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1096 - Guidelines On The Prevention And Management Of Severe Acute Respiratory Syndrome (Sars)
Geldigheid:16-06-2003 t/m Status: Geldig vandaag

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Ref. T2/4.1                                                                                     MSC/Circ.1096        

                                                                                                       16 June 2003


1 The Maritime Safety Committee, at its seventy-seventh session (28 May to 6 June 2003), considered submissions from Members on actions they had taken to prevent the spread of Severe Acute Respiratory Syndrome (SARS). The Committee welcomed the action taken by the Secretary-General and the MSC Chairman in issuing a precautionary circular on this issue (MSC/Circ.1068 on Severe Acute Respiratory Syndrome (SARS)).

2 The Committee also received updated information from the World Health Organization (WHO) on the emergence and spread of SARS and information on measures the WHO had adopted and the guidelines it had issued to assist in the prevention and control of cases of SARS. In order to assist the global effort to control SARS, the Committee agreed to promulgate the guidance given in the annexes, based on information provided by WHO, to ensure that the maritime community was fully aware of the precautions to be taken.

3 Member Governments are invited to bring this circular to the attention of all concerned and to note that the latest information available will be promulgated on the IMO website www.imo.org.


Annex 1 Guidelines For The Prevention And Management Of Severe Acute Respiratory Syndrome (Sars) (1)




1 TheseguidelineshavebeencompiledfrominformationavailablefromtheWorldHealthOrganization(WHO)website www.who.int/csr/sarsasat16June2003.

1 Preface

1.1 The World Health Organization International Health Regulations (IHR) contain provisions regarding routine point of entry control activities and specific measures for some diseases. In addition, the IHR reference technical guides for both ships and aircraft. The SARS outbreak, like other international disease outbreaks that occur around the world from time to time, requires that crew have a basic understanding of the disease, the risks and the public health precautions necessary for both passenger and crew protection. The information below, like the Guide to Hygiene and Sanitation in Aircraft and the Guide to Ship Sanitation, is provided as a technical reference for the development of operating procedures by international passenger transport companies. Although this information is provided for use by international ship and aircraft operators, it can apply, as appropriate, to other means of travel.




10 Information To Member States Regarding Goods And Animals Arriving From

10.1     WHOisawareofconcernoverthepossibilitythatSARSmaybecausedbycontactwith animals.WHOisthereforeworkingcloselywiththeFoodandAgricultureOrganizationofthe UnitedNations(FAO)andtheOfficeInternationaldesEpizooties(OIE),todetermineifthereisany evidence to suggest that SARS-related disease has occurred in animals.


10.2     WHO,FAOandOIEhavereviewedreportsreceivedregardingSARStransmission.Todate thereisnoepidemiologicalinformationtosuggestthatcontactwithgoods,productsoranimals shipped fromSARS-affected areas has been the source of SARS infection in humans.


10.3     For  the  above  reasons,  WHO  does  not  at  presentconcludethatanygoods,productsor animalsarrivingfromSARS-affectedareasposearisktopublichealth.WHOwillcontinueto closely monitor the evolution of SARS, in collaboration with Ministries ofHealthandourpartner agencies.



2 Background On Sars

2.1 From the information available at this time, SARS is a respiratory disease, spread by droplets from persons in the symptomatic stage of SARS. The incubation period of SARS is 2-10 days. Although serious illness and some deaths have resulted from SARS infection, the vast majority of SARS cases to date (96%) recover. Recent information suggests that SARS may also be spread for a short period of time by contact with surfaces contaminated by droplets or hands, and this is being investigated. Although the mode of transmission is similar, SARS is not spread as easily as influenza (flu), for example. Frequent handwashing is considered a useful preventive measure for SARS, as it would be for colds, flu and other common illnesses.

2.2 Remember that there is a good chance that an ill passenger does not have SARS, even though he or she has come from an affected area. Precaution is the best way to proceed, however, and the following advice is provided for reference.


3 Symptoms

3.1       AllpassengersandcrewshouldbeawareofthemainsymptomsandsignsofSARS,which include:


.1         highfever(>38o C,100.4degreesFahrenheit)andoneormorerespiratorysymptoms including cough or difficulty in breathing; and


              .2         eitherclosecontactwithapersonwhohasbeendiagnosedwithSARSorarecent history of travel to areas reporting cases of SARS.

