Editorial. Quis custodiet ipsos custodes? Pilot training for the Seafarers and Health Professionals

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1 Editorial Editor: Dr Nicol Black Editorial Board: Prof. Jenny Kremastinou, Assoc. Prof. Christos Hadjichristodoulou, Ms Niamh McGrath, Mr Nigel Stewart, Dr Barbara Mouchtouri, Ms Elina Kostara, Newsletter Secretariat and Content Managers: Elina Kostara, Persa Tserkezou Graphic Design: Nick Bitsolas Contents News from the leadership People from the project Update on progress. News from the project and working groups The Bo sun s locker Quiz Forthcoming dates 4 Page Quis custodiet ipsos custodes? There is a paper published in Clinical Infectious Diseases 2009:49 titled Cruise Ship Environmental Hygiene and the Risk of Norovirus Infection Outbreaks: An Objective Assessment of 56 Vessels over 3 Years, which is particularly relevant to SHIPSAN. The investigators evaluated the thoroughness of disinfection cleaning of surfaces and objects with a high potential for faecal contamination in cruise ship public restrooms. They did this by covertly applying a transparent, easily cleanable solution to the target objects which, if not cleaned off, fluoresced under ultraviolet light, and examined them daily for the 5 7 days of the cruise. This method had previously been validated in health care settings. The key points from the paper for SHIPSAN are; 95% of cruise ship AGE outbreaks are caused by norovirus Norovirus survives on stainless steel surfaces for weeks at ambient temperature a single norovirus particle can cause infection environmental contamination is particularly relevant to norovirus transmission in cruise ships however well a person washes their hands after using the toilet, prevention of transmission is unlikely when there is a high likelihood of becoming infected by touching contaminated toilet objects (door handles, etc) enhanced standards are needed for continual monitoring and improvement in toilet cleaning Interestingly, the researchers found no correlation between the thoroughness of disinfection cleaning score with the VSP inspection score. The VSP manual mandates that toilet and hand washing facilities be convenient and accessible in design and installation and that there is maintenance of hand cleanser, sanitary towels, waste receptacles and hand washing signs and recommends cleaning and disinfecting all public areas, including handrails and restrooms, on a continuous basis until the proportion of cases decreases to <2% during norovirus outbreaks. The authors conclude that the data from this study suggests that the VSP inspection criteria have "low sensitivity for identifying shortcomings in actual public restroom environmental hygiene practice". This aspect of the study is particularly pertinent to SHIPSAN. If the long established VSP program is not shown to correlate with good hygiene in practice, then how will SHIPSAN? Unless we can show how we will achieve the authors conclusion that enhanced standards are needed for continual monitoring and improvement in toilet cleaning, then it is possible that we will not be effective in our goal of preventing viral acute gastroenteritis outbreaks. A great deal of effort has gone on this year to produce the SHIPSAN manual, which is nearing completion in its final form. The summary of the meeting in Luxembourg gives more details. We aim to be evidence led. We should reflect on the evidence from this simple yet elegant study and ask ourselves how we are going to meet the challenge that this study presents us. Dr Nicol Black, SHIPSAN TRAINET Editor What s new on the website Hot Issues/Outbreaks News from the industry Port of the month News from the partners Pilot training for the Seafarers and Health Professionals SHIPSAN TRAINET will pilot test training modules for the health professionals working in EU ports and seafarers and will deliver a train the trainers course. First of all a train the trainers module will be held, where 6 experts will be training a total of 10 trainers. Then the 10 trainers will be delivering training modules to the port health officers and the seafarers. The subjects covered by the training will include issues addressed in the ship sanitation manual and on the standards the manual will be setting for the cruise ship industry in terms of hygiene and communicable disease surveillance. i.e (i) HACCP, food safety, drinking and recreational water safety, pest control, waste and ballast water management, housekeeping and infection control, equipment and facilities maintenance, IHR practical implementation (ii) Surveillance, outbreak investigation and management, contact tracing, guidelines on NoV and Legionnaires outbreaks prevention. A total of 5 training modules will be implemented: 3 training modules for the seafarers (2 modules for the cruise ship seafarers and 1 for the ferry seafarers) and 2 modules for the health professionals. The number of participants from the health professionals for the pilot implementation modules has been agreed to be 17 per training module. The training modules have been scheduled to take place during autumn 2010 and winter Specific dates and locations will be published in due time. In order to select the trainers for the training modules, the partnership will be publishing a Call for Tender in the website. 1 Dr Gordon Nichols, Dr Carmen Varela Martinez, Assoc. Prof. Hadjischristodoulou

