This information requires knowledgeable interpretation and is intended primarily for members of the professional health care community.

Your doctor feels that your symptoms are mild enough to send you home for observation. However, while at home it is important that you monitor your own health to be sure that your symptoms do not progress. In addition, you must take proper precautions so that you do not pass an infection on to others.

• Measure your temperature with your own thermometer twice a day over the next 72-hour period. Record the results on a piece of paper with the dates and times.
• If you develop a new fever (over 38° C / 100.4° F), you should call your doctor and/or Telehealth Ontario at 1-866-797-0000 (TTY 1-866-797-0007) where you will be advised how to seek medical attention.
• If you begin to develop other new symptoms such as shortness of breath, difficulty breathing, or if your symptoms worsen, you should immediately call your doctor and/or Telehealth Ontario at 1- 866-797-0000 (TTY 1-866-797-0007) where you will be advised how to seek medical attention.

• Remain at home for the next 72 hours or until you are feeling better. Do not go to work, school or public places.
• Wash your hands frequently.
• Remind others in your household to wash their hands often, especially if they have spent time in the same room as you.
• Limit your contact with other people.
• Cover your mouth with a tissue when you cough or sneeze. Wash your hands immediately after covering your mouth, and after blowing your nose.
• Do not share personal items, such as towels, drinking cups, cutlery, thermometers, and toothbrushes.
• Dispose of used tissues directly into a garbage bag used only by you.
• Rest and drink plenty of fluids.
• Family members who become ill must stay home and call their physician.
• At the end of 72 hours, if you are feeling entirely well, you can return to work or school and resume normal activity. If your symptoms persist, call your doctor.

You can find this information in a document called Potential SARS Exposure Sites, Local and Global on this Web site.
The dates provided show the time period of exposure. For screening purposes, your facility should identify the sites that have exposure dates within 10 days of the last date of the individual's contact with the affected site.
During an outbreak exposed local facilities may change daily. To stay current, please refer regularly to the Ministry of Health and Long-Term Care Web site for health care stakeholders and providers. Look at the Hospital Levels Report on this Web site for current Category 3 and Category 2 health care facility sites. These sites should also be considered as exposure sites.

No, the City of Toronto should not be listed as an affected area. While countries outside of Canada may be identified for international screening purposes, we have the ability in Ontario to provide specific epidemiology sites and links for greater accuracy and greater vigilance against transmission.

A Patient Transfer Authorization Number :

• Is required in any mode of transportation (taxi, relative's car, Wheeltrans, etc.) between any health care facilities (acute-care hospital, long-term care facility, rehabilitation or complex continuing care hospital, etc.), but


• Is not required for transfers from a health care facility to a medical appointment outside a health-care facility (dentist, family physician, ophthalmologist, podiatrist, etc.) or a transfer home.

Some information is available in French on the Ministry of Health and Long- Term Care Web site. Information is available in other languages on the City of Toronto Web site.

The diagnosis of SARS on an individual basis is in two parts :

1. epidemiological : seek carefully and thoroughly an epidemiological link: travel or exposure to a known affected site, household members who are ill with a similar illness, or health care worker exposure. If this is done thoroughly and no such links are made the likelihood you are dealing with a SARS case is remote enough that isolation precautions are not a high priority.
2. clinical : unfortunately this is the least useful in so far as you need to observe the patient over a period of time to see what direction the illness is taking, at least early on. Later on in the course of illness, persistent fever and severe dry cough and a clinical course consistent with SARS allows one to make the diagnosis, but this often requires several days of observation and is not a spot diagnosis. The diagnostic techniques are still too problematic to assist in the immediate clinical diagnosis. Where clinical and epidemiological features are consistent, the SARS viral cultures and PCR can be confirmatory.

Community events usually attract participants who are not ill. Organizers should stress that individuals who have fever and respiratory symptoms should not attend.
With this in mind, it is not necessary for health care workers at these events to wear personal protective equipment while on duty. They must practise proper hand hygiene and if they encounter any person with respiratory symptoms they should don an N95 mask or equivalent.
If the person has had contact with a SARS patient or has visited an affected setting (see Potential SARS Exposure Sites, Local and Global) in the last 10 days, the health care worker should put on full protective equipment (N95 mask or equivalent, protective eye-wear, gown, gloves) and the person should be transported by private vehicle to a SARS assessment clinic or Emergency Department wearing a surgical mask. Public Health must be notified.

