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Actions for prevention and control of health threats related to maritime transport in European Union
Travel Medicine and Infectious Disease (2013) 11, 238e242
Available online at www.sciencedirect.com
journal homepage: www.elsevierhealth.com/journals/tmid
Actions for prevention and control of health threats related to maritime transport in European Union Christos Hadjichristodoulou a,*, Varvara A. Mouchtouri a, Paolo Guglielmetti b, Cinthia Menel Lemos c, Gordon Nichols d, Thierry Paux e, Clara Schlaich f, Miguel Davila Cornejo g, Carmen Varela Martinez h, Mauro Dionisio i, Sybille Rehmet j, Bogdan Jaremin k, Jenny Kremastinou l, the SHIPSAN TRAINET partnershipm a
Department of Hygiene and Epidemiology, Faculty of Medicine, University of Thessaly, Larissa, Greece b Directorate General for Health and Consumers, European Commission, C3, Luxembourg c Executive Agency for Health and Consumers, European Commission, Luxemburg d Gastrointestinal, Emerging, and Zoonotic Infections Department, Health Protection Agency, Centre for Infections, London, United Kingdom e Department of Alert, Response, and Preparedness, General Directorate of Health, Ministry of Health and Solidarity, Paris, France f Hamburg Port Health Centre, Institute of Occupational and Maritime Medicine, Hamburg, Germany g Ministry of Health, Madrid, Spain h National Centre of Epidemiology, Madrid, Spain i Ministry of Health, Department of Public Health and Innovation, Rome, Italy j Training in Preparedness and Response Unit, European Centre for Disease Prevention and Control, Stockholm, Sweden k Interfaculty Institute of Maritime and Tropical Medicine, Gdynia, Poland l Department of Public and Administrative Health, National School of Public Health, Athens, Greece Received 21 October 2012; received in revised form 17 January 2013; accepted 4 February 2013 Available online 19 March 2013
* Corresponding author. Department of Hygiene and Epidemiology, Medical School, University of Thessaly, 22 Papakyriazi Str., 41222 Larissa, Greece. Tel.: þ30 6932264685. E-mail address: [email protected] (C. Hadjichristodoulou). m the SHIPSAN TRAINET partnership in collaborators listed in Appendix section. 1477-8939/$ - see front matter ª 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.tmaid.2013.02.001
Prevention and control of health threats
KEYWORDS Maritime; Ship; Travel; Health; International Health Regulations
239
Summary Background: Actions at European Union level for International Health Regulations (IHR) 2005 implementation and maritime transport were focused on two European projects implemented between 2006 and 2011. Method: Situation analysis and needs assessment were conducted, a Manual including European standards and best practice and training material was developed and training courses were delivered. Ship-to-port and port-to-port communication web-based network and database for recording IHR Ship Sanitation Certificates (SSC) were established. Results: Fifty pilot inspections based on the Manual were conducted on passenger ships. A total of 393 corrective actions were implemented according to recommendations given to Captains during pilot inspections. The web-based communication network of competent authorities at ports in EU Member States was used to manage 13 events/outbreaks (dengue fever, Legionnaires’ disease, gastroenteritis, meningitis, varicella and measles). The European information database system was used for producing and recording 1018 IHR SSC by 156 inspectors in 6 countries in accordance with the WHO Handbook for inspection of ships and issuance of SSC. Conclusions: Implementation of corrective actions after pilot inspections increased the level of compliance with the hygiene standards in passenger ships sailing within the EU waters and improved hygiene conditions. The communication tool contributed to improvement of outbreak identification and better management through rapid sharing of public health information, allowing a more timely and coordinated response. After the implementation of actions on passenger ships, the European Commission co-funded a Joint action that will expand the activities to all types of ships and chemical, biological and radio-nuclear threats (deliberate acts/accidental). ª 2013 Elsevier Ltd. All rights reserved.