2 News from the Leadership We would like to wish to all of you Merry Christmas and a prosperous and creative New Year. We have now reached the 13th month out of the 30 which make up the project s life span. We would like to thank the associated and collaborating partners for their contribution to the 2nd Collaborative Group Meeting in November Particularly, we would like to extend a special thanks to Dr Carmen Varela Santos from ECDC, Dr Daniel Menucci from WHO, Mr Nikolas Mikelis from IMO, Mr Ivo Snijders from Paris MoU, Capt. Jaret Ames from the VSP, the industry representatives Mr John Kutil, Mr Many Rivas and Dr Tim Lammerding, and for their continuous support and guidance. Thanks to everyone s contribution to the 2 nd Collaborative Group Meeting in Luxembourg we were able to address the issue of the sustainability of the project and to explore different possibilities for a legal basis. One important outcome was the consensus of the advisory board and steering committee to kick start consultation meetings with the competent authorities of Member States and with EU bodies such as EMSA. Moreover, SHIPSAN sees a value in combining the WHO ship sanitation certificate inspections with SHIPSAN inspections during the pilot phase of the communication network. Pre testing of the communication network prior to the pilot testing will be organised, involving different Member States and different competent authorities. In addition, the expansion of the communication network during the pilot phase will be explored not only for EU but also non EU countries. Regarding the training modules for seafarers and port health officers, SHIPSAN will work closely with WHO for IHR related training material and with ECDC for communicable disease surveillance and response related training material. Finally, SHIPSAN s collaboration with Paris MoU will be enhanced since the latter has vast experience in developing and delivering training modules. Assoc. Prof. Christos Hadjichristodoulou, Prof. Jenny Kourea Kremastinou Mr Matthijs Plemp People from the Project As being an advisor for the Dutch Centre for Hygiene and Prevention (LCHV RIVM) I got involved in the new Shipsan Trainet program since November Together with Corien Swaan and Linda Verhoef (both from RIVM) we `re part of the Dutch participation with the program. It is with most pleasure to see how the program evolves and how dedicated everyone is. For that it is easy to assist the programme management with input concerning (food) hygiene, HACCP and quality management. With a background in veterinarian hygiene in combination with the technical knowledge I gathered during my years as plant manager in the food industry I for sure feel myself at home in the world of hygiene on board of cruiseships. Together with the experiences I gained during the development of the WHO IHR Ship Sanitation programme in The Netherlands I hope to add a valuable contribution to Shipsan Trainet. 2

3 Update on progress, News from the project and from the working groups 2 nd Collaborative Group Meeting, Location: Luxembourg Date: November2009 The meeting gave the SHIPSAN partnership the opportunity to discuss and assess important aspects of the project in terms of the work currently under development as well as the future implementation of the project. During the two day meeting, participants also had the opportunity to review the Ship Sanitation Manual. A total of 41 representatives participated from 11 EU countries, the EC Health and Consumers Directorate C, the EC Executive Agency for Health and Consumers, the European Centre for Diseases Prevention and Control, the EURO WHO, the International Maritime Organisation, the Paris Memorandum of Understanding (MoU), the US Vessel Sanitation Programme, the UK Association of Port Health Authorities and the cruise ship industry. 3 rd Working Group Meeting Location: Luxembourg Date: 13 th November 2009 The objectives of the meeting were the discussion of trainers selection criteria and the training material. SHIPSAN TRAINET has to develop training material for the seafarers and port health authorities for the implementation of the Ship Sanitation Manual. During this WG meeting the participants discussed the topics, structure and the location of the training modules. Moreover, Mr Ivo Snijders, Secretary of Paris Memorandum of Understanding (MoU), presented Paris MoU training policy, the training modules, the distant learning and the evaluation of their programmes. Finally, the group discussed the trainers selection criteria list. The group concluded that a combination of trainers from different disciplines should be used (experts, experienced persons from the industry and inspectors). Moreover, the possibility to conduct the training modules on board a cruise ship during the winter time will be explored and a new plan with training dates and locations will be disseminated to the group for a final decision. Finally, the group will examine the possibility to also use facilitators for the training modules, especially for the practical training section. 3