Publicity for the events should include the message that people should not attend if they are feeling feverish and have respiratory symptoms, or are under quarantine. Individuals should practise hand hygiene frequently. Organizers should ensure that hand washing / hand hygiene facilities are available and accessible. No other precautions are needed.

Yes, they can be used interchangeably with N95 masks. It is reasonable to try these masks as an alternate when fit testing cannot be achieved with N95 masks. However, health care workers on working quarantine, staff in category 3 hospitals or affected areas of category 2 hospitals, or while performing sterile procedures must  NOT use masks with exhalation valves.

Health Canada recommends that N95 or equivalent masks should be changed if they become wet, interfere with breathing, are damaged or visibly soiled. An N95 mask or equivalent that has been exposed to a suspect or probable SARS case is considered contaminated and should be discarded in a designated waste receptacle after the health care worker has left the examination area. Masks are not considered to be a biohazard waste unless bloody.
N95 or equivalent masks are disposable but may be re-used repeatedly by the same health care worker (unless the health care worker was in contact with a suspect or probable SARS case) if the mask is stored in a clean, dry location.
Humidity, dirt, and crushing reduce the efficiency of the respirator according to Health Canada. When masks are worn for prolonged periods of time, a seal check should be done each time the mask is adjusted or reapplied.

People who are under investigation or have been diagnosed as a suspect or probable case should wear a surgical mask when out of their negative pressure room. A surgical mask will capture large, wet particles from the nose and mouth of the wearer, thus preventing the spread from the wearer to others. (see Health Canada for more information)

People on home quarantine should wear a surgical mask when in the same room as another member of the household.

The ministry is taking a cautious approach and has developed directives based on recommendations of Health Canada, the Centers for Disease Control, and the World Health Organization such as health care workers should wear an N95 approved respirator/mask or equivalent when protection from SARS is required.

Fit testing helps determine which respirator fits a worker. Both the qualitative and quantitative tests are effective. It is important that there is minimal leakage to prevent particles from entering, regardless of their size. The directive to all Ontario acute care facilities requires hospitals to have a formal qualitative fit testing program in place. Qualitative fit tests should continue. Formal qualitative or quantitative fit testing is more effective than the user personally checking for the apparent degree of seal provided by the mask (so called seal checking or fit checking). Seal checking is a not a replacement for fit testing.

Health care workers who are most at risk should be fit tested first. This includes people who work in hospital emergency departments, critical care units and SARS units.
The following companies provide mask fit testing services. This list is not exhaustive; you may wish to contact other suppliers in your community.

• 3M Canada
  Ontario Supervisor, Occupational Health Services
  Tel: 905 602-3769
• Hot Zone
  Tel: 1-888-898-8966
• Levitt Safety
  Tel: 905 829-3299 or 1 800 668-6153
• North Safety Products
  Tel: 416 675-2810

The sensitivity test should be conducted in a room separate from the room used for the fit test. The rooms should be well ventilated to prevent the odour of the test reagent to linger in the room where the testing takes place. (see OSHA ­ Accepted Fit Test Protocols, Appendix A to 1910.134). The fit testers will need access to a sink for clean up. Those providing the fit testing should be consulted for any other special requirements they may have.

The fit testing must be performed in accordance with CSA standards and the manufacturers' recommendations. A new cloth and a hospital-approved disinfectant (e.g. quaternary ammonium disinfectant) or a disposable disinfectant wipe should be used to clean the hood after each staff completes the test.

The Ministry has developed systems for coordinated distribution, continues to assess demand, has identified priorities for allocation and is sourcing masks internationally. Specifics regarding this are outlined in the Personal Protective Equipment Update issued June 7, 2003.

