1. Protecting Employees from SARS (Severe Acute Respiratory Syndrome) Jay Jamali, CSP, CHMM, CHCM Principal, Enviro Safetech Inc. www.envirosafetech.com

2. SARS OVERVIEW Potentially fatal respiratory disease Potentially fatal respiratory disease Believed to originate in China (Quang Dong Province) in November 2002, Believed to originate in China (Quang Dong Province) in November 2002, Corona virus—leading suspected causative agent Corona virus—leading suspected causative agent It belongs to the same family of viruses that causes the common cold. It belongs to the same family of viruses that causes the common cold. Some believe that source of the virus is from a wild cat and others believe it came from outer space Some believe that source of the virus is from a wild cat and others believe it came from outer space

3. SARS OVERVIEW Spread primarily by close person-to-person contact Spread primarily by close person-to-person contact Healthcare workers and family members face greatest risk of workplace transmission Healthcare workers and family members face greatest risk of workplace transmission Most U.S. cases contracted by those who’ve traveled to ASIA, more recently also Toronto Most U.S. cases contracted by those who’ve traveled to ASIA, more recently also Toronto

4. Confirmed Detection of antibody to SARS-CoV in specimens obtained during acute illness or >21 days after illness onset, or Isolation of SARS-CoV. Negative: Absence of antibody to SARS- CoV in convalescent serum obtained >21 days after symptom onset. Undetermined: Laboratory testing either not performed or incomplete. CASE CLASSIFICATION

5. Probable case: meets the clinical criteria for severe respiratory illness of unknown etiology and epidemiologic criteria for exposure; laboratory criteria confirmed, negative, or undetermined. Suspect case: meets the clinical criteria for moderate respiratory illness of unknown etiology, and epidemiologic criteria for exposure; When there is x-ray evidence of pneumonia or acute respiratory distress syndrome, a “suspect” case becomes a “probable” case.When there is x-ray evidence of pneumonia or acute respiratory distress syndrome, a “suspect” case becomes a “probable” case.

6. UNITED STATES SARS DATA As of 7/7/03 US 421 total and 347 Suspect and 74 probable and no deaths (so far) As of 7/7/03 US 421 total and 347 Suspect and 74 probable and no deaths (so far) California 79 total 55 suspect and 24 probable (highest in nation 7/10/03 ) California 79 total 55 suspect and 24 probable (highest in nation 7/10/03 ) New York 50T, 40S, 10P New York 50T, 40S, 10P Washington 32, 30, 2 Washington 32, 30, 2

7. SARS: Possible Symptoms The symptoms of SARS are similar to those for flu or respiratory illness such as: The symptoms of SARS are similar to those for flu or respiratory illness such as: Chills Chills Muscle aches Muscle aches Dry cough Dry cough Dizziness Dizziness Usually symptoms appear 3 to 5 days after exposure Usually symptoms appear 3 to 5 days after exposure

8. CLINICAL CRITERIA Asymptomatic or mild respiratory illness Asymptomatic or mild respiratory illness Fever of at least 100.4 degrees F and respiratory illness with one or more: Fever of at least 100.4 degrees F and respiratory illness with one or more: cough, cough, shortness of breath, shortness of breath, difficulty breathing, difficulty breathing, hypoxia (insufficient oxygen) hypoxia (insufficient oxygen)

9. SARS: Clinical Evidence Incubation period: 2-7 days, maybe up to 14 days Incubation period: 2-7 days, maybe up to 14 days Decreased white blood cell count Decreased white blood cell count Below normal blood platelet count Below normal blood platelet count Liver enzyme increase Liver enzyme increase Electrolyte disturbances Electrolyte disturbances

10. WHO has removed Taiwan from its list of areas with recent local transmission of SARS on 7/5/03. This achievement means that all known chains of person-to-person transmission of the SARS virus have now been broken. The last reported probable case in Taiwan, and – for the moment – in the world, was detected and isolated on 15 June. Two consecutive 10-day incubation periods have now passed with no further cases detected. The achievement comes just slightly more than four months since the virus began moving around the world, in late February, along the routes of international air travel. TAIWAN SARS OVERVIEW

11. Taiwan’s first case of SARS occurred in a 54-year-old businessman with a travel history, in late February, to Guangdong Province, China, where the earliest cases of SARS are now known to have occurred. The businessman was hospitalized on 8 March. Taiwan eventually had to cope with the third largest outbreak on record, including 674 cases and 84 deaths. The largest outbreaks occurred in mainland China (5327 cases and 348 deaths) and Hong Kong (1755 cases and 298 deaths). The outbreak in Taiwan initially grew slowly, with only 23 probable cases detected in the first month. Of these, a single health care worker, a doctor, became infected when he treated the wife of the businessman. TAIWAN SARS OVERVIEW

12. The outbreak began to escalate in mid-April in Taiwan following a lapse in infection control procedures, which allowed the disease to spread rapidly within the hospital setting and then into the wider community. Hospital procedures for infection control were tightened, and a logistics system was developed to ensure the efficient delivery of protective equipment and other supplies. Mass education campaigns persuaded the population to check frequently for fever and report promptly at fever clinics, which greatly reduced the time between onset of symptoms and isolation of patients.