4 Work Package 7: Training Material Development Start Date: 20th July 2009 Completion Date: 20th April 2011 Work Package Leader: Health Protection Agency, UK The training materials for Shipsan Trainet are being designed by the Health Protection Agency in the UK. The first stage of this Work Package was a review of existing training programmes on issues relating to ships, port health and environmental health. Materials such as photos demonstrating good and bad practice on ships and data for case studies are still being sought. Study plans have now been distributed to the authors of the manual chapters, and should give an insight into how authors envisage the content should be taught and aid us in deciding the overall structure of the four day course. The study plans received to date suggest that a combination of lectures, case studies, seminars and practical sessions are required. The structure of the training was discussed at the 3 rd Working Group Meeting in Luxembourg on 13 November. The possibility of performing some of the training on board a ship was discussed and is being further investigated. Following the meeting in Luxembourg, work on the Shipsan Trainet training materials began in earnest. The Communicable disease surveillance, gastroenteritis and airborne infection module is currently being drafted and we hope to have it ready for review in December. Dr Gordon Nichols The Bo sun s locker Quiz, Quiz, Quiz! The question in the last issue was who owns the Wallace Line? As you rightly guessed, it s not a cruise company; it s the scientific demarcation separating Asia from Oceania. Being a geophysical convention, I suppose it s owned by everyone, rather like the International Date Line. However, I m declaring the indefatigable Keith Rowlands from Anglsey the winner, as he was the only person to reply (and was nearly right!). Keith is our undisputed reigning champion of the quiz, but that shouldn t put you off trying as well (hint some more entries would be good!). For this issue I thought I would try and invoke some sunshine. Lots of people from Europe will be heading to the Caribbean for their cruises in the next few months. White beaches, warm sun, palm trees, rum punch and, of course, the stories of the buccaneers! Nowadays they are probably all tax men but the picture of the bearded pirate with the parrot on his shoulder saying pieces of eight is the stuff of legend. So, the question this time is how many pieces of eight were there in a doubloon? As always, answers to Elina (elkost@med.uth.gr) by 1st January please. What s new on the website? The SHIPSAN TRAINET Communication Network is currently being developed. The following databases will be available in the password restricted area of the portal: (i) a port registry including contact details of 355 ports, (ii) a port health authority, (iii) competent authority and (iv) industry database, (v) a case/ event database, (vi) a port health authority alert database and (vii) an inspection results and inspection reports database. The pilot phase for the SHIPSAN TRAINET communication network is scheduled to be implemented during the last 6 months of the project. Nick Bitsolas Forthcoming Dates WHO Informal technical consultation meeting: IHR Implementation and public health measures in response to public health emergency at ports, airports and ground crossings. Location: Lyon, France Date: December 2009 The Editor SHIPSAN TRAINET will be presented as regional experience during the meeting in Lyon. 4

5 SafeSeaNet Hot Issues/Outbreaks/Scientific Meetings A European data exchange system for reporting formalities in for ships arriving in and/or departing from ports of the MS A proposal has been submitted by the European Commission to the European Parliament on the reporting formalities for ships arriving in and/or departing from ports of the Member States (MS) of the community. Useful information could be attained for the current activities of SHIPSAN TRAINET project. Existing legislation and the need for a new directive There are currently more than 15 Directives or Regulations obliging the shipping industry to send specific information to the port authorities prior to their entry into port. The International Maritime Organisation through the Convention on Facilitation of International Maritime Traffic (1965) (FAL convention) aimed to facilitate and harmonise at a global level the administrative formalities to which ships entering or leaving ports are subject to. In accordance with the FAL Convention, the Directive 2002/6/EC entered in force requiring MS to establish computerised data exchange systems and to develop the necessary