News from the partners

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1 Editor: Dr Gordon Nichols Editorial Board: Prof. Jenny Kremastinou Assoc. Prof. Christos Hadjichristodoulou Dr Nicol Black Dr Clara Schlaich Dr Carmen Varela Martinez Mr Thierry Paux Dr Jelena Rjabinina Dr Barbara Mouchtouri Ms Elina Kostara Newsletter Secretariat and Content Managers: Elina Kostara Persa Tserkezou Graphic Design: Nick Bitsolas Next Issue: September 2011 Editorial Welcome to the June 2011 edition of the SHIPSAN TRAINET Newsletter. The SHIPSAN TRAINET project is attempting to improve hygiene inspections on passenger ships across Europe through developing common standards, arranging training and looking at harmonising inspections. We have started the pilot inspections in cruise ships from companies that have agreed to participate, and this should provide good feedback on both the usefulness of the Shipsan Inspection manual, the performance of Inspectors and the main areas where hygiene concerns are arising. The last few weeks have been marked by a very large outbreak in Germany of E. coli O104:H4 that carries the VT toxin gene. The outbreak has caused over 780 cases of Haemolytic Uremic Syndrome (HUS) and 35 deaths and 2,447 cases of non HUS diarrhoea. The organism has not previously been involved in an outbreak, has unique characteristics, and the Health Protection Agency has recently sequenced the genome. The outbreak highlights the need for continual vigilance in food hygiene and the importance of rapid outbreak investigation. Dr Clara Schlaich has provided SHIPSAN TRAINET with a communication about the Ship Sanitation Committee of German Federal States in relation to this outbreak. The SHIPSAN TRAINET project is organising the 3 rd Collaborative Group meeting and Final conference that will be on the 3rd and 4th of October 2011 to present the achievements of the project. The Editor, DrGordon Nichols Update on progress SHIPSAN TRAINET Pilot Inspections Pilot Implementation of the Communication network Read More News from the partners Hambourg Port Health Center Communication: Measures to be taken in the case of danger to ship s crews through radiation (sup plement) Ship Sanitation Committee of German Federal States Communication Outbreak of Haemolytic Uraemic Syndrome WHO Communication Guide to ship sanitation Read More People from the project Recent Publications International travel and health The 2011 version of the International travel and health book is now available. CDC Guidance for Cruise Ships on the Management of Varicella (Chickenpox) Nuclear accident in Japan and the shipping industry: After the tragic nuclear accident in Japan several countries have issued guidelines for the shipping industry aiming to protect seafarer s health. Large and ongoing outbreak of of haemolytic uraemic syndrome, Germany, May 2011 Read More Dr Nikos Mikelis from the International Maritime Organisation Read More Port of the Month Grand Harbour Malta Read More 1

2 Dear Readers, News from the leadership We are currently implementing the phase of the project where the pilot communication network and the pilot inspection programme are implemented. We would like to thank the port health authorities, the trainers and the cruise and ferry companies and crew for their enthusiasm and fruitful collaboration during the pilot phase. With the active participation of all interested parties we are certain we will be able to complete the pilot phase sucessfuly and to identify improvement possibilities and attain useful experiences. During the last two months the project leadership participated in the following meetings: On the 4 th April the project leadership participated in a high level ferry group meeting in Brusells with the European Community Shipowners Associations (ECSA). On the 5 th April a meeting was held in Brussels with representatives of DG MOVE and the Executive Agency for Health and Consumers. On the 23 rd May a meeting was held in London with the European Cruise Council (ECC) and Cruise Line International Association (CLIA). From the SHIPSAN TRAINET partnership the following participated: the project leadership, Dr Clara Schlaich (Germany), Dr Carmen Varela Martinez (Spain), Prof. Gordon Nichols (UK) and Prof. Chris Bartlett (UK) Finally, the SHIPSAN TRAINET 3 rd Collaborative Group meeting and Final Conference are currently being organised. The meetings will be held on the 3 rd and 4 th October 2011 in Athens, Greece. Assoc. Prof. Christos Hadjichristodoulou, Prof. Jenny Kourea Kremastinou, Dr Barbara Mouchtouri Dr Nikos Mikelis People from the project Graduated from the University of Newcastle upon Tyne with a Bachelors of Science in Naval Architecture. Postgraduate studies at University College London, for a Master of Science in Naval Architecture and then, while working for the University, a Doctorate of Philosophy in Numerical Hydrodynamics. After military service