Introduction Maritime transport can impact on human population health by providing the setting for person to person (such as norovirus and influenza outbreaks) or animal to human disease transmission, water and foodborne diseases.1e7 Ships have transmitted infections or vectors internationally and affected the quality of food products carried.1e7 Accidental or deliberate release of chemical, biological, radiological and nuclear (CBRN) agents on ships would have the potential to cause adverse health and financial consequences. Competent authorities at points of entry need to develop capacities to be able to assess and respond to public health events in order to meet the requirements of the Annex 1 b of IHR (2005).8 Different authorities are responsible for health, environment, security, customs, transport, employment and veterinary issues, making coordination of responses complex. Ships move from country to country, where different standards of hygiene are required, while diseases surveillance practices vary. Since ship itineraries often include many different ports of the European countries, there is a need for common rules and tools in implementing IHR and European Union (EU) standards on health related issues. Health threats need to be addressed at regional level, in EU, in a coordinated manner, based on common standards as defined in EU legislation and IHR (2005). In 2010 there were about 1,900,000 vessel calls at the main EU ports, 386 million passenger trips on ferries in EU Member States,9 5.5 million EU residents booked cruises and 50,000 European nationals were employed on cruise ships.10 The European Commission initiated actions related to maritime transport and IHR (2005) implementation by funding the EU SHIPSAN project under the Public Health
Program 2003e2008 and the EU SHIPSAN TRAINET project under the Public Health Program 2008e2013 (http://ec. europa.eu/eahc/projects/database.html?prjnoZ2007206). These projects involved partners in 19 EU Member States, two European Free Trade Association (EFTA) countries and nine countries of the European-Mediterranean (Euro-med) region.
Methods Methods used by both projects included situation analysis, needs assessment, development of hygiene standards and guidelines, training courses and establishment of webbased information tools. In particular, methodological tools used were: a) literature review, b) situation analysis through data collection by disseminating questionnaires to identify competent authorities, relevant legislation, national and local practices, training needs of health officers at ports and seafarers and national practices for IHR (2005) implementation and site visits, c) focus groups, d) development of a Manual with European standards, e) training courses, e) pilot testing of tools through table top and operational exercises, f) pilot inspections with trainers using the Manual with European standards, g) establishment of ship-to-port and port-to-port communication web-based network and h) database for recording IHR Ship Sanitation Certificates.
The EU SHIPSAN project Surveys conducted within the framework of the EU SHIPSAN project identified a diversity of practices, inspectors’
240 knowledge, qualifications, training and infectious disease reporting.11e13 A total of 45 outbreaks or incidents (36 gastrointestinal, 1 incident of legionellosis, 3 respiratory, and 1 influenza-like illness outbreak, occupational tuberculosis, varicella, scabies, and meningitis) were reported to EU competent authorities during 2006.13 Moreover, surveys showed heterogeneity in MS occupational health policies, seafarers medical certification and infectious diseases reporting; lack of legislation specific for ships, lack of communication and differences in IHR implementation.13,14 However, IHR (2005) requires the same level of core capacities at designated ports by June 2012. In this context, the European Commission followed up the conclusions and proposals of the SHIPSAN project by funding a subsequent project called EU SHIPSAN TRAINET.
EU SHIPSAN TRAINET project Under the EU SHIPSAN TRAINET project the European Manual for Hygiene Standards and Communicable Disease Surveillance on Passenger Ships was produced.15 This document includes a compilation of existing European legislation, procedures and best practices for medical facilities, food safety, potable and recreational water safety, pest management, housekeeping and facilities, hazardous substances, waste management, ballast water and surveillance of communicable diseases (www.shipsan.eu). Moreover, it includes guidelines for the management of influenza-likeillness, gastroenteritis and Legionnaires’ disease on board passenger ships. This manual is intended for passenger shipping companies and inspectors of public health authorities in European ports, who are responsible for performing passenger ship inspections. Its main objectives are to raise the hygiene level of passenger ships sailing to or within the EU waters, to raise the level of compliance with hygiene standards and to ensure the safety and quality of food, water and environmental conditions for passengers and crew and improve surveillance of communicable diseases on ships. Training material based on this Manual was developed. A pool of 35 trainers was established. Two “train-thetrainers” courses were conducted. Electronic (web-based e-learning), theoretical and