infrastructure. A study conducted by EMSA in 40 European ports identified that although the Directive 2002/6/EC is well implemented, the simplification aimed at, was not achieved and duplication and non harmonization of communication procedures was evident. Proposal for a directive on reporting formalities for ships arriving in and/or departing from ports of the MS The proposal for a new Directive, replacing Directive 2002/6/EC on the same subject, aims to facilitate maritime transport by simplifying certain administrative procedures for ships arriving in or departing from EU ports. The vision of the proposed Directive is to create a maritime transport space without barriers. In particular, the Commission proposal addresses (i) the harmonization of deadlines for notification of entry into port (ii) the appointment of one competent authority at national level for the collection of information that will be sent electronically through the SafeSeaNet system (iii) reporting requirements of EU directives if they do not exist under FAL convention (iv) the use of electronic means of transmission in alignment with the Directive 70/2008/EC entering into force on 15 th February 2013 on a paperless environment for customs and trade (v) the exemption to transmit a FAL form if the information requested is already required by EU legislation and for intra Community operations. The benefits of the proposed Directive, as outlined in the Commission s proposal, are that the national authorities will have fewer checks to carry out and the use of computerized communication methods will enable checks not covered by the proposal to be better organized, whilst improving their efficiency. SafeSeaNet SafeSeaNet is a community maritime data exchange system between maritime administrations of the EU MS based on the concept of a distributed database that has been developed and implemented under the leadership of the European Commission. Since October 2004, the European Maritime Safety Agency (EMSA) has taken over the management of the system. The main objective is to aid the collection, dissemination and harmonised exchange of maritime data. The system covers EU MS plus Iceland and Norway and involves different authorities per country both at a local and central level. SafeSeaNet functions as a central hub for all communication between data requesters and data providers. The main benefits of the system as they are outlined in the Global Implementation Plan Set up of the SafeSeaNet Architecture is that it will facilitate the communication of the competent authorities at local/regional level and the central authorities and their activities with regards to (i) prevention of accidents at sea and marine pollution, (ii) efficient implementation of EU maritime safety legislation (iii) collection and dissemination of data related to maritime activities (iv) harmonized exchange of this data. The objectives of the SafeSeaNet system present similarities with the objectives of the SHIPSAN TRAINET project in terms of harmonization and facilitation of the exchange of data between different authorities and MS. When SHIPSAN will be exploring the possibility of the legal basis for a potential permanent implementation, the proposed new Directive could be taken into consideration. Finally, the possibility and means for SHIPSAN to be incorporated in the SafeSeaNet system could be explored. For Further Information: d=114 Mrs Elina Kostara, Dr Barbara Mouchtouri, Mr Thierry Paux References IMO, Convention on Facilitation of International Maritime Traffic, (FAL Convention), EC, Proposal for a Directive on reporting formalities for ships arriving in and/or departing from ports of the Member States of the Community and repealing Directive 2002/6/EC, , COM(2009) 11 final EC, Directive 2002/6/EC on reporting formalities for ships arriving in and/or departing from ports of the Member States of the Community. EC, Directive 70/2008/EC on a paperless environment for customs and trade. SafeSeaNet, Global Implementation Plan Set up of the SafeSeaNet Architecture, Version 1.0 5

6 Recent Publications Cruise Ship Environmental Hygiene and the Risk of Norovirus Infection Outbreaks: An Objective Assessment of 56 Vessels over 3 Years Clinical Infectious Diseases 2009:49 Philip C. Carling, Lou Ann Bruno Murtha, and Jeffrey K. Griffiths Background. Norovirus infection outbreaks (NoVOs) occur frequently in closed populations, such as cruise ship passengers. Environmental contamination is believed to play an important role in NoVO propagation. Methods. Trained health care professionals covertly evaluated the thoroughness of disinfection cleaning (TDC) of 6 standardized objects (toilet seat, flush handle or button, toilet stall inner handhold, stall inner door handle, restroom inner door handle, and baby changing table surfaces) with high potential for fecal contamination in cruise ship public restrooms, by means of a previously validated novel targeting method. Results. Fifty six cruise ships (30% of 180 vessels operated by 9 large cruise