Workers' guide to Sars compiled by Occupational Health and Safety Authority

The Occupational Health and Safety Authority said yesterday it was being inundated with calls about the risks of contracting Sars faced by workers in various establishments.

While emphasising that there was no cause for alarm, the OHSA compiled the following guidance on Sars, severe acute respiratory syndrome.

OHSA underlined the legal duty of employers to carry out a risk assessment and inform the employees of its findings. Moreover, employers are obliged to train workers as appropriate and consult them in the measures that need to be taken.

What is Sars?

Sars is an infection in which affected individuals develop a fever, followed by respiratory symptoms such as cough, shortness of breath or difficulty in breathing. In some cases, the respiratory symptoms become increasingly severe, and people require oxygen support and mechanical ventilation. Other symptoms of Sars include muscle aches, headaches, and sore throat.

More information on the clinical feature of Sars are available through the World Health Organisation web site.

http://www.who.int/csr/Sars/clinical/en/

Which countries have reported cases of Sars?

The countries most affected to date are parts of Asia and Canada, although suspect cases have also been reported in Europe. The link to the World Health Organisation's web site has the latest figures.

http://www.who.int/csr/don/en/

How contagious is Sars?

Sars appears to be less infectious than influenza and the incubation period is usually two to seven days but may be as long as 10 days. Based on currently available evidence, close contact with an infected person poses the highest risk of the infective agent spreading from one person to another.

To date, the majority of cases have occurred in hospital workers who have cared for Sars patients and the close family members of these patients. Close contact includes living in the same household, providing health care to someone with Sars, or having direct contact with respiratory secretions and body fluids of a person with Sars.

Who is at risk of developing Sars?

The only risk factors identified to date are recent travel to affected countries or close contact with a person who has Sars.

What about more general information on Sars that is not in a work context?

In Malta, all general queries that are not work-related should be directed to the Department of Health, that is the entity responsible for public health. There are also various sources of information on the internet including that of the WHO.

http://www.who.int/csr/Sars/

Should customs, money handlers and post officials wear masks or gloves to prevent Sars?

From information provided by the WHO, to date there is no epidemiological information to suggest that contact with goods, products or animals shipped from Sars-affected areas has been the source of Sars infection in humans. Thus WHO at present concludes that these do not pose a risk to public health.

In these circumstances and for the above reasons, the use of masks or other personal protective equipment such as gloves is not considered necessary.

What about teachers and other staff at boarding schools or schools taking in students who have been to Sars affected areas?

As a precaution, such students should not go to school in the 10 days following their arrival from abroad. The guidance issued by the Department of Health should be followed in these cases. Employers in the education sector have a duty to inform members of staff of any risks from Sars and the steps they are taking to address these.

What about air flight cabin crew or crew on board ships?

Should a passenger on board a flight or a ship show symptoms of Sars, he should be interviewed in private. If he is deemed to be a suspect case, infection control measures should be taken, such as washing hands, which is the most important hygiene measure in preventing the spread of infection.

Moreover specific protective masks should be worn by both the suspected cases as well as the airline cabin crew in close contact with the passenger while providing services to the passengers they believe may be a suspect case.

As major cleaning cannot be undertaken on aeroplanes until the aircraft safely arrives at its destination, cabin crew should be supplied with materials to use to clean any surfaces in contact with respiratory secretions of the suspect case of Sars, according to guidance provided by the Department of Health.

What about immigration officials at airports and sea terminals?

Immigration officials are unlikely to become ill because their contact with passengers and clients are of reasonably short duration and not considered to be close contact.

In the case of intimate body searches involving contact with human body excretions/secretions that could contain any infectious agent, a risk assessment should have already been carried out by the employer and appropriate preventive measures should already be in place. Employers are advised to review these risk assessments in light of the information currently available on Sars to control the risk appropriately.

What about cleaning staff at airport and on board ships and aeroplanes?

From the information available, it is not necessary for cleaning crew to wear masks after the passenger has deplaned or gone ashore. However, cleaning crews may choose to wear a mask for their own personal protection from inhaling cleaning fumes. The recommended airline and airport cleaning guidelines should be followed, since the employers should have already carried out a risk assessment and put preventive measures in place.

If a passenger is a suspect case, disinfect or destroy magazines and toys if there is a possibility that the sick passenger may have contaminated them. Disinfect passenger furniture and environmental surfaces using detergent. Linen, such as pillows or blankets, should be transported in leak-resistant, closed laundry bags. All waste should be disposed of in a plastic garbage bag and sealed. Gloves should be worn and appropriate hand washing is required after handling waste such as tissues or napkins.

What about other maritime port or airport staff?

If a passenger is a Sars suspect case and an employee is involved in transporting him/her through the airport or maritime port, the employee should be given an appropriate mask to wear and be asked to avoid transporting the passenger through crowds as much as possible. The symptomatic passenger should have been given a surgical mask when symptoms are noted.

Can workers make use of public conveniences used by other persons, such as at airports?

Yes. There is no indication at present that Sars could be contracted by using public conveniences, even at airports or places accommodating various people of different nationalities.

What about health care workers in outpatient and triage settings?