4 Pre-Boarding

4.1 In the event of a crew member or passenger of a vessel experiencing this combination of symptoms, he or she should immediately seek medical attention and ensure that information about symptoms, recent travel and close contacts is passed on to the health care staff and the master of the vessel. Any crew or passengers who develop these symptoms are advised not to undertake the voyage until they have recovered or have been cleared for travel by a medical officer.


5 Screening For Suspect Cases Of Sars On Departure From Affected Areas


5.1       WHOrecommendsthatgovernmentandpointofentryauthoritiesinaffectedareasestablish asystemincollaborationwithaircraftandotherconveyanceoperatorssothatpassengersorcrew departingforinternationaldestinationsfromanaffectedareaareinterviewed,preferablybyahealth careworker,intheportofdeparturebeforecheck-in(forlatestinformationonareaswithlocal transmissionseewww.who.int/csr/sars).Theinterviewshouldassesswhetherthepassengerorcrew member:


.1         currently has or has experienced in the past 48 hours any symptoms of SARS

(http://www.who.int/csr/sars/case definition/en/) and


.2         has had any contact with suspect or probable SARS cases;


.3         has a fever (body temperature may be checked if appropriate).


5.2       PersonsmeetingtheSARScasedefinitionsshouldbereferredtoahealthcarefacility. Persons with only fever should be requested to postpone travel and seek medical attention.

6 Management Of Possible Sars Cases On Board

( Pleasenotethatthisappliesonlytoaircraft/shipscarryingapassengerwhomeetstheSARS symptoms listed above.)


6.1       IfapassengeronaflightfromanareawhereSARStransmissionisoccurringbecomes noticeablyillwithfeverandrespiratorysymptoms,thefollowingactionisrecommendedforthe cabincrewattendingtotheillpassenger.Othercrewdonotrequirepersonalprotection,butmust washhandsbeforeandafter:eating,handlingmaterialsthatcouldhavebeencontaminatedbytheill person, using areas of the ship or aircraft where the ill person moved about.




6.2       The passenger should be, as far as possible, isolated fromother passengers and the crew, and should be asked to wear a protective mask.2

Crewand passenger protection


6.3       Thosecaringfortheillpassengerorcrewmembershouldfollowinfectioncontrolmeasures (seebelow)recommendedforcasesofSARS,includinghandwashingaftercontactwiththeill person or with any materials that the person may have contacted.


The other protective measures are to:


.1         providetheillpersonwithamask(seebelow) tohelpensurethatdropletspreadis contained;


.2         keep contact with the ill person to a minimum, and avoid being close to the face of the person if possible;


.3         wearasuitablemaskandfollowthemanufacturer'sinstructionstoensurethatthe maskfitsproperly.If,foranyreasontheattendingcrewmemberneedstoremove his/hermask,thenanewmaskshouldbeused.Themask(s)andothermaterialsused

bytheillpersonshouldbedisposedofasa potential biohazard. The cleaning crew mustbeinformedofthepossiblycontaminatedmaterials(e.g.glovesrequired)and theneedtothoroughlydisinfecttheseatingareawheretheillpersonwasisolated, and the washroomareas in particular;


.4         weardurabledisposablegloves,rememberingthathandsshouldbewashedbeforethe gloves  are  removed,  then  again  after  removal,  and  that  touching  the  face  while wearing gloves provides the same risk of infection as when using bare hands;


.5         althoughtheriskofvirusentryfromdropletsorhandcontacttotheeyeislow, gogglesthatfittightlytotheface,withasoftsealingsurfaceshouldbewornbythe crewmemberattendingtotheillperson.Gogglesshouldbewashedbeforere-use, according to the manufacturer's instructions;


.6         a separate toilet should be made available for the exclusive use of the ill person;


.7         disposablemasks,glovesandothermaterialincontactwiththeillpersonmustbe bagged and sealed and treated as biohazard waste;


.8         asageneralprecaution,allpersonsonaflightorvoyagewhereapossibleSARScase iscarriedshouldbeadvisedtowashtheirhandsbeforeandafterusingthetoiletson board; and


.9         aircraft/ship  operators  should  ensure  that  flights/sailings  fromaffected  areas  are providedwithsufficientgloves,facemasks,gogglesanddisinfectant,andthataseat or berth in an isolated area can be made available when needed.