lines) were evaluated from July 2005 through August Overall, 37% (range, 4% 100%; 95% confidence interval, 29.2% 45.4%) of 8344 objects in 273 randomly selected public restrooms were cleaned daily. The TDC did not differ by cruise line and did not correlate with the Centers for Disease Control and Prevention (CDC) Vessel Sanitation Program inspection scores (r2,.002; P=75). More than half the vessels had overall TDC scores <30%, although several of these lowscoring ships had near perfect CDC sanitation scores. The mean TDC of the 3 ships evaluated within 4 months before a NoVO (10.3%) was substantially less than the mean TDC of the 40 ships that did not experience NoVOs (40.4%) (P <.004). Conclusions. An objective evaluation of public restroom environmental hygiene on 56 cruise ships found that only 37% of selected toilet area objects were cleaned on a daily basis. Low TDC scores may predict subsequent NoVO prone vessels. Enhanced public restroom cleaning may prevent or moderate NoVOs on cruise ships. Available from: We would like to point out certain limitations of the study. The correlation of the TDC with the VSP score was made using the overall score of inspections and not the score of the individual items referring to cleaning and disinfection. Assoc. Prof. Hadjichristodoulou Estimating the Risk of Communicable Diseases aboard Cargo Ships Journal of Travel Medicine, Volume 16 Issue 6, Pages Clara C. Schlaich, MD, PhD, MPH, Marcus Oldenburg, MD, PhD, and Maike M. Lamshöft, Dipl. Public Health (MPH) Background. International travel and trade are known to be associated with the risk of spreading communicable diseases across borders. No international surveillance system for infectious diseases on ships exists. Outbreak reports and systematic studies mainly focus on disease activity on cruise ships. The study aims to assess the relevance of communicable disease occurrence on cargo ships. Methods. Retrospective analysis of all documented entries to 49 medical log books from seagoing cargo ships under German flag between 2000 and Incidence rates were calculated per 100 person years at sea. Case series of acute respiratory illness, influenza like illness, and infectious gastrointestinal illness affecting more than two persons within 1 successive week were classified as an outbreak. Attack rates were calculated based on number of entries to the medical log book in comparison to the average shipboard population during outbreak periods. Results. During more than 1.5 million person days of observation, 21% of the visits to the ship's infirmary were due to presumably communicable diseases (45.8 consultations per 100 person years). As many as 33.9 patients per 100 person years sought medical attention for acute respiratory symptoms. Of the 68 outbreaks that met predefined criteria, 66 were caused by acute respiratory illness with a subset of 12 outbreaks caused by influenza like illness. Attack rates ranged between 3 and 10 affected seafarers per ship (12.5& 41.6% of the crew). Two outbreaks of gastrointestinal illness were detected. Discussion. Respiratory illness is the most common cause of presumably communicable diseases aboard cargo ships and may cause outbreaks of considerable morbidity. Although the validity of the data is limited due to the use of nonprofessional diagnoses, missing or illegible entries, and restriction of the study population to German ships, the results provide guidance to ship owners and to Port Health Authorities to allocate resources and build capacities under International Health Regulations Hepatitis E Outbreak on Cruise Ship Emerging Infectious Diseases, Volume 15, Number 11 November 2009 Bengü Said, Samreen Ijaz, George Kafatos, Linda Booth, H. Lucy Thomas, Amanda Walsh, Mary Ramsay, and Dilys Morgan, on behalf of the Hepatitis E Incident Investigation Team In 2008, acute hepatitis E infection was confirmed in 4 passengers returning to the United Kingdom after a world cruise. Epidemiologic investigation showed that of 789 persons who provided blood samples, 195 (25%) were seropositive, 33 (4%) had immunoglobulin [Ig] M levels consistent with recent acute infection (11 of these persons were symptomatic), and 162 (21%) had IgG only, consistent with past infection. Passenger mean age was 68 years. Most (426/789, 54%) passengers were female, yet most with acute infection (25/33, 76%) were male. Sequencing of RNA from 3 case patients identified hepatitis E virus genotype 3, closely homologous to genotype 3 viruses from Europe. Significant association with acute infection was found for being male, drinking alcohol, and consuming shellfish while on board (odds ratio 4.27, 95% confidence interval , p = 0.019). This was probably a common source foodborne outbreak. Available from: 6