practical on-the-job training was provided to 58 crew members and managers of passenger ship companies and 50 port health officers working in ports of EU and the Euro-med region. Evaluation of training activities showed that the training network and modules improved public health knowledge of port health professionals and assisted the passenger shipping industry in preventing and dealing with public health threats more effectively. A total of 50 pilot inspections based on the guidance published in the Manual were conducted on passenger ships in summer 2011. A total of 62 inspectors working in 16 ports from 9 countries, 7 trainers, 7 cruise ship and 8 ferry companies participated in the pilot phase, on a voluntary basis. A total of 393 corrective actions were implemented according to recommendations given to Captains during pilot inspections. All inspection findings and corrective actions were recorded in a database developed for this purpose. Evaluation of pilot inspections showed an increase in the level of compliance with the hygiene standards in
C. Hadjichristodoulou et al. passenger ships sailing within the EU waters and improvement in hygiene conditions in those ships. A web-based platform has been developed which enables ship-to-port, port-to-national authorities and port-to-port communication and the electronic submission of the Maritime Declaration of Health from the ship to the competent authority. This platform strengthens existing systems for communicable disease surveillance and response. Enhanced information about the description of the event, number of ill persons, health status, diagnosis, health measures implemented etc can be recorded in the web-based platform. This information can be viewed and updated according to the new information available by competent authorities at local, intermediate and national level, as well as from the ship. This tool used initially in two simulation exercises and in the management of 13 real outbreaks (dengue fever, Legionnaires’ disease, gastrointestinal diseases, meningitis, varicella and measles). Evaluation of this tool showed that it helped to improve outbreak identification, contributing to better management of outbreaks through rapid sharing of public health information which allowed a more timely and coordinated response. A European information database system for IHR Ship Sanitation Certificates (SSC) has also been developed. It is based on the WHO Handbook for inspection of ships and issuance of SSC.16 This is a web based application that records information on ports, ships, port authorities and other authorities at national level such as IHR National Focal Points, health inspectors, shipping companies and shipping agents. The European information database system was used for producing and recording 1018 IHR SSC by 156 inspectors in 6 countries in accordance with the WHO Handbook for inspection of ships and issuance of SSC. Both EU projects SHIPSAN and SHIPSAN TRAINET addressed only infectious diseases on passenger ships. However, other types of ships such as cargo ships can influence population health. A large number of all kinds of products are transported by sea. Invasion of unwanted species such as vectors or contaminated ballast water can take place.17,18 The European Commission decided to cofund a Joint Action that will build on previous projects and will expand the scope to CBRN threats (deliberate acts/ accidental) in all types of ships. This Joint Action called "SHIPSAN ACT" (The impact on maritime transport of health threats due to biological, chemical and radiological agents, including communicable diseases) is aligned with the European Union strategic framework on health security.
The way forward: SHIPSAN ACT Joint Action The general objective of the SHIPSAN ACT Joint Action is to strengthen an integrated strategy and sustainable mechanisms at EU level for safeguarding the health of travelers and crew of passenger and cargo ships and preventing the cross-border spread of diseases, improving citizens’ health security. Actions will focus on prevention, identification, assessment and response coordination to serious cross border threats to health caused by CBRN agents, linking with existing mechanisms. In particular, the SHIPSAN communication platform will comply with the current European legislation on communicable diseases (Decisions
Prevention and control of health threats 2119/98/EC of the European Parliament and of the Council). The Joint Action will facilitate electronic implementation of the Maritime Declaration of Health (Directive 2010/65/EU) as required by the Convention on Facilitation of International Maritime Traffic. Core capacities development of IHR Annex 1b will be supported by providing training related to response to CBRN events, occupational health, hygiene and IHR; by facilitating inspections and by giving guidance on contingency planning at ports. Guidelines will be produced for dealing with chemical/radiological events on ships, allowing consistent preparedness planning in the EU based on shared and common standards.
Disclaimers The SHIPSAN projects have received funding from the European Commission under the Public Health Programs 2003e2008 and 2008e2013. However, the sole responsibility for the project lies with the authors, and the European Commission is not responsible for any use that may be made of the information contained herein.