13. GLOBAL SARS OVERVIEW WHO continues to receive rumors of possible cases, which indicates that surveillance systems are working well. To date, all recently reported possible cases have been aggressively investigated and determined to have other causes. Failure to detect new cases over the next two weeks will greatly increase confidence that the SARS corona virus (CoV) has indeed been pushed out of its new human host, although a return of the disease cannot be ruled out completely on the basis of current knowledge. Return of the flu season may trigger another outbreak or mass hysteria.

14. SARS FINANCIAL IMPACT Economic analysts in the Far East estimate initial SARS-related damage to regional GDP growth at US$ 10.6–$15 billion. China’s losses, at US$2.2 billion, are the highest, but Hong Kong, where the outbreak has already cost US$1.7 billion, is the biggest SARS-related economic casualty. In Hong Kong, retail sales have fallen by half since mid-March, tourism arrivals from mainland China have fallen 75% to 80%, and the entertainment and restaurant industries have recorded an 80% drop in business.

15. SARS: Potential High Risk Population Age 40 or older; especially those over 65 Age 40 or older; especially those over 65 Have other medical conditions (heart/liver disease) Have other medical conditions (heart/liver disease) Hospital worker or family member of victim Hospital worker or family member of victim

16. SARS: Transmission Spread through airborne droplets released when infected person coughs or sneezes Spread through airborne droplets released when infected person coughs or sneezes Or through contact with body fluids Or through contact with body fluids Not likely but possible to be transmitted in offices or on public transportation Not likely but possible to be transmitted in offices or on public transportation Virus viable from 4 to 24 hours. Virus viable from 4 to 24 hours.

17. PUBLIC HEALTH AGENCY ISSUES Detection Detection Isolation Isolation Quarantine (now one of 7 diseases per Bush) Quarantine (now one of 7 diseases per Bush) Travel restriction Travel restriction Points of arrival Points of arrival Public gathering cancellation Public gathering cancellation

18. SARS: Treatment Antibiotics is not effective since SARS is viral rather than bacterial Antibiotics is not effective since SARS is viral rather than bacterial Steroids may help Steroids may help 80-90% get better in a week 80-90% get better in a week 10-20% get worse, may need mechanical ventilators to breathe 10-20% get worse, may need mechanical ventilators to breathe Death rate estimated at 6%; higher for those over 60 Death rate estimated at 6%; higher for those over 60

19. Precautions for Employers Develop a plan and communicate it Develop a plan and communicate it Train employees at risk Train employees at risk Equip employees at risk with Personal Protective Equipment Equip employees at risk with Personal Protective Equipment Limit gathering or cancel Limit gathering or cancel Limit travel Limit travel

20. Precautions for Healthcare Facilities Standard precautions Standard precautions PPE: gowns, gloves, N95 respirators, eye protection PPE: gowns, gloves, N95 respirators, eye protection Appropriate ventilation Appropriate ventilation Isolation rooms for suspected SARS cases Isolation rooms for suspected SARS cases Low or Intermediate level disinfectants Low or Intermediate level disinfectants

21. Precautions for Laboratories PPE: disposable gloves, gowns, eye protection and respiratory protection— N95, N100 or PAPRS with HEPA filters PPE: disposable gloves, gowns, eye protection and respiratory protection— N95, N100 or PAPRS with HEPA filters Manipulation/testing of specimens—certified biological safety cabinet Manipulation/testing of specimens—certified biological safety cabinet Low or intermediate level disinfectants Low or intermediate level disinfectants

22. Precautions for Airline Flight Crews/Airport Personnel PPE not recommended by CDC for airline crews PPE not recommended by CDC for airline crews Airline cleaning crews, INS, TSA workers should wear gloves Airline cleaning crews, INS, TSA workers should wear gloves All workers should use good hygiene practices including frequent hand washing All workers should use good hygiene practices including frequent hand washing

23. Precautions for Airplane Cleaning Crews Wear disposable gloves Wear disposable gloves Do not use compressed air for cleaning Do not use compressed air for cleaning Discard gloves after cleaning Discard gloves after cleaning Use soap and water to wash hands after cleaning Use soap and water to wash hands after cleaning If soap and water are not available, use alcohol-based hand wash If soap and water are not available, use alcohol-based hand wash Wipe down frequently touched surfaces in the passenger cabin with low or intermediate level disinfectant Wipe down frequently touched surfaces in the passenger cabin with low or intermediate level disinfectant

