Notification to Public Health Authorities of Ill Passengers and Crew on Ships
According to its International Health Regulations of 2005, the World Health Organization (WHO) requires all ships to provide health authorities in every port with a completed Maritime Declaration of Health, reporting any case(s) of persistent fever, acute skin rash, severe vomiting (other than seasickness), severe diarrhea, and recurrent convulsions (Annex 8, www.who.int/ihr/en).
The CDC require the Master of a ship destined for a US port to report immediately any death or any ill person among the ship's passengers or crew. This includes those who have disembarked or have been removed from the ship due to illness or death. Any illnesses or deaths that occur during the 15 days before the ship arrives at the port, or during the period since the ship left a U.S. port (whichever period of time is shorter, must be reported immediately to the CDC Quarantine Station at or closest to the U.S. port or arrival. The doctor must advise the Master accordingly.
Any reports made to a Quarantine station is not instead of or in replacement of other applicable local, state and federal reporting requirements.
Handling and Treatment of Infections Caused by Specific Micro-Organisms
If there appears to be an outbreak aboard, efforts should be made to identify the causative organism by blood, vomit or stool samples and try to find the source as soon as possible. (Legionnaires’ disease: shower heads, hot tubs, fountains, air conditioners; enteric bacterial infections - suspected water, food and food handlers).
Acute Gastroenteritis - Outbreak Prevention and Control
Cruise ships are isolated communities with a high population density, crowded public rooms and living accommodation, shared sanitary facilities, and common water and food supplies. Hence, infectious diseases are easily transmitted aboard, and gastroenteritis has always been a major health concern aboard cruise ships. The doctor must immediately report any unusual number of cases (generally more than 10 per 7 day cruise or 6 cases within 6 hours) of gastroenteritis (diarrhea and or vomiting) to the Master and the MCA and keep them updated with regard to further cases.
As the North American market covers 2/3 of the global cruise volume, the US Centers for Disease Control and Prevention (CDC) established in the 1970s the Vessel Sanitation Program (VSP), and it has been regularly updated. All foreign vessels visiting US ports with 13 or more passengers are subject to a comprehensive reporting system prior to entering a US port, as well as twice-yearly inspections and, when necessary, re-inspections. Each inspection results in a sanitation score, which is posted on the internet (‘Green Sheets’). High scores are used by the companies and travel agents for sales promotion, while scores below 85 (of a total of 100 possible) points can stop a ship from sailing.
Cruise lines with ships that are not able – or willing to try - to pass US inspections can only visit ports with less rigorous sanitation demands. However, they should not feel too confident: The ‘European Centre for Disease Control and Prevention’ (ECDC) has been established and presently coordinates European actions to ’prevent and control norovirus outbreaks on cruise ships, including development of practical and standardized guidelines based on best practices identified from previous experience’ (http://www.ecdc.europa.eu/en). Other countries, such as Canada, Australia, and Brazil, have created their own programs, based on CDC’s VSP. Certainly more countries will follow, and hopefully they will not all attempt to ‘re-invent the wheel’. For the cruise industry it is very important to get the health authorities of
The VSP has proven an effective tool to keep all involved in sanitation on their toes. For many years ‘food poisoning’ was the most feared type of gastrointestinal illness on cruise ships, but lately gastroenteritis symptoms caused by norovirus have gotten much more attention. It usually causes vomiting, diarrhea and stomach cramping, lasts between 24 and 48 hours. It is very contagious and easily transmitted by person-to-person contact, making a closed environment like cruise ships a prime setting for an outbreak. Several ships have had to stop operations and cancel cruises following such outbreaks to decontaminate the vessels.
Since gastroenteritis outbreaks on ships are easy to spot and follow, norovirus have been referred to as the “cruise ship virus” or the “cruise bug” in media. This is rather undeserved, as the virus is always brought on board by someone or something from ashore. The risk of contracting norovirus is much greater shore-side than on a cruise ship, but outbreaks on land are far less visible – and seem to be of far less media interest.