Appendix Collaborators e SHIPSAN TRAINET partnership: Jaret Ames, Ioannis S Arvanitoyannis, Christopher LR Bartlett, Marie Baville, Nick Bitsolas, Tomasz Chodnik, George Georgallas, Mathias Kalkowski, Vasiliki Karaouli, Athina Kirlesi, Elina Kostara, Charilaos Koutis, Angel Kunchev, Naomi Launders, Audrone Lavruvianec, Androula Pavli, Tasos Mastrogiannakis, Niamh McGrath, Paul Mckeown, Daniel Menucci, Nikos Mikelis, Foteini Pantazopoulou, Nina Pirnat, Matthijs Plemp, George Rachiotis, Tobias Riemer, Christoph Sevenich, Aleksandra Shatalova, Maja Socan, Ona Sokolova, Georgia Spala, Corien Swaan, Persefoni Tserkezou, Carmen Varela Santos, Candice Vente, Dominique Wagner, Ninglan Wang. Affiliations of Collaborators: Training in Preparedness and Response Unit, European Centre for Disease Prevention and Control (C. Varela Santos), World Health Organization (D. Menucci, N. Wang), CDC d Vessel Sanitation Program, Atlanta, USA (J. Ames), International Cruise Line Association and European Cruise Council, Department of Hygiene and Epidemiology, Faculty of Medicine, University of Thessaly, Larissa, Greece (I. S. Arvanitoyannis, N. Bitsolas, E. Kostara, G. Rachiotis, P. Tserkezou), Hamburg Port Health Centre, Institute of Occupational and Maritime Medicine, Hamburg, Germany (M. Kalkowski, T. Riemer, C. Sevenich). Gastrointestinal, Emerging, and Zoonotic Infections Department, Health Protection Agency, Centre for Infections, London, United Kingdom (N. Launders), Ministry of Health, Medical and Public Health Services, Nicosia, Cyprus (G. Georgallas), Consulting Management Training (C.M.T.) PROOPTIKI LTD, Athens, Greece (T. Mastrogiannakis), Department of Alert, Response, and Preparedness, General Directorate of Health, Ministry of Health and Solidarity, Paris, France (M. Baville, C. Vente), Health Protection Surveillance Centre, Dublin, Ireland (P. Mckeown), Environmental Health, Health Services Executive, Dublin North East, Ireland (N. McGrath), Hellenic Centre for Disease Control and Prevention, Athens, Greece (A. Pavli, G. Spala), National Institute of Public Health, Ljubljana, Slovenia
241 (N. Pirnat, M. Socan), Interfaculty Institute of Maritime and Tropical Medicine, Gdynia, Poland (T. Chodnik), Klaipeda Public Health Centre, Klaipeda, Lithuania (A. Lavruvianec, O. Sokolova), Latvian State Public Health Agency, Riga branch, Riga, Latvia (A. Shatalova), Ministry of Health and Social Solidarity, Athens, Greece (V. Karaouli, Athina Kirlesi, F. Pantazopoulou), Federal Ministry of Public Health, Brussels, Belgium (D. Wagner), National Institute for Public Health and the Environment, Bilthoven, Netherlands (M. Plemp, C. Swaan), Pollution Prevention, Marine Environment Division, International Maritime Organization, London, United Kingdom (N. Mikelis), Section of Communicable Diseases Surveillance, Ministry of Health, Sofia, Bulgaria (A. Kunchev), Technological Educational Institute of Athens, Greece (C. Koutis, F. Babatsikou). UCL Centre for Infectious Disease, Epidemiology Department of Primary Care and Population Sciences, Royal Free and University College Medical School, London, United Kingdom (C.L.R. Bartlett).
References 1. Babic-Erceg A, Klismanic Z, Erceg M, Tandara D, Smoljanovic M. An outbreak of Yersinia enterocolitica O: 3 infections on an oil tanker. Eur J Epidemiol 2003;18:1159e61. 2. Cayla JA, Maldonado R, Gonzalez J, Pellicer T, Ferrer D, Pelaz C, et al. A small outbreak of Legionnaires’ disease in a cargo ship under repair. Eur Respir J 2001;17:1322e7. 3. Mouchtouri VA, Nichols G, Rachiotis G, Kremastinou J, Arvanitoyannis IS, Riemer T, et al. State of the art: public health and passenger ships. Int Marit Health 2010;61:49e98. 4. Rooney RM, Cramer EH, Mantha S, Nichols G, Bartram JK, Farber JM, et al. A review of outbreaks of foodborne disease associated with passenger ships: evidence for risk management. Public Health Rep 2004;119:427e34. 5. Rooney RM, Bartram JK, Cramer EH, Mantha S, Nichols G, Suraj R, et al. A review of outbreaks of waterborne disease associated with ships: evidence for risk management. Public Health Rep 2004;119:435e42. 6. Rowbotham TJ. Legionellosis associated with ships: 1977 to 1997. Commun Dis Public Health 1998;1:146e51. 7. Schlaich C, Riemer T, Lamshoft M, Hagelstein JG, Oldenburg M. Public health significance of chickenpox on ships - conclusions drawn from a case series in the port of Hamburg. Int Marit Health 2010;61:28e31. 8. World Health Organization. International health regulations. Geneva: World Health Organization; 2005. 9. Lund V. The Netherlands emerged as the largest maritime freight country in the EZ. Maritime ports freight and passenger statistics 2010. Eurostat Statistics in Focus; 2012. 10. The Cruse Industry. A leader in Europe’s economic recovery. In: Contribution of Cruise Tourism to the Economies of Europe 2011 [Edition]. 11. Arvanitoyannis IS, Hadjichristodoulou C, Tserkezou P, Mouchtouri V, Kremastinou J, Nichols G. EU legislation on food and potable water safety which could be potentially applied on board ferries and cruise ships: a comparison with US legislation. Crit Rev Food Sci Nutr 2010;50:533e66. 12. Mouchtouri VA, Westacott S, Nichols G, Riemer T, Skipp M, Bartlett CL, et al. Hygiene inspections on passenger ships in Europe - an overview. BMC Public Health 2010;10:122. 13. Hadjichristodoulou C, Mouchtouri VA, Martinez CV, Nichols G, Riemer T, Rabinina J, et al. Surveillance and control of communicable diseases related to passenger ships in Europe. Int Marit Health 2011;62:138e47.