in the Hellenic Navy he worked at the headquarters of Lloyd s Register for nine years, rising to the rank of Principal Surveyor. From 1991 he worked for a Greek shipping company as Technical Manager and from 1995 as Director. In that period he became Council Member of INTERTANKO, Chairman of the "INTERTANKO Safety, Technical & Environmental Committee", member of the Safety of Navigation & Protection of the Marine Environment Committee of the Union of Greek Shipowners, and Chairman of the London Greek Technical Committee of Det norske Veritas. At the end of 2003 he started his own consultancy where he worked until employed by the International Maritime Organization in February 2006, where he currently is Head of the Marine Pollution Prevention and Ship Recycling Section. He has written more than 50 learned papers and numerous articles in the international maritime press. He is a freeman of the City of London. 2

3 Update on progress, News from the project and from the working groups Work Package 10: Pilot Communication Network Work Package Leader: University of Thessally The SHIPSAN TRAINET pilot implementation of the Communication Network THE SHIPSAN TRAINET designed a pre testing exercise. It started on the 14th March and finished on the 23rd of March. All participants worked through a fictional scenario of a gastroenteritis outbreak. During this pilot test, seventeen (17) Port Health Authorities from eight (8) different EU Member States (Cyprus, Greece, Italy, Spain, UK, Netherlands, Germany and Estonia) participated. A second pre test exercise is currently under development. Pilot Inspections A total of 17 inspections have been completed during the last 3 months (March, April, and May) in 6 European ports. The pilot inspections are conducted in collaboration with the participating authorities and the cruise ship and ferry companies and in accordance with a preapproved timetable from all interested parties. The first pilot inspections gave feedback to improve the pilot inspection report, to introduce the corrective action statement, to identify the appropriate roots of communications and to identify needs for training. For more information regarding the pilot inspections please contact us at: infoeushipsan@eu shipsan.gr SHIPSAN TRAINET PILOT INSPECTION SCHEDULE A total of 50 inspections have been scheduled from March till September March April May June July August September Chania, Greece Heraklio, Greece Piraues, Greece Barcelona, Spain Malaga, Spain Piraues, Greece Hamburg, Germany Limassol, Cyprus Tallin, Estonia Istanbul, Turkey Palermo, Italy Valetta, Malta Amsterdam, Netherlads Chania, Greece Heraklio, Greece Kiel, Germany Rhodes, Greece Piraues, Greece Patra s, Greece Civitavecchia Italy Participants: 47 inspectors, 6 trainers, 18 ports from 9 countries, 10 cruise and 6 ferry companies 3

4 International travel and health 2011 Recent Publications This book explains how travellers can stay healthy and provides WHO guidance on vaccinations, malaria chemoprophylaxis and treatment, personal protection against insects and other disease vectors, and safety in different environmental settings. It covers all the principal risks to travellers' health, both during their journeys and at their destinations. It describes all relevant infectious diseases, including their causative agents, modes of transmission, clinical features and geographical distribution, and provides details of prophylactic and preventive measures. This book is intended for the medical and public health professionals who advise travellers, but it is also a standard reference for travel agents, airlines and shipping companies and for travellers themselves. Read more: CDC Guidance for Cruise Ships on the Management of Varicella (Chickenpox) In most years, varicella, commonly known as chickenpox, is the most common vaccine preventable disease reported by cruise ships to the CDC Division of Global Migration and Quarantine (DGMQ) and is a frequent cause of outbreaks onboard cruise ships. Varicella is highly communicable, and secondary attack rates can be as high as 90%. Complications occur more frequently in persons older than 15 years, and as crew members and most cruise ship passengers are adults, outbreaks have the potential to involve more serious illness. Travelers at highest risk for severe disease are immunocompromised persons or pregnant women without a history of varicella disease or vaccination. A substantial proportion of crew members are from tropical countries where infection generally occurs at a later age than in temperate climates. Because of this differing epidemiology of varicella disease and lower rates of immunization, crew members are more likely to be susceptible to varicella than the general adult population in the United States. This document provides guidance to cruise ships for the reporting, investigation, management, and control of varicella related illness and deaths in cruise ship passengers and crew members traveling on international voyages destined for U.S. ports. Read more: cruise ships varicella.htm Large and ongoing outbreak of haemolytic uraemic syndrome, Germany, May Frank C, Faber MS, Askar M, Bernard H, Fruth A, Gilsdorf A, Höhle M, Karch H, Krause G, Prager R, Spode A, Stark K, Werber D, on behalf of the HUS investigation team. Euro Surveill. 