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Interim Guidance: Air Medical Transport for Severe Acute Respiratory Syndrome (SARS) Patients April 25, 2003, 11:30 AM

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Introduction
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 air transport of patients during this outbreak.

Currently recommended infection control measures for hospitalized 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 a parent is to accompany a sick child, the parent should use protective equipment during transport as described in section IV, below.
• If possible, a single primary-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 might 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
Cabin airflow characteristics may reduce exposure of occupants to airborne infectious particles; however, based on current understanding of how SARS is transmitted, airflow alone does not provide complete protection of personnel when sharing airspace with an infectious SARS patient. N-95 (or better) respirators are recommended for personnel in any part of an aircraft that shares air (directly or through the ventilation system) with the patient-care cabin.

Fixed-wing, pressurized aircraft:

• 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 preferred for transport of SARS patients. Aft-to-forward cabin airflow may increase the risk of airborne exposure of cabin and flight deck personnel.
• Aircraft ventilation should remain on at all times during transport of SARS patients, including during ground delays. Aircraft that re-circulate cabin and flight-deck air without HEPA filtration should not be selected for SARS patient transport.
• Aircraft that provide space for crew members to perform necessary personal activities (eating, drinking, handling contact lenses, etc.) in an area that does not share air with the patient-care cabin should be selected for flights likely to exceed 4 hours.

Rotor-wing, and non-pressurized aircraft:

• In aircraft with uncontrolled interior airflow such as rotor-wing and small, non-pressurized fixed-wing aircraft, all personnel should wear disposable, N-95 or better respirators during transport of SARS patients.

III. Patient Placement
The in-flight environment might preclude the creation of a true negative pressure space; 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.
• In AMT aircraft with vertical litter tiers and top-to-bottom airflow, 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 characteristics as described above.

IV. Infection Control
General:

• 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.

Protective equipment and procedures:

• Disposable, non-sterile gloves must be worn for all patient contact.
• Gloves should be 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 immediately after removal of gloves.
• Disposable fluid-resistant gowns should be worn for all patient care activity.
• Gowns should be 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.
• Disposable, N-95 respirators are approved for in-flight use. Personnel using N-95 respirators should be fit-tested.
• If air is shared between the cockpit/flight deck and the patient-care cabin, cockpit/flight deck crew should wear disposable N-95 respirators.
• 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.
• Personal activities that require removal of respirators should not be performed in the patient-care cabin.
• Patients should 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.
• Positive pressure ventilation should be performed using a resuscitation bag-valve mask. If available, units equipped for HEPA or equivalent filtration of expired air should be used.
• Cough-generating procedures should be avoided during transport (e.g., nebulizer treatments).

V. Mechanically Ventilated Patients

• Mechanical ventilators for SARS patients should provide HEPA or equivalent 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 self-sealing 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 or equivalent filtration. Portable suction devices should be fitted with in-line HEPA or equivalent 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, exits and doors should be closed and aircraft air conditioning turned on at maximum capacity for several minutes in accordance with the airing time specified by aircraft-manufacturers to provide at least one complete air-exchange. Non-pressurized aircraft should be aired out with exits and doors open long enough to ensure a complete air-exchange. Blowers and high-powered fans that might re-aerosolize infectious material should not be used for airing out aircraft.
• 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) at least once daily for 10 days for evidence of fever or respiratory illness that would require evaluation and follow-up.

* There are no disinfectant products currently registered by the U.S. Environmental Protection Agency (EPA) specifically for the inactivation of the newly identified viruses associated with SARS. However, related viruses with physical and biochemical properties similar to the possible SARS agents are known to be readily inactivated by EPA-registered chemical germicides that provide low- or intermediate-level disinfection during general use.

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 situations.

Acknowledgements:
This guidance was prepared in cooperation with and with contributions from:

United States Department of Defense

U.S. Transportation Command (USTRANSCOM)
Headquarters Air Mobility Command (HQ AMC)
U.S. Pacific Command (USPACOM)
Headquarters Pacific Air Forces (HQ PACAF)
U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID)

United States Department of State
Commission on Accreditation of Air Medical Transport Services (CAMTS)
Aerospace Medicine Association (AsMA)
Air Medical Physician Association (AMPA)

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