242 14. Rachiotis G, Mouchtouri VA, Schlaich C, Riemer T, Martinez CV, Nichols G, et al. Occupational health legislation and practices related to seafarers on passenger ships focused on communicable diseases: results from a European cross-sectional study (EU SHIPSAN PROJECT). J Occup Med Toxicol 2010;5:1. 15. EU SHIPSAN TRAINET Project partnership. European manual for hygiene standards and communicable diseases surveillance on passenger ships 2011.
C. Hadjichristodoulou et al. 16. World Health Organization. Handbook for ship inspection and issuance of ship sanitation certificates 2011 [Geneva]. 17. Cohen NJ, Slaten DD, Marano N, Tappero JW, Wellman M, Albert RJ, et al. Preventing maritime transfer of toxigenic Vibrio cholerae. Emerg Infect Dis 2012;18:1680e2. 18. Derraik JG. Exotic mosquitoes in New Zealand: a review of species intercepted, their pathways and ports of entry. Aust N Z J Public Health 2004;28:433e44.
Available online at www.sciencedirect.com
journal homepage: www.elsevierhealth.com/journals/tmid
Actions for prevention and control of health threats related to maritime transport in European Union Christos Hadjichristodoulou a,*, Varvara A. Mouchtouri a, Paolo Guglielmetti b, Cinthia Menel Lemos c, Gordon Nichols d, Thierry Paux e, Clara Schlaich f, Miguel Davila Cornejo g, Carmen Varela Martinez h, Mauro Dionisio i, Sybille Rehmet j, Bogdan Jaremin k, Jenny Kremastinou l, the SHIPSAN TRAINET partnershipm a
Department of Hygiene and Epidemiology, Faculty of Medicine, University of Thessaly, Larissa, Greece b Directorate General for Health and Consumers, European Commission, C3, Luxembourg c Executive Agency for Health and Consumers, European Commission, Luxemburg d Gastrointestinal, Emerging, and Zoonotic Infections Department, Health Protection Agency, Centre for Infections, London, United Kingdom e Department of Alert, Response, and Preparedness, General Directorate of Health, Ministry of Health and Solidarity, Paris, France f Hamburg Port Health Centre, Institute of Occupational and Maritime Medicine, Hamburg, Germany g Ministry of Health, Madrid, Spain h National Centre of Epidemiology, Madrid, Spain i Ministry of Health, Department of Public Health and Innovation, Rome, Italy j Training in Preparedness and Response Unit, European Centre for Disease Prevention and Control, Stockholm, Sweden k Interfaculty Institute of Maritime and Tropical Medicine, Gdynia, Poland l Department of Public and Administrative Health, National School of Public Health, Athens, Greece Received 21 October 2012; received in revised form 17 January 2013; accepted 4 February 2013 Available online 19 March 2013
* Corresponding author. Department of Hygiene and Epidemiology, Medical School, University of Thessaly, 22 Papakyriazi Str., 41222 Larissa, Greece. Tel.: þ30 6932264685. E-mail address: [email protected] (C. Hadjichristodoulou). m the SHIPSAN TRAINET partnership in collaborators listed in Appendix section. 1477-8939/$ - see front matter ª 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.tmaid.2013.02.001
Prevention and control of health threats
KEYWORDS Maritime; Ship; Travel; Health; International Health Regulations
239
Summary Background: Actions at European Union level for International Health Regulations (IHR) 2005 implementation and maritime transport were focused on two European projects implemented between 2006 and 2011. Method: Situation analysis and needs assessment were conducted, a Manual including European standards and best practice and training material was developed and training courses were delivered. Ship-to-port and port-to-port communication web-based network and database for recording IHR Ship Sanitation Certificates (SSC) were established. Results: Fifty pilot inspections based on the Manual were conducted on passenger ships. A total of 393 corrective actions were implemented according to recommendations given to Captains during pilot inspections. The web-based communication network of competent authorities at ports in EU Member States was used to manage 13 events/outbreaks (dengue fever, Legionnaires’ disease, gastroenteritis, meningitis, varicella and measles). The European information database system was used for producing and recording 1018 IHR SSC by 156 inspectors in 6 countries in accordance with the WHO Handbook for inspection of ships and issuance of SSC. Conclusions: Implementation of corrective actions after pilot inspections increased the level of compliance with the hygiene standards in passenger ships sailing within the EU waters and improved hygiene conditions. The communication tool contributed to improvement of outbreak identification and better management through rapid sharing of public health information, allowing a more timely and coordinated response. After the implementation of actions on passenger ships, the European Commission co-funded a Joint action that will expand the activities to all types of ships and chemical, biological and radio-nuclear threats (deliberate acts/accidental). ª 2013 Elsevier Ltd. All rights reserved.