7 News from the Industry WORLD S MOST REVOLUTIONARY CRUISE SHIP OFFERS UNPARALLELED VACATION EXPERIENCE Architectural marvels at sea, Royal Caribbean International s Oasis of the Seas and Allure of the Seas span 16 guest decks and feature the cruise line s new neighborhood concept, seven themed areas throughout the ship that offer different guest experiences, depending on their personal styles, preferences or moods. Inspired by seaside entertainment esplanades, Boardwalk engages the entire family whether young or young at heart with eateries, retail outlets, games, and an original, handcrafted carousel the only at sea. Nine decks above, the first zip line at sea whisks guests from end to end on a thrilling aerial adventure. Boardwalk leads to the AquaTheater at the stern of the ship, where the amphitheater another first at sea offers a guest pool by day and a performance venue at night, featuring dramatic acrobatics and high diving, synchronized swimming, and elaborate fountain shows synchronized to music and lights. The cruise line s signature Royal Promenade, the heart of the ship, includes a mezzanine level that overlooks the main boulevard of boutiques, restaurants, bars and entertainment lounges below. The Rising Tide bar, the first moving bar at sea, offers guests the opportunity to enjoy a cocktail as it slowly ascends into Central Park, the neighborhood above. Central Park, a revolutionary design in which the center of the ship opens to the sky, features lush, tropical grounds spanning the length of a football field. With its serene pathways, seasonal flower gardens and canopy trees, Central Park evolves from a tranquil and peaceful atmosphere during the day to a gathering space for alfresco dining and entertainment in the evenings. The Pool and Sports Zone features a sloped entry beach pool (exclusive to the Oasis class ships) and two FlowRider surf simulators, each larger than those found on the Freedom class ships. Building on Royal Caribbean s popular Vitality wellness program, guests can soothe mind, body and soul in the Vitality at Sea Spa and Fitness Center, which also includes a dedicated spa area just for teens. Entertainment Place includes the cruise line s signature after dark spaces in more intimate venues that offer a variety of entertainment options. And the Youth Zone offers a wealth of kid and teen friendly programs, featuring the cruise line s first nursery for infants and toddlers (six months or older). Oasis of the Seas and Allure of the Seas also debuts new categories of onboard accommodations. Park View and Boardwalk View balcony staterooms will face inward and overlooking the open air neighborhoods. Another industry first, new contemporary bi level loft suites with double height, floor to ceiling windows will offer incomparable vistas of the sea and feature LCD televisions, separate vanity areas, a downstairs guest bathroom and an upstairs master bathroom that feature his and hers shower heads and limestone mosaic tile accents. Oasis of the Seas began service in December 2009, with Allure of the Seas to follow one year later. Both ships will sail alternating sevennight Eastern and Western Caribbean itineraries from Port Everglades in Fort Lauderdale. For more information or to book a cruise, please contact your travel agent, call (800) ROYAL CARIBBEAN, or visit Mr Manny Rivas, Royal Caribbean International, Celebrity Cruises and Azamara Cruises 7

8 Port of the Month Mahon Harbour, Spain Mahon Harbour, on the East coast of Menorca (the second largest of the Spanish Balearic islands), is one of the largest natural harbors in the world, a deep inlet extending some five kilometers inland. Strategically placed in the centre of the west Mediterranean, its importance had been recognized since classical times, when the island was occupied by the Carthaginian general Mago, brother of Hannibal who gave his name to the town and harbor, later the Romans referred to the town as Port Magonis. The British gained sovereignty in Menorca in 1713, with the signing of the Treaty of Utrecht, and the harbour was chosen by Admiral Nelson as the base for the British Mediterranean fleet. Rivalry between the British and French during the 19th century was evident in Menorca, which was on the shipping routes used by both the British and the French, between Toulon and Algeria, and Gibraltar and Malta. Menorca was finally handed back to the Spanish, after British sovereignty was brought to an end under the signing of the Treaty of Amiens in Nowadays in Mahon harbour you will see everything from the local fishing boats to luxury yachts, cruise ships of various sizes and navy cutters. It also has the principal cargo port of the island. At the northern entrance of the Mahon harbor lies the La Mola peninsula that encloses a military fortress. In the centre of the port is the Isla del Rey, an island with buildings from the 18th century. Nearby, on Lazareto Island, there is a public health facility comprising 12 hectares that belongs to the Ministry of Health which is also used as a summer residence for civil servants and for hosting scientific events. Its construction goes back to 1793 and in the XIX Century it was used as a lazaret (quarantine station for maritime travelers and ships). Camen Varela Martinez 8