Compulsory isolation of passengers and crew with gastroenteritis is a necessary measure to prevent and control norovirus outbreaks on ships. So far there is no quick diagnostic test for norovirus that has proven completely reliable. Therefore, to prevent outbreaks, cruise companies cooperating with US authorities demand that all patients with gastroenteritis symptoms are to be isolated for up to 3 days after their last symptom
Although viruses are shed longer than that, the danger of contamination is significantly reduced after the symptoms have subsided, especially if proper hand-washing procedures are followed. It is therefore a matter of continuous discussion how long and how rigorously the patients really must be isolated.
The Norovirus Working Group in UK has published a comprehensive European program, entitled ‘Guidance for the Management of Norovirus Infection in Cruise Ships’: http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1206520183347
Isolation is taxing, not only for the patient, but also for family and other travel and cabin mates, as well as for all the various ship employees who must get involved. The doctors’ unwanted role as warden puts a heavy strain on the doctor-patient relationship from the beginning. The medical staff members are regularly threatened, - with physical harm, poor service ratings or lawsuits, and all the extra work, especially during outbreaks, makes the MC staff less available for more serious emergencies. Furthermore, the obligatory isolation policy also increases the number of sick leave days for crew, and thereby impairs daily ship operations. And simple fear of isolation has kept patients from seeking prompt medical attention, thus delaying diagnosis and treatment of life-threatening illnesses, i.e. peritonitis following appendicitis.
Influenza Protocols and Recommended Measures
The medical staffs of ships visiting US ports, especially those on Alaska and Caribbean itineraries, are expected to do active surveillance for influenza according to CDC recommendations. This means that the MC must have test kits for influenza A & B, as well as recommended medication for prophylaxis and treatment (oseltamivir), and obtain from CDC’s web-sites (www.cdc.gov) the clinical algorithms, including recommended isolation for passengers and crew, respiratory illness surveillance forms and respiratory illness logs, if an increased number of cases are seen.
CDC recommends full crew vaccination every year and most cruise ships aim for more than 80% coverage, not only to achieve CDC goodwill, but also to protect their (old, frail) passengers and reduce the number of crew sick days.
The events around the 2009 A/H1N1 Influenza Pandemic highlighted the need for better global planning to ensure protection of those on vessels, protection for port of calls, and protection of business continuity. Where ports and their visiting ships had good working relationships, like in USA, processes ran smoothly and effectively. The European SHIPSAN project and Brazilian ANVISA collaboration also aim to improve cooperation in the passenger shipping sector,
Lower Respiratory Infections – Pneumonia – Legionnaires’ Disease
All patients with suspected or confirmed pneumonia (by chest x-ray) should have a Legionella Urinary Antigen test performed.
The doctor shall maintain an adequate supply of antibiotics to treat the pneumonia and other symptoms that could be caused by Legionella pneumophilia, with particular attention given during the flu seasons.
For additional information, see the Center for Disease Control's Vessel Sanitation Program Manual:
Measles, Mumps, Rubella (MMR) and Varicella
Major cruise lines now require proof of immunity of measles, mumps and rubella (antibodies or MMR vaccination) before hiring and some have added proof of varicella immunity as well. The onboard medical staff may have to immunize those without valid MMR certificates.
CDC has issued detailed ‘Guidance for Cruise Ships on the Management of Varicella (Chickenpox)’. Every varicella case aboard must be considered a potential index case and trigger a number of time-consuming and expensive measures to prevent or control outbreaks, including isolation and mass vaccination.
(http://wwwnc.cdc.gov/travel/page/guidance-cruise-ships-varicella.htm).Estimating need, ordering, obtaining, and transporting vaccines all over the world to ships that are often days at sea between ports are logistically demanding, time-consuming and costly measures. An extra challenge is the fact that the varicella vaccine should be administered in 2 doses 4-8 weeks apart. The second dose will be due after most passengers and many crew members have left the vessel.