2  RespiratoryprotectionshouldbeprovidedatHEPAFilteror*P100(NIOSH)or*FFP3(EN149:2001)filter(99.97% efficiency)level.*N95filters(95%efficiency)andabove*(N,R,P99orFFP2)alsoprovidehighlevelsofprotectionand shouldbewornwherenoacceptablealternativesofahigherlevelofprotectionareavailable.Ideally,themasksused shouldbefittestedusinganappropriate"fittestkit"inaccordancewiththemanufacturinginstructions.Disposablemasks shouldnotbereused.

7 Communication And Hand-Off To Airport/Port

7.1       Thepilot/shipmastershouldradioaheadtotheairport/portofdestinationsothatairport/port management can alert the health authorities.


7.2       Onarrival,thepublichealthauthoritiesshouldtaketheillpassengerdirectlyfromtheaircraft orshipbytheexitclosesttowherethepassengerisseated,andavoidpassingthroughtheairportor port.Theillpassengershouldthenbeplacedinisolationandassessedasquicklyaspossiblebya healthauthorityphysician.Anyonewaitingforthepassengershouldbenotifiedofthedelayby airline/shipstaff.Otheragencies,suchasimmigration,willneedtoknowthatapassengerhas by-passed normal airport/port arrival procedures.


8 Management Of Contacts (3) Of The Ill Person And Of Other Persons On Board

8.1       Contactsandotherpassengersorcrewshouldbeallowedtocontinuetravelaslongastheydo nothavesymptomscompatiblewithSARS.Seeannex2formanagementofprobablecasesofSARS

on international cruise vessels.


On arrival at the next port


8.2       Thehealthauthorityatthescheduledportofarrivalmustbeinformedimmediatelybyradio ofthesuspectcase,andaskedifthenecessarycapacitytoisolate,transportandcarefortheillcrew memberorpassengerisavailableattheport.Dependingonthelocalsituation,themasterofthe vessel may be asked to proceed to another national port that has this capacity.


8.3       Onarrivalattheportrequestedbythehealthauthority,noone mayleavethevesseluntila medicalofficerhasexaminedtheillcrewmemberorpassenger,aswellastherestofthecrewand any passengers on board.


8.4       Ifthemedicalofficerfortheportdeterminesthattheillcrewmemberorpassengermeetsthe SARScasedefinition,thecrewmemberorpassengershallberemovedfromthevessel,usingall necessaryprecautions,andtransportedtothenearestdesignatedmedicalfacilityfortreatmentof SARS cases.


8.5       Thevesselshallbeconsideredasbeinginisolation,andnoone,otherthanhealthauthority stafforotherpersonnelworkingdirectlywiththehealthauthority,shallbeallowedtoboardorleave the vessel. Security personnel should be posted to ensure compliance with this requirement.


8.6       Thevesselandcrewwillbeheldinportforaperiodof10days,toensurethatnoneofthe othercreworpassengershavebeeninfectedwithSARS.Attheendoftheisolationperiod,priorto departureofthevessel,thecabinorquarterswheretheSARSpatientwasisolatedandmanaged, shouldbecleanedanddisinfected(seelastparagraph)beforeacrewmemberorpassengerisallowed

to occupy that cabin or quarters.


8.7       Thevesselwillbeallowedtoproceedtoitsnextportofcallafteramedicalofficerhas determined that none of the other crew or passengers has been infected.


8.8       Iftheownersofthevesselwishtohaveitreleasedfromisolation,analternatecrewmaybe provided.Agreementwiththehealthauthoritieswouldneedtobereachedtoprovidefacilitiesforthe isolatedcrewleftbehind.Athoroughcleaningofthevesselísquarters,includingdiningroom, washroomandrecreationareaswouldalsoberequired before the new crew boards. This cleaning should be carried out under the supervision of the port health authority.


3  Forthepurposesofairtravel,acontactisdefinedas:


·        Passengerssittinginthesameseatroworwithinatleast2rowsinfrontorbehindtheillpassenger

·        Allflightattendantsonboard

·        Anyonehavingintimatecontact,providingcareorotherwisehavingcontactwithrespiratorysecretionsofthe


·        Anyoneontheflightlivinginthesamehouseholdastheillpassenger

·        IfitisaflightattendantthatisconsideredtobeaSARScase,allpassengersareconsideredtobecontacts.