9 News from our Partners MINISTERIO DE SANIDAD Y POLÍTICA SOCIAL TRAINING COURSE FOR FOREIGN HEALTH MEDICAL DOCTORS (Cartagena, Spain, October 2009) Dr. Miguel Dávila Cornejo Head of the Unit of International Alerts Subdirectorate General of Foreign Health Directorate General of Public Health and Foreign Health Ministry of Health and Social Policy, Spain First of all, I d like to thank all the people who have collaborated in the organization of the course as well as all the course attendees for their enthusiasm in taking part in this simulating exercise. I would also like to thank my colleagues in the Ministry of Health for their help in the elaboration of this report that pretends to be useful for those who deal with situations like these. The Subdirectorate General of Foreign Health, belonging to the Ministry of Health and Social Policy of Spain, has been organising on an annual basis a training course for medical doctors dealing with sanitary control on international borders. The course always takes place in a city which has an international port as it s intended to be practical. This year, the course was held in Cartagena on October We d sincerely like to thank Daniel Menucci (WHO), Carmen Varela Santos (ECDC) and Carmen Varela Martinez (SHIPSAN TRAINET) for their participation in the course as observers. Their comments were very useful for all of us. OBJETIVES OF THE COURSE The main goals of the course were the following: 1. To train Foreign Health sanitary staff when they have to face with a sanitary incident on board, according to the International Health Regulations To acquire knowledge regarding sanitary inspections on ships and to put in practice the inspection procedures on board. STRUCTURE OF THE COURSE The course was divided into two separate parts: Theoretical part: discussion on different aspects regarding Maritime Administration, sanitary inspections etc. Practical part: 1. Active participation in the exercise FAMEX Sanitary inspection on a ship EXERCISE FAMEX 09 Background Since 2006, the Subdirectorate General of Foreign Health of Spain has been taking part in an exercise called FAMEX, organized on an annual basis by the Spanish Army. Different scenarios are simulated in the exercise with the participation of several national institutions (Maritime Administration, Spanish Sea Rescue, Red Cross, Police etc.). Foreign Health participates in those scenarios simulating emergencies of public health concern in maritime borders. This year, a general scenario representing a fight against piracy was proposed and other scenarios were simulated as well. Foreign Health took part in two of them: Scenario IX: suspicion of anthrax on board Scenario XI: arrival of a ship with a great number of irregular immigrants in bad sanitary conditions on board. Unfortunately, this scenario had to be cancelled due to the adverse weather conditions. Objectives of the exercise General objectives o To check the immediate response of Foreign Health in the presence of an emergency of public health concern in maritime borders. o To evaluate the coordination among different institutions involved in situations like these. Specific objectives o To test the Foreign Health protocol for these situations. o To test the internal and external communication flow. o To test the Personal Protective Equipment (wearing and removal). o To establish links of collaboration with the other institutions involved. Description of the scenario Arrival of a merchant ship coming from North Africa. The ship was carrying in a hold some livestock hides acquired in that port. Five crew members showed symptoms suggesting Bacillus Anthracis infection. All of them had been manipulating the boxes containing the hides. Foreign Health was immediately informed and the protocol regarding emergency of public health in frontiers was activated. The ship was denied to enter the port until the situation was had been evaluated. A Foreign Health team was created in order to plan the response to this situation of public health concern. After collecting all the available information and after evaluating the situation, three medical doctors were taken to the ship together with the Civil Guard (institution in charge of evaluating the situation in the suspicion of a terrorist attack) The Civil Guard took several environmental samples demonstrating the presence of B. Anthracis only in the hold where the hides were been carried. Once a bioterrorist attack was ruled out, the Foreign Health medical doctors embarked the ship to evaluate the patients and organize the subsequent evacuation. Then, Foreign Health medical doctors authorised the ship to enter the port. The patients were disembarked, decontaminated and transferred to the health care facilities that had been put up in the port, where the Red Cross gave them first aid. The rest of the crew members were evaluated in a separate tent where five Foreign Health medical doctors carried out epidemiological surveys. Medical doctors involved in the assessment on board were also decontaminated and the hold was cleaned and 9 disinfected.