Yes, non-acute care facilities, including long-term care facilities, can accept patients from Category 2 hospitals if the following criteria are met :

• The hospital is a Category 2 based on unprotected exposure in a specific unit
• The patient did not spend any time on the affected unit during the affected period
• The patient passes the SARS screen on discharge from the sending facility and admission to the receiving facility.

The hospital will perform the SARS Screening Tool prior to discharge. Patients who pass the screening tool will be discharged. These patients do not require quarantine, but they should self-monitor (or caregiver should monitor) for symptoms for the next 10 days. If symptoms develop, the patient or caregiver should contact Public Health. Patients who fail the screening tool will be assessed medically by the hospital. If after medical assessment SARS is not suspected, the patient is discharged with instructions to monitor for symptoms for the next 10 days. Please note for discharge to non-acute care facilities, hospitals must consult with Public Health as to the suitability of the discharge. If SARS is suspected, the hospital will not discharge the patient and will contact Public Health and hospital Infection Control.

As described in the June 16, 2003, Non-Acute Care Directive, facilities should use routine practices as defined by Health Canada for all resident contact. For exposure to patients/residents with respiratory symptoms (unexplained cough, shortness of breath, or difficulty breathing) or fever suggestive of an infectious respiratory illness, staff are directed to use SARS precautions (N95 mask or equivalent, gown, gloves and protective eye-wear.) Isolate the resident if possible and place a surgical mask on the resident until SARS has been ruled out by medical assessment.

As stated in the Directive to Acute Care Facilities in the Greater Toronto Area – Directive 03-10, June 16, 2003 – health care providers in emergency departments and critical care areas will wear SARS precautions and will maintain heightened vigilance. Additional steps are required for any patients that raise suspicions of a respiratory condition where SARS cannot be ruled out. All acute care facilities in Toronto, York and Durham regions must develop and implement an active SARS surveillance program. Screening of staff and visitors, in addition to restricting visitor numbers, continues to be an important part of the vigilant approach to surveillance.

Health care workers should wear N95 masks or equivalent in the operating room only if intubating or operating on a suspected SARS patient. For normal operating procedures, surgical masks should be worn. For high-risk procedures, see Directive to All Acute Care Hospitals for High-Risk procedures (Directive 03-11, June 16, 2003).

Directive 03-03(R), June 20, 2003 regarding the discharge of SARS patients still applies.
This Directive requires that a recovering SARS patient remain on isolation in the home, or designated care facility, for a total of 10 days after resolution of the fever (without antipyretic medication) with resolving (or resolved) cough. Recovering SARS patients (in either acute or convalescent stage) must not be discharged to non-acute care facilities (including long-term care facilities, complex continuing care hospitals, rehabilitation hospitals, provincial psychiatric hospitals and other residential facilities such as retirement homes and seniors' residences). This recommendation acknowledges the uncertainty regarding the transmissibility of this illness in the elderly.

Directive 03-02(R), June 25, 2003 regarding discharge of non-SARS patients and Directive 03-03(R) June 20, 2003 regarding the discharge of SARS patients still apply.
All patients (SARS and non-SARS) who pass the SARS screening tool upon discharge will be discharged under quarantine for the next 10 days. Therefore, a recovering SARS patient must remain on isolation in the home for a total of 10 days after resolution of the fever (without antipyretic medication) with resolving (or resolved) cough. Public Health must be notified of all discharges.

There are three inter-related strategies to the SARS strategy: identification; protection; and isolation. The early identification using active surveillance of potential cases of SARS in an environment where those most at risk are protected from exposure to SARS and those with SARS are isolated, contains the spread of the virus and keeps people safe.

An active surveillance program is part of the early identification strategy. While individuals are screened when entering the facility, it is important to have a mechanism to maintain vigilance with patients/residents who remain in the facility.
The active surveillance program requires staff to assess every patient daily for signs and symptoms of a respiratory illness: fever, cough, shortness of breath.
These assessments are reviewed daily by infection control staff to identify any situations which require further intervention and any patient or groups of patients with symptoms that should be reported to the local public health unit.