Introduction Maritime transport can impact on human population health by providing the setting for person to person (such as norovirus and influenza outbreaks) or animal to human disease transmission, water and foodborne diseases.1e7 Ships have transmitted infections or vectors internationally and affected the quality of food products carried.1e7 Accidental or deliberate release of chemical, biological, radiological and nuclear (CBRN) agents on ships would have the potential to cause adverse health and financial consequences. Competent authorities at points of entry need to develop capacities to be able to assess and respond to public health events in order to meet the requirements of the Annex 1 b of IHR (2005).8 Different authorities are responsible for health, environment, security, customs, transport, employment and veterinary issues, making coordination of responses complex. Ships move from country to country, where different standards of hygiene are required, while diseases surveillance practices vary. Since ship itineraries often include many different ports of the European countries, there is a need for common rules and tools in implementing IHR and European Union (EU) standards on health related issues. Health threats need to be addressed at regional level, in EU, in a coordinated manner, based on common standards as defined in EU legislation and IHR (2005). In 2010 there were about 1,900,000 vessel calls at the main EU ports, 386 million passenger trips on ferries in EU Member States,9 5.5 million EU residents booked cruises and 50,000 European nationals were employed on cruise ships.10 The European Commission initiated actions related to maritime transport and IHR (2005) implementation by funding the EU SHIPSAN project under the Public Health
Program 2003e2008 and the EU SHIPSAN TRAINET project under the Public Health Program 2008e2013 (http://ec. europa.eu/eahc/projects/database.html?prjnoZ2007206). These projects involved partners in 19 EU Member States, two European Free Trade Association (EFTA) countries and nine countries of the European-Mediterranean (Euro-med) region.
Methods Methods used by both projects included situation analysis, needs assessment, development of hygiene standards and guidelines, training courses and establishment of webbased information tools. In particular, methodological tools used were: a) literature review, b) situation analysis through data collection by disseminating questionnaires to identify competent authorities, relevant legislation, national and local practices, training needs of health officers at ports and seafarers and national practices for IHR (2005) implementation and site visits, c) focus groups, d) development of a Manual with European standards, e) training courses, e) pilot testing of tools through table top and operational exercises, f) pilot inspections with trainers using the Manual with European standards, g) establishment of ship-to-port and port-to-port communication web-based network and h) database for recording IHR Ship Sanitation Certificates.
The EU SHIPSAN project Surveys conducted within the framework of the EU SHIPSAN project identified a diversity of practices, inspectors’
240 knowledge, qualifications, training and infectious disease reporting.11e13 A total of 45 outbreaks or incidents (36 gastrointestinal, 1 incident of legionellosis, 3 respiratory, and 1 influenza-like illness outbreak, occupational tuberculosis, varicella, scabies, and meningitis) were reported to EU competent authorities during 2006.13 Moreover, surveys showed heterogeneity in MS occupational health policies, seafarers medical certification and infectious diseases reporting; lack of legislation specific for ships, lack of communication and differences in IHR implementation.13,14 However, IHR (2005) requires the same level of core capacities at designated ports by June 2012. In this context, the European Commission followed up the conclusions and proposals of the SHIPSAN project by funding a subsequent project called EU SHIPSAN TRAINET.