2011;16(21):pii= Since early May 2011, an increased incidence of haemolytic uraemic syndrome (HUS) and bloody diarrhoea related to infections with Shiga toxin producing Escherichia coli (STEC) has been observed in Germany, with most cases in the north of the country. Cases reported from other European countries had travelled to this area. First results of a case control study conducted in Hamburg suggest an association between the occurrence of disease and the consumption of raw tomatoes, cucumber and leaf salad. Read more: Comment: Sprouted seeds are now implicated, based on epidemiological investigations. Nuclear accident in Japan and the shipping industry After the nuclear accident in Japan during March 2011 the IMO, WHO, the EU and port health authorities published a series of guidelines in relation to seafarer s health, measures for ships entering European ports, imported food safety, processing readioactive freights etc. Click on the links below for further information: European Union: World Health Organisation: International Maritime Organisation: radiation.aspx Port of Roterdam: regulations/port healthauthority/documents/img ENG.pdf Greek Atomic Energy Commission: 4

5 News from the partners Communication from the Hamburg Port Health Center regarding measures to be taken in the case of danger to ship s crews through radiation (sup plement) 16 March 2011 Dear Sir or Madam, Following numerous queries on the subject of protection against radiation/radioactive contamination of crew members on board merchant vessels, the Port Health Authority of Ham burg in cooperation with TMAS Germany and Dienststelle Schiffssicherheit, Seeärztlicher Dienst der BG Verkehr (Port State Control) is issuing the following information and advice, which make no claim to be exhaustive. (For information about the position and extension of the area considered to be endangered by radiation, consult the local official administration and use the following link by the BMU ((German Federal Ministry for the Environment, Nature Conservation and Nuclear Safety)).: /47088.php) 1. Avoid all activities outside the air conditioned superstructures. 2. In the sea area endangered by radiation, exterior work, maintenance work, paint work outside the ship s superstructures should be reduced to a minimum that meets the safety requirements on board. 3. Sailing within the evacuation zone, which also applies to the sea area around a damaged reactor, is strongly discouraged. 4. After leaving a sea area considered to be endangered by radiation, all ship s superstructures especially those housing the living quarters should be decontaminated with sea water (fire hose) as a temporary measure, starting with the sundeck or bridge. During these activities, the wearing of masks, protective goggles, rubber boots and, possibly, disposable protective suits must be observed. All persons participating in cleaning measures must shower several times directly afterwards under running water, using fresh water and liquid soap. Used clothing should be wrapped in a plastic bag and stored outside the accommodation in a dry place. In the next port of call the plastic bag should be checked by a radiation detection device. 5. Any necessary replenishment of ship s supplies should not be carried out in the sea area regarded as endangered, particularly no fresh fruit, fresh vegetables, fresh water seafood, fish, milk or mushrooms. There should be no production of drinking water from sea water in the area considered to be endangered; a sufficient amount of fresh water should be produced in sea areas considered to be safe and then bunkered. The subsequent economical use of this bunkered fresh water should be a matter of course. 6. Whether and, if so, in what quantities, iodine (iodine tablets) should be stored and used on board the ships as a protection against consequential damage to the thyroid gland from radioactive iodine depends on the availability of such medication. The directive is to be issued by the BMU (German Federal Ministry for the Environ ment, Nature Conservation and Nuclear Safety). The administration of any iodine medication is not recommended without having checked the radiation in the surrounding area and only under strong medical criteria. In Germany a protective intake of iodine tablets is required for a special group of people including children and pregnant women in a radius of 100km around an affected nuclear power plant. 7. Ballastwater loaded in a sea area considered to be endangered by radiation needs to be changed in open sea while the ship is sailing. Please consider the ships stability while doing these activities. You will find further information in the appendix and at the following links: Henning Leu, Port Doctor, Central Institute of occupational and maritime medicine, Ministry of health and consumer protection 5