The intent of the active surveillance program is to identify patients at risk of respiratory infection. It is anticipated that every acute care facility will take the responsibility very seriously in terms of protecting their patients and their staff. It is anticipated that the presence of an active surveillance program will be part of the annual business plan for the facility.

The directives anticipate situations where negative pressure rooms are not available. Isolation rooms, private rooms and, least preferable, cohorting of like patients are all appropriate responses as required.

The directives continue to be rigorous around the need for personal protective equipment (PPE). The directives are more specific about the circumstances in which PPE is required. The use of PPE is part of a package that includes screening, active surveillance and heightened precautions in high-risk activities.
All three components are important both individually and as a coordinated response.

The response to SARS has been predicated on science as new information about this virus has come forward, and on the need for caution. While barrier masks would be sufficient for most droplet spread situations, the use of N95 or equivalent fit-tested masks was recommended by the Ontario SARS Scientific Advisory Committee for care of at-risk patients in high risk areas. This recommendation is supported by the Centers for Disease Control (CDC) as the most conservative approach.

The Protected Code Blue Team (PCBT) is designed to maximize safety for health care workers in situations where immediate response with limited information may be necessary. It is suggested that hospital management, in consultation with health care workers, develop a strategy for their organization that reflects the level of outbreak, the skill sets available and the safety of staff.

No. A hydrophobic submicron filter should be placed on the expiratory circuit of a ventilated SARS patient.

There is no requirement for staff who enter the room post-procedure to wear a full-hood PAPR. No staff who have been exposed after procedures are completed have become ill to date, and no transmission has occurred from patients once they are ventilated and stable. However, because the environment may become contaminated during a high-risk procedure, it is recommended that other procedures requiring prolonged exposure to the patient (e.g. central line insertion) be avoided until the room can be thoroughly cleaned (i.e. excess medications must be discarded at the end of the procedure, immediate clean up of room and equipment must be done in such a way as to reduce the re-release of aerosols, staff performing the procedure must ensure that contaminated equipment and surfaces are discarded/disinfected and cleaned before leaving the room, and potentially contaminated surfaces in the room must be wiped with a hospital approved disinfectant). If the patient is moved to a new room post-procedure (e.g. intubated in the Emergency Department, then transferred to ICU), the new clean room may be used as necessary.

1. Provide up-to-date education and information that emphasizes that most people are at low risk of contracting SARS.
2. Include information about SARS such as how to recognize the symptoms, the importance of regular hand washing and other infection prevention activities.
3. Ensure that people know where they can get more information or advice. The most recent fact sheets and other supporting materials for the public and for health care professionals can be found on the following Web site  :  www.health.gov.on.ca

It is recommended that CSS Agencies follow the same precautions that the CCACs do in your geographic area. For example GTA agencies should follow the same precautions as the GTA CCACs.

If there is SARS or suspected SARS in your region, agencies should call the SARS Operation Centre at 1-866-212-2272 for assistance.

Yes. If you are using precautions requiring the use of masks, you should be following the sections of the CCAC Directive which refer to fit testing.

Directive CC03-04(R), June 17, 2003
Personal protective equipment must be properly used and maintained consistent with the Occupational Health and Safety Act Reg. 67/93 s.10. N95 or equivalent masks must be qualitatively fit tested to ensure maximum effectiveness. (See NIOSH Web site - Publication No.99-143).

You might look for a local solution in your community by arranging to work with the local hospital or CCAC in their fit testing initiatives. This will enable you to provide fit testing services to your community-based service providers. In addition, there are travelling fit testing services being offered in communities across the province. By coordinating this process with other CSS agencies, institutions, facilities or programs, you may be able to arrange fit testing for your agency.
Many of the fit test providers offer Train-the-Trainer sessions. Depending on the provider, up to 20 staff can be trained at one time. Sessions range from two to four hours. Providers have several trainers and can train up to 120 staff a day.

See Masks for more information.

Agencies can be assured that all preventative measures and authorities have cleared a patient from hospital before discharge.