9 Disinfecting The Cabin Or Quarters Occupied By Sars Patient

9.1       The  cabin  or  quarters  occupied  by  a  SARS  patient,  should  be  disinfected  with  sodium hypochlorite  (bleach)  and  formalin4  or  chloro  meta  xylenol  (see  WHO  Guide  to  Hygiene  and Sanitation  in  Aviation).   Allsurfacesthatthepatientmayhavetouchedshouldbespecifically targetedforcleaning.Thoroughlyrinseandcleanhousekeepingequipmentafteruseinthecabinor quarters of the SARS patient.


9.2       More information on SARS can be obtained fromthe WHO website, www.who.int.







4 Sodiumhypochloritedilutedtoastrengthof100mg/landa5%solutionofformalin,whichitselfisa40%solutionof formaldehydegasinwater.

Annex 2 Recommended Procedures For Prevention And Management Of Probable Cases Of Sars On International Cruise Vessels

1 Preface

1.1 In response to the outbreak of Severe Acute Respiratory Syndrome (SARS) in several countries, the World Health Organization has developed the following procedures for personnel on international cruise vessels and local port health authorities when there is a suspected or probable case of SARS on board. All individuals, groups and authorities involved in the cruise ship industry including crew, health care staff, cruise line operators, owners, and port health authorities should be aware of these procedures.

2 General Information And Symptoms Of Sars

2.1       Allinternationaltravellersincludingcrewandpassengersofcruisevesselsshouldbeaware of the main symptoms and signs of SARS, which include:


.1         high  fever  (>38°C)  and  one  or  more  respiratory  symptoms  including  cough, shortness of breath, difficulty breathing;  and


.2         eitherclosecontactwithapersonwhohasbeendiagnosedwithSARSorrecent historyoftravel(previous10days)toareaswithrecentlocaltransmissionofSARS1.









1SeeWHOweblinkfor areas with local transmission




3 Pre-Departure Screening

3.1 Prior to boarding, all passengers and crew on international voyages originating in areas with recent local transmission of SARS2should receive and complete a short pre-departure SARS Screening Form with questions as to symptoms, contacts, and recent history of travel to an area(s) with recent local transmission of SARS.

3.2 A person presenting symptoms compatible with SARS, should not travel until s/he is fully recovered. The local health authority should be notified and the patient must be assessed immediately.

3.3 A person reporting having been in close contact3with a probable case of SARS in the last 10 days, but who is otherwise healthy, should not travel. S/he should be advised to be vigilant for SARS symptoms over the 10 days following exposure and continuously monitored by the local public health authority.

3.4 A person exhibiting none of the above symptoms, and who has not been in contact with a suspect or probable case/s of SARS over the previous 10 day period, should be provided with information on SARS and instructed to seek medical attention immediately if any symptoms consistent with SARS develop.



2SeeWHOweblinkfor areas with local transmission

3CloseContact:havingcaredfor,livedwith,orhaddirectcontactwithrespiratorysecretionsorbodyfluidsofasuspect orprobablecaseofSARS.SeeWHOweblink


4 Managing Passengers And Crew

4.1 Following preliminary medical examination, if the ship's medical officer determines that there is a suspected or probable case of SARS on board, the following measures should be taken:

     .1 the suspected case should be isolated in an isolation ward, cabin, room or quarters with, if possible, an independent ventilation and toilet system;

     2 infection control measures including respiratory and standard precautions should be implemented4; and

    .3 designated staff taking care of the patient should wear a protective face mask5, gloves and eye protection and wash hands before and after contact with the patient.

4.2 The officer in charge of the vessel should immediately alert the medical authority at the next port of call regarding the suspected case to determine if the necessary capacity for transportation, isolation, and care is available at the port. The vessel may be asked to proceed to another national port in close proximity if this capacity is not available or if warranted by the critical medical status of  the suspected or probable SARS case.