6 Communication from the Ship Sanitation Committee of German Federal States in relation to the outbreak of haemolytic uraemic syndrome in Northern Germany th June 2011 RECOMMENDATION TO ABSTAIN FROM RAW SPROUTS! Since early May 2011 more than 2000 cases of EHEC and more than 700 cases of Haemolytic Uraemic Syndrome (HUS) with at least 20 deaths related to infections with Shiga toxin producing Escherichia coli have been observed in Germany, with most cases in the north of the country. HUS is a serious complication of the bacterial intestinal infections with Shiga toxin producing Escherichia coli (EHEC). The complete clinical picture is characterized by acute renal failure, haemolytic anaemia and thrombocytopenia. Also, neurological symptoms have been observed. Typically HUS is preceded by diarrhoea, often bloody. The infection can be transmitted directly or indirectly from animals to humans. Ruminants are considered to be the reservoir, especially cattle, sheep and goats. Transmission occurs via the faecal oral route through contact with animals (or their faeces), by consumption of contaminated food or water, but also by direct contact from person to person. The incubation period from the infection to the beginning of gastrointestinal symptoms is 2 to 10 days, the severe renal and gastrointestinal symptoms may occur up to a week later. Recommendations to the Shipping Industry: 1) Consumption of food: Based on the results of their case control studies the National Public Health Institute (Robert Koch Institute) and the Federal Institute for Risk Assessment (BfR) have today abandoned their recommendation to abstain from consuming raw tomatoes, cucumbers and leafy salads on June 10 th Instead, it is recommended to abstain from raw sprouts until further notice. Also, stocks of sprouts should be discarded. These recommendations may change at any time, please see for updates: enterohaemorrhagische_escherichia_coli 5233.html Please ask your ship supplying catering company to follow these recommendations. Continue to observe regular food hygiene rules on board of ship. Strict hand hygiene is emphasized. 2) Persons with (bloody) diarrhea on board of your ship On a cargo ship with no ship s Medical Doctor available. If a crew member falls sick with bloody diarrhea he/she should seek medical aid in the next possible port immediately. If this is not possible please contact the German Telemedical Maritime Assistance Service in Cuxhaven for further advice Tel: or medico@tmasgermany.de Notify the port health authority as soon as possible about the case of disease on board as required under the International Health Regulations (via Maritime Declaration of Health). The contacts of the German Port Health Authorities are found under: The Port Medical Officer will assess the risk of the disease under consideration of your itinerary. If necessary the service will assist in performing hygiene measures on your ship, to coordinate clinical care in the port and to initiate laboratory tests on board. While on board please isolate any sick crew member in his or her cabin (separate toilette necessary). Strict hand hygiene is the single most important measure when following up! For further details on hygiene measure please see the Guideline Nr. 3 of the Ship Sanitation 6

7 Committee of German Federal States: achment1.pdf On a passenger ship with a Medical Doctor available. If a crew member or passenger falls sick with bloody diarrhea he/she should disembark and be referred to medical care in the next possible port immediately for further diagnosis and care. Notify the port health authority as soon as possible about the case of disease on board as required under the International Health Regulations (via Maritime Declaration of Health). The contacts of the German Port health Authorities are found under: sanitation.de The Port Medical Officer will assist in performing necessary hygiene measures on your ship and will be supportive in coordinating clinical care in the port and to initiate laboratory tests on board. While the patient is under your care on board, follow the recommendations of the German National Public Health Institute (Robert Koch Institute) concerning diagnosis, treatment, and hygiene measures Please make sure that the crew has three negative stool cultures before returning back to work. You are reminded to take stool samples from persons with diarrhea. Please contact the port health authority in advance for support to initiate the stool diagnosis. Dr. med. Clara Schlaich, MPH Head of Hamburg Port Health Center Executive Director Ship