The hospital will perform the SARS Screening Tool prior to discharge. Patients who pass the screening tool will be discharged. These patients do not require quarantine, but they should self-monitor (or caregiver should monitor) for symptoms for the next 10 days. If symptoms develop, the patient or caregiver should contact Public Health.
Patients who fail the screening tool will be assessed medically by the hospital. If after medical assessment, SARS is not suspected, the patient is discharged with instructions to monitor for symptoms for the next 10 days.
If SARS is suspected, the hospital will not discharge the patient and will contact Public Health and hospital Infection Control.

Yes, CSS agencies can provide services at home to recovering SARS patients in the convalescent stage, if these services are essential. Consultation with the program supervisor, Public Health and the CCAC will assist in determining how necessary your services are at this time. However it is prudent to wait, if possible, until the 10-day isolation period has passed.

Staff and volunteers must use full protective precautions in the home when providing services to a recovering SARS patient for the full period the client is on home isolation. Full protective precautions include the use of gloves, gowns, protective eyewear and N95 masks or equivalent. As the patient may also be seen by the CCAC, it is advised to co-ordinate visits and care.

He/she should be transported in a private vehicle, and must wear a surgical mask. A medical transport service may be considered.

In this time of Ontario's efforts to contain the spread of SARS, the Ministry has directed all health care facilities to adopt increased alertness in the detection and monitoring (following up) of infectious respiratory illnesses. If a health care worker observes signs that the client may be ill, the worker should contact his/her supervisor for advice.
Signs of a respiratory infection are unexplained cough, difficulty breathing, with shortness of breath. Fever alone must be considered as a sign of potential infection, and should be considered even in the absence of other signs. The worker should immediately follow the instructions for routine practices (Enhanced), detailed in the CCAC Directive CC03-04(R) of June 17, 2003. The worker may continue to provide the care for which the visit was initiated on advice from the program supervisor.

Household members who are on home isolation should be wearing masks whenever they are in the same room with others. If agency staff is uncertain that this procedure is being followed then, they should wear full protective wear (N95 mask or equivalent, gloves, gown and protective eyewear) when providing in-home services.
For further information on fit testing, please refer to Masks.
Please note that this site is for health care workers only, and not for the general public.

Agencies should review with the local Medical Office of Health, the frequency of client screening required, based on the evaluated risk in a particular community.

Agencies providing in-home services should develop screening protocols that reduce the instances of multiple screenings. Where possible, agencies should work in cooperation with the CCAC and other service providers in the local community, basing screening on the evaluated risk in a particular community.

Depending where in the province they are located agencies should establish a screening program for staff, visitor and volunteers based in their various administrative sites. Taking into consideration the risk of transmission in each local community, the agency should establish the extent of screening for visitors to the site. Agencies may require staff to complete a daily self-assessment using the SARS Screening Tool when working off-site. In the event of a failed screen, the employee must not report for work and should be directed to contact TeleHealth Ontario at 1-866-797-000.

Employees may self-screen as they enter the agency for work using the SARS screening tool, but a responsible screener must still review the forms at every shift change. The forms are to be kept at the agency and not discarded without authorization.

It is recommended that agencies follow the same screening protocols that are followed by the CCACs and their service providers in the local area.

Spirometry should not be performed if you are considering a diagnosis of SARS in your patient because of possible exposure to respiratory droplets generated as a result of the expiratory effort. When doing spirometry in your office, gown, gloves, N95 or equivalent mask, and protective eye-wear must be worn if there is the likelihood that body substances will soil clothing, skin or mucous membranes.
To minimize exposure to respiratory droplets, stand either behind, or at least two metres in front of the patient.
If you are within two metres in front of the patient, wear an N95 or equivalent mask and protective eyewear. The two-metre distance gives you an extra margin of safety compared to the routinely advocated one metre distance for droplet spread of infection.
Gloves must be worn if you are handling the mouthpiece of the apparatus after it is used, and a gown added if you are concerned about soiling your clothing.
Other infection control procedures that must be used between patients are:

• using a disposable mouthpiece,
• cleaning the entire instrument in hot water with a mild detergent followed by high-level disinfection (e.g. immersion in 1:50 dilution household bleach or accelerated hydrogen peroxide product for 20 minutes) and a final tap water rinse.

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