EU SHIPSAN TRAINET project Under the EU SHIPSAN TRAINET project the European Manual for Hygiene Standards and Communicable Disease Surveillance on Passenger Ships was produced.15 This document includes a compilation of existing European legislation, procedures and best practices for medical facilities, food safety, potable and recreational water safety, pest management, housekeeping and facilities, hazardous substances, waste management, ballast water and surveillance of communicable diseases (www.shipsan.eu). Moreover, it includes guidelines for the management of influenza-likeillness, gastroenteritis and Legionnaires’ disease on board passenger ships. This manual is intended for passenger shipping companies and inspectors of public health authorities in European ports, who are responsible for performing passenger ship inspections. Its main objectives are to raise the hygiene level of passenger ships sailing to or within the EU waters, to raise the level of compliance with hygiene standards and to ensure the safety and quality of food, water and environmental conditions for passengers and crew and improve surveillance of communicable diseases on ships. Training material based on this Manual was developed. A pool of 35 trainers was established. Two “train-thetrainers” courses were conducted. Electronic (web-based e-learning), theoretical and practical on-the-job training was provided to 58 crew members and managers of passenger ship companies and 50 port health officers working in ports of EU and the Euro-med region. Evaluation of training activities showed that the training network and modules improved public health knowledge of port health professionals and assisted the passenger shipping industry in preventing and dealing with public health threats more effectively. A total of 50 pilot inspections based on the guidance published in the Manual were conducted on passenger ships in summer 2011. A total of 62 inspectors working in 16 ports from 9 countries, 7 trainers, 7 cruise ship and 8 ferry companies participated in the pilot phase, on a voluntary basis. A total of 393 corrective actions were implemented according to recommendations given to Captains during pilot inspections. All inspection findings and corrective actions were recorded in a database developed for this purpose. Evaluation of pilot inspections showed an increase in the level of compliance with the hygiene standards in
C. Hadjichristodoulou et al. passenger ships sailing within the EU waters and improvement in hygiene conditions in those ships. A web-based platform has been developed which enables ship-to-port, port-to-national authorities and port-to-port communication and the electronic submission of the Maritime Declaration of Health from the ship to the competent authority. This platform strengthens existing systems for communicable disease surveillance and response. Enhanced information about the description of the event, number of ill persons, health status, diagnosis, health measures implemented etc can be recorded in the web-based platform. This information can be viewed and updated according to the new information available by competent authorities at local, intermediate and national level, as well as from the ship. This tool used initially in two simulation exercises and in the management of 13 real outbreaks (dengue fever, Legionnaires’ disease, gastrointestinal diseases, meningitis, varicella and measles). Evaluation of this tool showed that it helped to improve outbreak identification, contributing to better management of outbreaks through rapid sharing of public health information which allowed a more timely and coordinated response. A European information database system for IHR Ship Sanitation Certificates (SSC) has also been developed. It is based on the WHO Handbook for inspection of ships and issuance of SSC.16 This is a web based application that records information on ports, ships, port authorities and other authorities at national level such as IHR National Focal Points, health inspectors, shipping companies and shipping agents. The European information database system was used for producing and recording 1018 IHR SSC by 156 inspectors in 6 countries in accordance with the WHO Handbook for inspection of ships and issuance of SSC. Both EU projects SHIPSAN and SHIPSAN TRAINET addressed only infectious diseases on passenger ships. However, other types of ships such as cargo ships can influence population health. A large number of all kinds of products are transported by sea. Invasion of unwanted species such as vectors or contaminated ballast water can take place.17,18 The European Commission decided to cofund a Joint Action that will build on previous projects and will expand the scope to CBRN threats (deliberate acts/ accidental) in all types of ships. This Joint Action called "SHIPSAN ACT" (The impact on maritime transport of health threats due to biological, chemical and radiological agents, including communicable diseases) is aligned with the European Union strategic framework on health security.
The way forward: SHIPSAN ACT Joint Action The general objective of the SHIPSAN ACT Joint Action is to strengthen an integrated strategy and sustainable mechanisms at EU level for safeguarding the health of travelers and crew of passenger and cargo ships and preventing the cross-border spread of diseases, improving citizens’ health security. Actions will focus on prevention, identification, assessment and response coordination to serious cross border threats to health caused by CBRN agents, linking with existing mechanisms. In particular, the SHIPSAN communication platform will comply with the current European legislation on communicable diseases (Decisions
Prevention and control of health threats 2119/98/EC of the European Parliament and of the Council). The Joint Action will facilitate electronic implementation of the Maritime Declaration of Health (Directive 2010/65/EU) as required by the Convention on Facilitation of International Maritime Traffic. Core capacities development of IHR Annex 1b will be supported by providing training related to response to CBRN events, occupational health, hygiene and IHR; by facilitating inspections and by giving guidance on contingency planning at ports. Guidelines will be produced for dealing with chemical/radiological events on ships, allowing consistent preparedness planning in the EU based on shared and common standards.