According to guidance given by WHO, when a suspect or probable case is brought to their attention, triage staff should wear an appropriate face mask and eye protection. They should also wash their hands before and after contact with any patient, after activities likely to cause contamination and after removing gloves. It is to be noted that soiled gloves, stethoscopes and other equipment have the potential to spread infection. WHO advises that disinfectants such as fresh bleach solutions, should be widely available at appropriate concentrations. One can also find further information on the following websites:

UK Department of Health: http://www.phls.co.uk/topics_az/Sars/health_profesional_page.htm
Health Canada: http://www.Sars.gc.ca

What about health care workers in inpatient settings?

Should a person be a probable case, WHO advises that infection control measures should include airborne precautions such as isolating the person and accommodating him in either of negative pressure rooms with the door closed, or single rooms with their own bathroom facilities or cohort placement in an area with an independent air supply, exhaust system and bathroom facilities.

Droplet and contact precautions should also be taken, including the use of long sleeve fluid repellent gown and latex or similar non-latex gloves with tight fitting cuffs for contact with patients or their environment.

A member of staff must be identified who will have the responsibility of observing the practice of others and provide feedback on infection control. Moreover, all staff, including ancilliary staff should be trained in the infection control measures required for the care of such a patient. All non-essential staff (including students) should not be allowed on the unit/ward.

The room should be cleaned by staff wearing PPE using a broad spectrum disinfectant of proven antiviral activity. Alcohol-based skin disinfectants could be used if there is no obvious organic material contamination.

Particular attention should be paid to interventions such as the use of nebulisers, chest physiotherapy, bronchoscopy or gastroscopy; any other intervention which may disrupt the respiratory tract or place the healthcare worker in close proximity to the patient and potentially infected secretions.

Personal protective equipment (PPE) should be worn by all staff and visitors accessing the isolation unit. The PPE worn in this situation should include: a face mask providing appropriate respiratory protection, a single pair of gloves, eye protection, disposable gown, apron and footwear that can be decontaminated.

All sharps should be dealt with promptly and safely.

Linen from the patients should be prepared on site for the laundry staff. Appropriate PPE should be worn in this preparation and the linen should be put into biohazard bags and labelled accordingly.

Personal hygiene is essential and hands should be washed before and after contact with any patient, after activities likely to cause contamination and after removing gloves.

Further information is available through the following websites:

UK Department of Health: http://www.phls.co.uk/topics_az/Sars/health_profesional_page.htm
Health Canada: http://www.Sars.gc.ca

What about laboratory workers handling potential Sars blood samples or specimens?

WHO advises that Sars specimens should be handled according to appropriate biosafety practices in order to avoid laboratory-related infections and spread of disease to close contacts. As the primary route of infection is thought to be via droplets, extreme caution must be exercised to eliminate the unguarded production of aerosols.

According to the latest findings, the etiologic agent is a coronavirus and thus all laboratory work practices should be appropriate for work with viral agents, with particular emphasis on potential spread by droplets, air, and/or contaminated surfaces and objects. No procedure should be undertaken in which there is any doubt about the ability to adequately contain the specimen and prevent the uncontrolled release of the virus.

The following precautions are strongly recommended by WHO for work in BSL-2 laboratories with potential Sars specimens:

¤ Any procedure that may generate aerosols should be performed in a biological safety cabinet.

¤ Laboratory workers should wear protective equipment, including disposable gloves, solid-front or wrap-around gowns with cuffed sleeves, eye protection and a surgical mask, or full-face shield, according to the risk of aerosols and exposure when performing specific manipulations. When working at a biological safety cabinet, a full-face shield is not necessary.

¤ Centrifugation of human specimens should be performed using sealed centrifuge rotors or sample cups. These rotors or cups should be unloaded in a biological safety cabinet.

¤ Procedures performed outside of a biological safety cabinet should be performed in a manner that minimises the risk of exposure to an inadvertent release of the etiologic agent.

¤ Work surfaces and equipment should be decontaminated after specimens are processed. Standard decontamination agents that are effective against lipid-enveloped viruses should be sufficient.

¤ Biological waste should be treated as outlined in the WHO Laboratory Biosafety Manual, (available at: http://www.who.int/csrresources/publications/biosafety/Labbiosafety.pdf) that renders viral particles inactive.

For further information visit the following websites:

http://www.phls.co.uk/topics_az/Sars/health_profesional_page.htm
http://www.who.int/csr/Sars/biosafety2003_04_25/en/

Which masks provide the necessary respiratory protection?

WHO advises that the type of masks used should ideally conform to European CE EN149:2001 (FFP 2,3) and EN143:2000 (P2). These standards have been adopted in Malta and their equivalent national manufacturing standard is MSA EN149:2001 and MSA EN143:2000. Further information on these standards is available from the Malta Standards Authority on tel. 2124 2420.

Ideally, the masks used should be fit tested using an appropriate "fit test kit" in accordance with the manufacturing instructions. Disposable masks should not be reused.

Workers identified by their employers as requiring respiratory PPE should also receive instructions on the proper way of wearing and using such PPE. Where cartridge masks are to be used, the cartridge should be changed before the expiry date and according to the manufacturer's specifications.