Guidance for primary care practitioners

Background 

Case definition 

Assessing and managing 

Community infection control 

Management of contacts 

Surveillance

1. Background

Background Information is available.

2. Case definitions for severe acute respiratory syndrome (SARS)

 Case definitions are available.

3. Assessing and managing a potential SARS case

Patients should initially be assessed at home, if at all possible, rather than in the practice setting. It is important that clinicians obtain a detailed travel history from patients with symptoms and signs consistent with clinical SARS as well as ascertain whether other family members and/or close contacts (particularly within the hospital setting) have had a similar illness within the 10 days prior to the patient's onset of illness.

Universal precautions should be taken when examining or taking samples from a potential SARS case (please see below for details). GPs should make an initial assessment and provisionally classify the patient according to the case definition.

If the patient fits the current case definition of possible SARS they will have a severe illness and require hospitalisation.

3.1 If the patient fits the current case definition of possible SARS refer to hospital:

• Patients should be dealt with through normal channels, and the receiving hospital should be alerted to the patient's possible SARS diagnosis in advance of their arrival.
• A surgical mask should be used where possible for symptomatic patients whether at home, in hospital or in transit.
• Patients with possible SARS should be reported by telephone to the Health Protection Agency, Communicable Disease Surveillance Centre (CDSC) duty doctor on 020 8200 6868 and the local CCDC

3.2 If the patient's illness is mild/resolving/or they do not require hospitalisation:

• they do not fit the case definition and should be managed at home in the usual way for any respiratory illness.

4. Community infection control

Healthcare workers

• Universal precautions should be taken by all community healthcare workers who come into close contact (see below) with a possible case of SARS, this would usually include gloves and a respirator conforming to at least European standard EN149:2001 FFP3. (See the detailed guidance on the use of face-masks and respirators.) If a respirator is not immediately available, a surgical face-mask should be worn.
• All healthcare workers in close contact with a possible SARS case should be considered a contact of that case and should follow the guidelines below.
• Healthcare workers include community/primary care teams, ambulance staff, physiotherapists and other professional support staff.
• Instructions on the correct way of using the respirator are supplied with the respirator and should be read carefully. Fit is critically important and a fit check or user seal check should be done each time a respirator is worn. The respirator should fit tightly to the face so that no air enters from the sides. Masks or respirators should be disposed of immediately after use as clinical waste, according to local infection control policy. They should only be removed when the wearer is in a safe area, outside the patient's room.
• Standard infection control precautions should be followed (including careful attention to hand hygiene with the use of alcohol hand rubs where available).
• Disposable gloves should be used when in direct contact with body fluids of the patient.
  Gloves and aprons should be worn to clean up blood and body fluid spillages. Spillages should be mopped up using paper towels first and then the area cleaned and disinfected using a chlorine releasing agent 10,000ppm available chlorine (household bleach diluted to 1:10).
• Environmental surfaces should be cleaned with general-purpose detergent and cold water, and then dried using disposable paper towels. If surfaces are contaminated disinfect using a chlorine releasing agent 1000ppm available chlorine (household bleach diluted to 1:100).
• Standard precautions should be used when handling any clinical waste, which must be placed in leak-proof biohazard bags or containers and disposed of safely, following the local clinical waste policy.

Patients

• Patients with possible SARS should use a surgical mask while symptomatic whether in hospital, at home or in transit.
• The mask should fit snugly over the face, with the coloured side out and the metal strip at the top. The strings should be positioned to keep the mask firmly in place over the nose, mouth and chin and the metallic strip moulded to the bridge of the nose. The mask should not be touched again until it is removed.
• When the patient is unable to wear a mask, carers should wear a mask when in close contact.
• The patient should be advised to cough/sneeze into a paper tissue and dispose of this safely into the toilet/or a plastic bag tied off at the top, prior to placing it in a bin.
• Hands of the patient should be frequently washed particularly after contact with body fluids ( eg respiratory secretions, urine or faeces).
• Hands of close contacts should be thoroughly washed before and after contact with a patient and after activities that are likely to cause contamination.

General

• Laundry in the home should be washed on the highest temperature recommended for the fabric.
• Eating utensils should not be shared but can be used by others after routine cleaning either in a dishwasher or with hot water and washing-up liquid.
• Blood and body fluid spillages should be mopped up using gloves and paper towels first, then the area cleaned and disinfected using household bleach diluted to 1 in 10 with cold water.
• Environmental surfaces should be cleaned with general-purpose detergent and cold water and dried using disposable paper towels. If surfaces are contaminated disinfect using household bleach diluted to 1 in 100.

5. Management of close contacts of a SARS case

• Close contacts are considered to be family, friends or health care workers who lived with, or who had direct contact with respiratory secretions, body fluids and/or excretions ( eg. faeces) of possible or probable case of SARS, while that case was symptomatic.
• Management depends on whether the case is a possible, probable or confirmed SARS case.
• Close contacts remain at risk until ten days after their last contact with a symptomatic case, and the following recommendations apply for this period only.

5.1 Management of close contacts of a possible case

• Contacts of a possible case should be given information on SARS. No specific follow-up of contacts is needed.
• Contacts are free to continue with usual activities unless they become unwell.
• A close contact who develops symptoms of SARS within ten days of contact with a possible case should phone their GP and seek medical advice. They should inform medical staff of their contact with a possible or probable case.

5.2 Management of close contacts of a probable case

• Generate a list of such contacts and record the date on which they last had contact with the case
• Liaise with the local CCDC/Health Protection team on follow-up responsibilities
• On day one, the GP or local Health Protection Team should telephone the contact to assess their health and provide them with information on SARS.
• On day ten following last contact with the case the GP or local Health Protection Team should telephone the contact to assess their health.
• If the contact develops symptoms consistent with SARS they should be assessed at home. GPs should make an initial assessment as to the clinical severity and provisionally classify the patient according to the case definition.
• If the patient meets the clinical case definition for SARS, they should be referred to hospital as 3.1
• If the case is mildly unwell, they should be managed at home by their GP. They should stay indoors and keep contact with other people to a minimum until their symptoms have resolved and they are afebrile for 48 hours

5.3 Management of close contacts of a confirmed case

Voluntary home isolation is recommended for a close contact of a confirmed case of SARS. Such close contacts should:

• stay indoors and keep contact with other people to a minimum for a period of ten days from the time of last contact with the case
• inform their GP of their contact
• monitor their health for SARS symptoms over this ten day period, and phone their GP if they develop any symptoms.

In addition, the GP or local health protection team should telephone the contact daily to assess their health during the ten-day home isolation period.

6. Surveillance

See case definitions. 

Patients fitting the case definition of possible SARS should be reported by telephone to the Health Protection Agency, Communicable Disease Surveillance Centre (CDSC) duty doctor on 020 8200 6868.

Last reviewed: 27 February 2009