24. Precautions for Air Medical Transport of SARS Patients Use respiratory protection (N95) Use respiratory protection (N95) Wear protective clothing if there is potential for exposure to blood or body fluids Wear protective clothing if there is potential for exposure to blood or body fluids Follow standard hygiene practices Follow standard hygiene practices

25. Precautions for Handling Human Remains of SARS Patients Use N95 or higher respirators Use N95 or higher respirators Wear surgical scrub suit, surgical cap, gown or apron, eye protection, shoe covers, double gloves Wear surgical scrub suit, surgical cap, gown or apron, eye protection, shoe covers, double gloves Use good hygiene practices Use good hygiene practices

26. TRAINING All employees with potential exposure should receive training All employees with potential exposure should receive training Training should cover hazards and protocols at worksite to reduce exposures and isolate and report SARS cases Training should cover hazards and protocols at worksite to reduce exposures and isolate and report SARS cases Workers who experience SARS symptoms should be excluded from duty Workers who experience SARS symptoms should be excluded from duty

27. FOREIGN TRAVEL Some countries have implemented measures such as mandatory screening of incoming passengers at airports, and persons with SARS-like symptoms may be quarantined and/or sent to designated hospitals until the authorities are satisfied they do not have SARS. American citizens currently in or planning to travel to SARS-affected areas should also consult the Consular Information Sheets for these countries available at the Consular Affairs web site at http://travel.state.gov.

28. FOREIGN TRAVEL Before you travel check your health insurance to see if it covers medical evacuation. If you get sick during travel with SARS symptoms put on a mask and see a healthcare provider immediately If you do not know of a provider contact the US embassy or consulate Limit your contact with fellow employees and clients The best way to prevent getting sick is to wash your hand with soap and water frequently and always before eating

29. FOREIGN TRAVEL If you become sick soon after your return see your healthcare provider and inform them of the countries you visited Monitor your health for at least 10 days after your return

30. TRAVEL KIT N95 masks enough for length of travel Hand wipes for decontamination Mini first aid kit to cover open wounds Instructions on do’s and dont’s Contact numbers

31. FOREIGN TRAVEL Effective 6/24/03, the World Health Organization (WHO) is removing its recommendation that people should postpone all but essential travel to Beijing, China. Beijing was the last area in the world to which this advice still applied. The recommendation to consider postponing all but essential travel to Beijing was issued on 23 April in order to minimize the international spread of severe acute respiratory syndrome (SARS). The last new case in Beijing was isolated on May 29, since when a number of suspect cases have been considered but ruled out as SARS. No cases have recently been exported from Beijing and all recent cases have been traced to known chains of transmission

32. Since the infectivity and route of transmission of SARS are unknown, the use of Personal Protective Equipment (PPE) appropriate for bloodborne and airborne exposures is recommended. Appropriate PPE includes protective gowns, gloves, N95 respirators, in addition to and eye protection. Proper training should be provided to all employees expected to use PPE. PERSONAL PROTECTIVE EQUIPMENT

33. Respiratory protection is the most important piece of PPE. The minimum level recommended by CDC is an N95 respirators. There are many types available Folds flat With or without valve Different sizes

34. FIT TESTING For the mask to work properly it should be fit tested according to the OSHA fit testing protocol as listed in Cal-OSHA Title 8 GISO 5144 or Fed-OSHA 29CFR1910.134: Quantitative (TSI portacount with adapter) Qualitative (Bitrex or banana oil we do not recommend irritant smoke)

35. FIT CHECK & CHANGE OUT SCHEDULE Users should be trained on proper fit checking procedure Once a respirator is used it should be considered contaminated and removed by using the straps Reuse of masks may be necessary due to supply Masks should be changed out based on negative resistance worst case scenario

36. PERSONAL PROTECTIVE EQUIPMENT

37. DECONTAMINATION There are no disinfectant products currently registered by the U.S. Environmental Protection Agency (EPA) for the newly identified viruses associated with SARS. The CDC recommends the use of EPA-registered chemical germicides that provide low- or intermediate-level disinfection during general use because these products are known to inactivate related viruses with physical and biochemical properties similar to the suspected SARS agents.

38. DECONTAMINATION We have selected the sani cloth wipe for use in conditions where access to running water is limited. The wipe comes in small or large single packs or tubs. When using soap use liquid soap. One to 10 solution of bleach is effective for cleaning surfaces Should be prepared daily

39. WEB SITES www.cdc.gov/ncidod/sars www.cdc.gov/ncidod/sars www.baesg.org/forntrav.htm www.osha.gov/dep/sars/index.html www.dhs.ca.gov/ps/dcdc/disb/sars.htm www.who.int/csr/sars/en/ www.who.int/csr/sars/en/

40. QUESTIONS Jay Jamali Jay Jamali 408-941-9393 408-941-9393 jayjam@envirosafetech.com jayjam@envirosafetech.com