Sanitation Committee of German Federal States Further Information on the outbreak of Haemolytic Uraemic Syndrome: European Food Safety Agency : European Center for Disease Prevention and Control: e a a&ID=435&RootFolder=%2Fen%2Fpress%2Fnews%2FLists%2FNews SHIPSAN TRAINET European Manual for Hygiene Standards and Communicable Diseases Surveillance on Passenger Ships Guideline II: Prevention and control of gastroeneteritis on passenger ships. This chapter sets out recommendations for all the professional groups involved in the control of gastroenteritis on passenger ships. The overview is followed by detailed guidance on how to recognise outbreaks of viral and bacterial gastroenteritis, the modes of transmission of all forms of gastroenteritis, control measures and the management of outbreaks. The layout of this chapter is suggested as a guide to ship operators, ships crews, port health authorities and others to enable them to conduct their own analysis of their vulnerabilities and to assist in identifying mitigation actions. Please click on the link below to download the European Manual for Hygiene Standards and Communicable Disease Surveillance on Passenger Ships: 7

8 WHO Communication Guide to ship sanitation Historically, ships have played a significant role in the global transmission of infectious disease. Some of the earliest recorded evidence of attempts to control human disease transmission via ships dates to the 14th century, when ports denied access to ships suspected of carrying the plague. In the 19th century, the spread of cholera pandemics was thought to have been facilitated by merchant shipping. A World Health Organization (WHO) review identified more than 100 disease outbreaks associated with ships between 1970 and 2003 (Rooney et al., 2004). Because of the international nature of ship transport, international regulations relating to sanitary aspects of ship transport have been in place for more than half a century. The International Sanitary Regulations of 1951 were replaced by the International Health Regulations (IHR) adopted by WHO in The IHR were revised at the Fifty eighth World Health Assembly in The WHO Guide to ship sanitation has become the official WHO global reference on health requirements for ship construction and operation. Its original purpose was to standardize the sanitary measures taken in ships, to safeguard the health of travellers and workers and to prevent the spread of infection from one country to another. Today, however, given the number of specific guidance documents, conventions and regulations currently available that provide full accounts of the design and operational detail relating to ships, the primary aim of the guide is to present the public health significance of ships in terms of disease and to highlight the importance of applying appropriate control measures. The guide was first published in 1967 and amended in This revised third edition of the guide has been prepared to reflect the changes in construction, design and size of ships since the 1960s and the existence of new diseases (e.g. legionellosis) that were not foreseen when the 1967 guide was published. The guide has been developed through an iterative series of drafting and peer review steps. In revising the guide, expert meetings were held in Miami, United States of America (USA), on 3 4 October 2001 and in Vancouver, Canada, on 8 10 October 2002 to discuss and recommend the proposed contents. Expert meetings to review the draft guide were held on 25 October 2007 in Montreal, Canada, and on October 2009 in Lyon, France. Participants represented cruise ship operators, seafarer associations, collaborating member states for the IHR 2005, port state control, port health authorities and other regulatory agencies. A complete list of contributors to the guide can be found in the Acknowledgements section. This third edition of the WHO Guide to Ship Sanitation is the official WHO global reference on health requirements for ship construction and operation. It presents the public health significance of ships in terms of disease and highlights the importance of applying appropriate control measures. It is intended to be a basis for the development of national approaches to controlling the hazards, providing a framework for policymaking and local decision making. It may also be used as a reference for regulators, ship operators and ship builders as well as for assessing the potential health impact of projects involving the design of ships. The Guide to ship sanitation and the International medical guide for ships (WHO, 2007) are companion volumes oriented towards preventive health and curative health, respectively, on board ships. ne/ships/en/index.html?bric_app_uri= 8

