetics, and handling of contact lenses should not be done in the immediate patient care area.
- Handling or storage of medication or clinical specimens should not be done in areas where food or beverages are stored or prepared.
- Disposable, non-sterile gloves must be worn for all patient contact.
- Gloves are removed and discarded in designated trash bags after patient care is completed (e.g., between patients) or when soiled or damaged.
- Hands must be washed or disinfected with waterless hand sanitizer after removal of gloves.
- Disposable fluid-resistant gowns should be worn for all patient care activity.
- Gowns are removed and discarded in designated trash bags after patient care is completed or when soiled or damaged.
- Goggles or face-shields must be worn for all patient care within 6 feet of the patient. Corrective eyeglasses alone are not appropriate protection.
- Fit-tested N-95 respirators are approved for in-flight use and should be worn by personnel in the patient-care cabin at all times.
- Fit-tested N-95 respirators should be worn by cockpit/flight-deck crew if an aircraft cannot provide forward-to-aft airflow.
- For cockpit crews, aircraft aviator tight-fitting face-pieces capable of delivering oxygen that has not mixed with cabin air may be used in lieu of a disposable N-95 respirator.
- Respirators may not be removed to eat or drink. Personal activities that require removal of respirators should not be performed in the patient-care cabin.
- The patient may wear a paper surgical mask to reduce droplet production, if tolerated.
- Oxygen delivery with simple and non-rebreather facemasks may be used for patient oxygen support during flight.
- Cardiopulmonary resuscitation (CPR) should only be performed using a resuscitation bag-valve mask equipped with HEPA filtration of expired air.
V. Mechanically Ventilated Patients
- Mechanical ventilators for SARS patients must provide HEPA filtration of airflow exhaust.
- AMT services should consult their ventilator equipment manufacturer to confirm appropriate filtration capability and the effect of filtration on positive pressure ventilation.
VI. Clinical Specimens
- Standard precautions must be used when collecting and transporting clinical specimens.
- Specimens should be stored only in designated coolers or refrigerators.
- Clinical specimens should be labeled with appropriate patient information and placed in a clean zip-lock bag for storage and transport.
VII. Waste Disposal
- Dry solid waste, e.g., used gloves, dressings, etc., should be collected in biohazard bags for disposal as regulated medical waste in accordance with local requirements at the destination medical facility.
- Waste that is saturated with blood or body fluids should be collected in leak-proof biohazard bags or containers for disposal as regulated medical waste in accordance with local requirements at the destination medical facility.
- Sharp items such as used needles or scalpel blades should be collected in puncture resistant sharps containers for disposal as regulated medical waste in accordance with local requirements at the destination medical facility.
- Suctioned fluids and secretions should be stored in sealed containers for disposal as regulated medical waste in accordance with local requirements at the destination medical facility. Handling that might create splashes or aerosols during flight should be avoided.
- Suction device exhaust should not be vented into the cabin without HEPA filtration. Portable suction devices should be fitted with in-line HEPA filters. Externally vented suction should not be used during ground operation.
- Excretions (feces, urine) may be carefully poured down the aircraft toilet.
VIII. Cleaning and Disinfection
- After transporting a SARS patient, all exits and doors should be opened and the interior of the aircraft should be aired out with the aircraft air conditioning running at maximum capacity for a specified time based on aircraft-specific engineering features. Personnel boarding the aircraft must wear N-95 respirators until this "airing out" is complete.
- Cleaning should be postponed until airing out is complete.
- Compressed air that might re-aerosolize infectious material should not be used for cleaning the aircraft.
- Non-patient-care areas of the aircraft should be cleaned and maintained according to manufacturer's recommendations.
- Cleaning personnel should wear non-sterile gloves, disposable gowns and face shields while cleaning patient-care areas.
- Patient-care areas (including stretchers, railings, medical equipment control panels, and adjacent flooring, walls and work surfaces likely to be directly contaminated during care) should be cleaned using an EPA-registered hospital disinfectant in accordance with aircraft manufacturer's recommendations.
- Spills of body fluids during transport should be cleaned by placing absorbent material over the spill and collecting the used cleaning material in a biohazard bag. The area of the spill should be cleaned using an EPA-registered hospital disinfectant. Ground service personnel should be notified of the spill location and initial clean-up performed.
- Contaminated web seats or seat cushions should be placed in a biohazard bag and labeled with the location and type of contamination for later disposal or cleaning.
- Contaminated reusable patient care equipment should be placed in biohazard bags and labeled for cleaning and disinfection at the AMT service medical equipment section.
- Personnel should wear non-sterile gloves, disposable gowns and face shields while cleaning reusable equipment.
- Reusable equipment should be cleaned and disinfected according to manufacturer's instructions.
IX. Logistical Planning and Post-Mission Follow-Up
- Sufficient infection control supplies should be on board to support the expected duration of the mission plus additional time should the aircraft experience maintenance delays or weather diversions.
- Flight planning should identify emergency or unexpected diversion airfields, and coordinate with authorities in advance.
- Upon mission termination, the AMT team should provide the following information to their medical director: mission number/date; address of the team/aircraft basing; duration of patient transport; names, contact information, and crew positions (including estimated duration of direct patient care provided) of mission personnel.
- AMT services should designate individuals responsible for performing post-mission monitoring of mission personnel and reporting results to the AMT service medical director.
- Mission personnel should be monitored (directly or by telephone) twice daily for 10 days for evidence of fever or respiratory illness.
X. Ground/In-Flight Emergency Procedures
AMT service providers should have a written plan addressing patient handling during in-flight and/or ground emergency situations. Activities such as donning life vests and litter-patient emergency egress may create special exposure risks. Use of N-95 respirators must be weighed against time constraints and on-board emergency conditions (e.g., smoke in the cabin, sudden cabin decompression). Gowns and latex gloves represent a fire/flash hazard and should not be worn during ground or in-flight emergency response situations.
This guidance was prepared in cooperation with and with contributions from:
United States Department of Defense
US Transportation Command (USTRANSCOM) United States Department of State
Headquarters Air Mobility Command (HQ AMC)
US Pacific Command (USPACOM)
Headquarters Pacific Air Forces (HQ PACAF)
US Army Medical Research Institute of Infectious Diseases (USAMRIID)
Commission on Accreditation of Air Medical Transport Services (CAMTS)
Aerospace Medicine Association (AsMA)