10 Evaluation of the exercise The main goal of the evaluation is to identify the positive and negative aspects of the intervention in order to draw conclusions and improve the procedures in situations of public health concern. Positive aspects 1. Joint preparation of the exercise the previous day. 2. Leadership of Foreign Health as the Port Health Authority. 3. The initial meeting in the port with all the actors in order to plan the response 4. The communication flow with the superiors 5. The permanent and fluent communication between the sanitary team on board and the leader of the team in the port. 6. The rapidity of decision making of the sanitary team Aspects to be improved 1. Information regarding last ports of call was not requested (not the last one, but the previous ones) 2. The possibility of existing of more contaminated goods in the North African port that could require an international communication was not investigated 3. The leader of the sanitary team didn t order the ship to raise the yellow flag 4. The Foreign Health sanitary team on board: a. Didn t have their clothes marked with their names, so they couldn t be recognised b. Didn t establish any communication with the members of the Civil Guard on board c. Worked together all the time instead of distributing their duties on board. 5. Ship documentation was not evaluated and no further action was taken on it (SCC, Free pratique certificate etc.) 6. Privacy was not respected during the epidemiological surveys 7. Notification to National Focal Point was not performed in order to communicate to WHO and EWRS 8. It was not determined when the ship, not only the persons, shouldn t be considered as a risk for public health. Conclusions of the exercise In general terms, the evaluation of Foreign Health intervention in the exercise can be considered as very positive. The position of leadership of Foreign Health and its role coordinating all of the actors is an important characteristic that must be strengthened. We can also conclude that it s very important to have a Manual of procedures to help sanitary staff to deal with these situations. This Manual must be checked in simulating exercises in order to improve it. The collaboration among different institutions worked well, always under the leadership of Foreign Health. It s important to emphasise the role played by the Red Cross as a collaborative institution that made available to Foreign Health all their human and material resources. The Civil Guard played also an important role working under the orders of Foreign Health once a bioterrorist attack was ruled out. Recommendations 1. To develop agreements and Memorandum of understanding among different stakeholders in order to perform a joint intervention in case of situations of public health concern. 2. To develop collaborative procedures among all of the institutions involved. 3. To guarantee appropriate communication systems among all of the actors 4. To work in the design and development of emergency intervention equipments made up of trained staff and with the availability of travelling when necessary. 5. To clearly define the criteria and procedures for risk assessment and decision making in order to notify the event to every levels (local, national and international) SANITARY INSPECTION ON A SHIP A sanitary inspection was performed on a ship. It was a merchant ship whit Liberian flag that was unloading cereals at the moment of the visit. The crew was mainly original from Poland. Course attendees were divided into four different groups. The ship was also divided into four different areas with an expert in sanitary inspections on ships situated in each one. All of the groups went past the different areas where the experts gave the practical contents: Documentation and sanitary settings Quarters and water samples Galleys Holds and food storage CONCLUSIONS OF THE COURSE We think that it s very interesting to celebrate these courses in a port, maintaining this practical profile which let us put in place the procedures in situ. The IHR is a very useful tool in order to develop the Foreign Health functions, either for routinely inspections or for situations that could suppose a risk for public health. Implementation of IHR in borders is a priority. Madrid, November 25, 2009 FOR SUBSCRIPTION PLEASE CONTACT US ON: infoeushipsan@eu-shipsan.gr 10