9 Port of the Month Grand Harbour Malta Grand Harbour Malta (Il Port il Kbir), the largest harbour in Malta, is a key Mediterranean crossroad and the single most important geographic feature of the country. The history of the Grand Harbour history began when the Phoenicians spread across the Mediterranean from about 1550 to 300 B.C., making port in Malta. But is seems clear that ancient mariners made their way here long before that.the islands of Gozo and Malta provide evidence that ancient mariners were present in the island before the Phoenicians. It is thought that the megalithic temples found here were build by mariners from Sisily between about 3000 and 2600 B.C. In fact, two of the ancient temples, the Hal Salflieni Hypogeum and the Tarxien Temples, are located very close to the port. The Knights of Malta, also known as the Knights Hospitaller or the Knights of Rhodes that ruled since 1530 for 268 years are the ones that transformed Malta from what they called at the time "merely a rock of soft sandstone", into a prosperous kingdom. The Grand Harbour in Malta was developed to be a major port for world commerce with formidable defences and massive forts. The Grand Harbour is on the southeast coast of the island, and actually consists of two twin harbours. The northern harbour is Marsamxett, forming the southern shore of the town of Sliema. The peninsula occupied by the city of Valletta separates Marsamxett from its sister harbour. The harbour mouth faces north east and is bounded to the north by St Elmo's Point and further sheltered by an isolated breakwater and is bounded to the south by Ricasoli Point. Its North West shore is formed by the Scebarras peninsula, which is largely covered by the city of Valletta and its suburb Floriana. The main waterway of Grand Harbour continues inland almost to Marsa. The south eastern shore of the harbour is formed by a number of inlets and headlands, principally Rinella Creek, Kalkara Creek, Dockyard Creek, and French Creek, which are covered by Kalkara and the Three Cities: Vittoriosa, Cospicua, and Senglea. The history of the Knights of Malta Grand Harbour began in these three cities, which comprised their headquarters when they first arrived from Rhodes. The six formidable citadels built by the Knights, protect the harbour in Malta and during the Great Siege of 1565 helped the vastly outnumbered Knights to repel the forces of the Ottoman Empire from Turkey, The Knights moved to Valletta where they continued building scores of cathedrals, churches, palaces, and grand summer villas. After a short rule of the French, Malta came under British Rule in The Treaty of Paris in 1814 officially recognized the British occupation of Malta and Malta went through a period of prosperity and the Grand Harbour became a flourishing naval base. 9

10 This harbour of exceptional importance, made huge steps as a military post and as a naval arsenal and was a secure place of depot for British merchants. Malta s central position in the Mediterranean was the reason that Britain established the HM Dockyard which originated at the Galley Creek and was to expand to French Creek. The history of this dockyard is an integral part of the Grand Harbour as it occupied vast areas for a long period of time. The Grand Harbour was to witness a great revival of shipbuilding and by 1820 established local ship constructors started to launch excellent merchant ships like the brig, the barque, the bombard and the schooner. During World War II the harbour area was bombed by Italian and German forces, as the docks and military installations around the port were strategically important. Much of Valletta and The Three Cities, including the now restored Pinto Wharves (Valletta Waterfront) were damaged and there were large numbers of civilian casualties. Operation Pedestal Convoy arrived in Grand Harbour in 1942 and helped save Malta from starvation and surrender. Today, much of the commercial shipping traffic has shifted to the Malta Freeport on the southern tip of the island near the town of Marsaxlokk, but large ships on Mediterranean cruises still come into Grand Harbour. It is said that a picture is worth a thousand words hope that the reader finds the time to view the selected videos!!! Valletta Waterfront Videos 3&clip[]=58 Grand Harbour and Valletta Videos Grand Harbour webcam References: Mr Mario Cassar, Senior Principal Environmental Health Officer, Environmental Health Directorate, Port Health Services, Malta The Bo sun s locker Quiz, Quiz, Quiz! Answer to Issue 13 quiz Cutty Sark the last tea clipper For further information: Congratulations to Mr John Sleith, Food and Safety Regulation Manager, Falkirk Council, Mr John Ambrose, Chartered Environmental Health Practitioner Port Health Officer/Quality Manager, London Port Health Authority and to Ms Persa Tserkezou, University of Thessaly, Greece. This month s QUIZ: What was the name of the first ship to bring cholera to the USA, what port did it land at and what was the date? Please send your answers to Ms Elina Kostara (elkost@med.uth.gr) no later than the 1 st August st 10