Disclaimers The SHIPSAN projects have received funding from the European Commission under the Public Health Programs 2003e2008 and 2008e2013. However, the sole responsibility for the project lies with the authors, and the European Commission is not responsible for any use that may be made of the information contained herein.
Appendix Collaborators e SHIPSAN TRAINET partnership: Jaret Ames, Ioannis S Arvanitoyannis, Christopher LR Bartlett, Marie Baville, Nick Bitsolas, Tomasz Chodnik, George Georgallas, Mathias Kalkowski, Vasiliki Karaouli, Athina Kirlesi, Elina Kostara, Charilaos Koutis, Angel Kunchev, Naomi Launders, Audrone Lavruvianec, Androula Pavli, Tasos Mastrogiannakis, Niamh McGrath, Paul Mckeown, Daniel Menucci, Nikos Mikelis, Foteini Pantazopoulou, Nina Pirnat, Matthijs Plemp, George Rachiotis, Tobias Riemer, Christoph Sevenich, Aleksandra Shatalova, Maja Socan, Ona Sokolova, Georgia Spala, Corien Swaan, Persefoni Tserkezou, Carmen Varela Santos, Candice Vente, Dominique Wagner, Ninglan Wang. Affiliations of Collaborators: Training in Preparedness and Response Unit, European Centre for Disease Prevention and Control (C. Varela Santos), World Health Organization (D. Menucci, N. Wang), CDC d Vessel Sanitation Program, Atlanta, USA (J. Ames), International Cruise Line Association and European Cruise Council, Department of Hygiene and Epidemiology, Faculty of Medicine, University of Thessaly, Larissa, Greece (I. S. Arvanitoyannis, N. Bitsolas, E. Kostara, G. Rachiotis, P. Tserkezou), Hamburg Port Health Centre, Institute of Occupational and Maritime Medicine, Hamburg, Germany (M. Kalkowski, T. Riemer, C. Sevenich). Gastrointestinal, Emerging, and Zoonotic Infections Department, Health Protection Agency, Centre for Infections, London, United Kingdom (N. Launders), Ministry of Health, Medical and Public Health Services, Nicosia, Cyprus (G. Georgallas), Consulting Management Training (C.M.T.) PROOPTIKI LTD, Athens, Greece (T. Mastrogiannakis), Department of Alert, Response, and Preparedness, General Directorate of Health, Ministry of Health and Solidarity, Paris, France (M. Baville, C. Vente), Health Protection Surveillance Centre, Dublin, Ireland (P. Mckeown), Environmental Health, Health Services Executive, Dublin North East, Ireland (N. McGrath), Hellenic Centre for Disease Control and Prevention, Athens, Greece (A. Pavli, G. Spala), National Institute of Public Health, Ljubljana, Slovenia
241 (N. Pirnat, M. Socan), Interfaculty Institute of Maritime and Tropical Medicine, Gdynia, Poland (T. Chodnik), Klaipeda Public Health Centre, Klaipeda, Lithuania (A. Lavruvianec, O. Sokolova), Latvian State Public Health Agency, Riga branch, Riga, Latvia (A. Shatalova), Ministry of Health and Social Solidarity, Athens, Greece (V. Karaouli, Athina Kirlesi, F. Pantazopoulou), Federal Ministry of Public Health, Brussels, Belgium (D. Wagner), National Institute for Public Health and the Environment, Bilthoven, Netherlands (M. Plemp, C. Swaan), Pollution Prevention, Marine Environment Division, International Maritime Organization, London, United Kingdom (N. Mikelis), Section of Communicable Diseases Surveillance, Ministry of Health, Sofia, Bulgaria (A. Kunchev), Technological Educational Institute of Athens, Greece (C. Koutis, F. Babatsikou). UCL Centre for Infectious Disease, Epidemiology Department of Primary Care and Population Sciences, Royal Free and University College Medical School, London, United Kingdom (C.L.R. Bartlett).
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