4.3 For persons meeting the definitions of suspect or probable case of SARS, confinement to isolation ward, cabin, room or quarters with infection control measures should be continued until 10 days after the resolution of fever, provided respiratory symptoms are absent or improving. However, if the illness does not meet the case definition, but the individual has persistent fever or unresolving respiratory symptoms, the person should not be allowed to return to public areas of the vessel or interact with the public. Infection control precautions including confinement to isolation ward, cabin, room or quarters and further monitoring of symptoms should be continued. A decision as to returning to public areas can be reviewed in collaboration with the public health authority of the next port of call. All contacts (see below for details) on board should be identified and monitored.

4.4 While case management is in progress on board a cruise vessel, a high level of cleaning and disinfection measures should be maintained on the vessel. Cabins and quarters occupied by patients and contacts of SARS should be cleaned and disinfected according to WHO6and local public health recommendations.


4SeeWHOweb link

5 N/R/P95/100orFFP2/3oranequivalentnationalmanufacturingstandard(NIOSH(N,R,P95,99,100)orEuropeanCE EN149:2001(FFP2,3)andEN143:2000(P2)orcomparablenational/regionalstandardsapplicabletothecountryof manufacture.




5 On Arrival At The Next Port

5.1 No one may leave the vessel until a medical officer for the health authority has examined the suspect or probable case and has identified and examined all possible contacts on board.

5.2 If the medical officer for the port determines that the ill crewmember or passenger meets the SARS case definition, the crew member or passenger shall be removed from the vessel, using all necessary precautions, and transported to the nearest medical facility. If the patient is determined to be a probable case of SARS, his/her contacts should be asked to be in voluntary isolation and not permitted to travel until 10 days after the contact.

5.3 As soon as the suspected or probable case had been removed from the cruise vessel, the cabin or quarters where the SARS patient was isolated and managed should be thoroughly cleaned and disinfected (see below).

5.4 The local public health authority should provide information on symptoms and transmission of SARS to all passengers and crew.

5.5 The vessel may be allowed to proceed to its next port of call after the health authority has determined that none of the other crewmembers or passengers has symptoms consistent with SARS.

6 Procedures For Contacts

6.1 All contacts of a suspected7 or probable8 SARS case should be provided with information on symptoms and transmission of SARS. They should be placed under active surveillance for 10 days and directed to observe voluntary isolation. Designated health staff on board should monitor and record the temperature of contacts daily. Both embarking and disembarking ports must be notified immediately of SARS contacts being on board and measures taken. If, after 10 days of voluntary isolation and observation, the contacts do not develop symptoms of SARS, then contacts can be discharged from the follow up.



7  seeWHO web linkfordefinitionofsuspectedcaseofSARS

8  seeWHO web linkfordefinitionofprobablecaseofSARS

7 Disinfecting The Cabin Or Quarters Occupied By A Suspect Or Probable Sars Case


7.1       Cleaning  and  hygiene  staff  should  be  well-briefed  on  infection  control.  Precautionary proceduresshouldbeobservedwhencleaninganddisinfectingtheisolationarea(s)(ward,cabin room,orquarters)oftheSARSpatient.Personscleaningtheisolationarea(s)shouldwearadequate personalprotection(gloves,protectivefacemask5,eyeprotection,disposableoutergarments).These areasshouldbedisinfectedwithsodiumhypochlorite(bleach)andformalin9,chlorometaxylenol,or an  equivalent  product.  All  surfaces  and  objects  that  the  patient  may  have  touched  should  be specificallytargetedforcleaning.Materials,suchassheetsandtowelsthathavebeenusedbythe possibleSARScase,shouldbethoroughlycleanedanddisinfected.Allcleaningequipmentshould bedisinfectedafteruse.Areascontaminatedbybodyfluidsfromthesuspectcase(e.g.vomitus) shouldnotbevacuumedunlessaHEPAfiltervacuumisavailable.Wetmoppingwithadisinfectant cleaner (hard surfaces) or steamcleaning (carpets) is recommended.





5 N/R/P95/100orFFP2/3oranequivalentnationalmanufacturingstandard(NIOSH(N,R,P95,99,100)orEuropeanCE EN149:2001(FFP2,3)andEN143:2000(P2)orcomparablenational/regionalstandardsapplicabletothecountryof manufacture.


9 Sodiumhypochloritedilutedtoastrengthof100mg/1anda5%solutionofformalin,whichitselfisa40%solutionof formaldehydegasinwater.

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