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State of the Art: Public Health and Passenger Ships Int Marit Health 2010; 61, 2: 49–98 www.intmarhealth.pl Copyright © 2010 Via Medica ORIGINAL PAPER ISSN 1641–9251 State of the art: public health and passenger ships Varvara A Mouchtouri1,2, Gordon Nichols1, George Rachiotis2, Jenny Kremastinou3, Ioannis S Arvanitoyannis2, Tobias Riemer4, Bogdan Jaremin5, Christos Hadjichristodoulou2, for the SHIPSAN partnership* *Christopher LR Bartlett6, Rainer Meilicke7, Carmen Varela Santos8, Elina Kostara2, Nikolaos Bitsolas2, Tasos Mastrogiannakis9, Paul Mckeown10, Carmen Varela Martinez11, Sandra Westacott12, Clara Schlaich4, Ona Sokolova13, Corien Swaan14, Nina Pirnat15, Jelena Rjabinina16, Jaret Ames17, Nikos Mikelis18, Athina Kirlesi19, Vasiliki Karaouli19, Georgia Spala20, Marie Baville21, Thierry Paux21, George Georgallas22, Maria Do Ceu Madeira23, Aleksandra Shatalova24, Daniel Menucci25 1Gastrointestinal, Emerging, and Zoonotic Infections Department, Health Protection Agency, Centre for Infections, London, United Kingdom 2Department of Hygiene and Epidemiology, Faculty of Medicine, University of Thessaly 3Department of Public and Administrative Health, National School of Public Health, Athens, Greece 4Hamburg Port Health Centre, Institute of Occupational and Maritime Medicine, Hamburg, Germany 5Interfaculty Institute of Maritime and Tropical Medicine, Gdynia, Poland 6UCL Centre for Infectious Disease, Epidemiology Department of Primary Care and Population Sciences, Royal Free and University College Medical School, Rowland Hill Street, London NW3 2PF, United Kingdom 7Directorate General for Health and Consumers, European Commission, C3, Luxembourg 8Training in Preparedness and Response Unit, European Centre for Disease Prevention and Control 9C.M.T. PROOPTIKI LTD, Athens, Greece 10Health Protection Surveillance Centre, Dublin, Ireland 11National Centre of Epidemiology, Madrid, Spain 12Association of Port Health Authorities, Southampton Port Health Authority, United Kingdom 13Klaipeda Public Health Centre, Klaipeda, Lithuania 14National Institute for Public Health and the Environment, Bilthoven, Netherlands 15Institute of Public Health, Ljubljana, Slovenia 16Health Protection Inspectorate, Tallinn, Estonia 17CDC — Vessel Sanitation Program, Atlanta, USA 18International Maritime Organisation, Pollution Prevention, Marine Environment Division London, United Kingdom 19Ministry of Health and Social Solidarity, Athens, Greece 20Hellenic Centre for Disease Control and Prevention, Athens, Greece 21Department of Alert, Response, and Preparedness, General Directorate of Health, Ministry of Health and Solidarity, Paris, France 22Ministry of Health, Medical and Public Health Services, Nicosia, Cyprus 23Directorate General of Health, Ministry of Health, Lisbon, Portugal 24Latvian State Public Health Agency, Riga branch, Riga, Latvia 25World Health Organization Corresponding author: Christos Hadjichristodoulou, Department of Hygiene and Epidemiology, Faculty of Medicine, University of Thessaly, 22 Papakiriazi Str., Larissa, 41222, Greece. Tel:+ 0030 2410 565 259, 0030 6932 264 685; fax: 0030 2410 565 259; e-mail: [email protected] www.intmarhealth.pl 49 Abstract BackgroundBackground. The purpose of this report is to describe issues relevant to public health and to review all passenger ship associated diseases and outbreaks. Moreover, legislation and practices on sanitation and diseases surveillance related to ships internationally were also reviewed. Some relevant historical information about infections on merchant ships is provid- ed as well. Material and methodsmethods. The methods used to develop the state-of-the-art report included a scientific literature review and an extensive and thorough search of the websites of orga- nisations and government departments. A considerable effort was made to capitalise on previous experience in the field. In particular, for the literature review, a total of 158 scientific articles were used including 91 full papers and 67 abstracts, 7 guidelines pub- lished by the WHO, and 13 guideline documents published by other organisations. Moreover, 5 international conventions relevant to passenger ships were identified. ResultsResults. At the international level, public health issues related to ships are regulated by the revised International Health Regulations (2005). Other conventions of the International Maritime Organization regulate safety on board ships and waste and ballast water mana- gement, while conventions of the International Labour Organization regulates issues related to working conditions on board ships. Guidelines for preventing and controlling public health threats on board ships can be found in seven Guidelines published by the World Health Organization, including the WHO Guide to Ship Sanitation, which provides a framework for policy making and local decision making. The literature review results revealed that the infections/outbreaks that occur on passenger ships include Norovirus, Legionella spp., Salmonella spp., E. coli, Vibrio spp., and influenza A and B virus. The modes of transmis- sion include person to person, waterborne, foodborne, airborne, and vectorborne, and shore excursions are responsible for some outbreaks. ConclusionsConclusions. The industry (especially the ferry industry) and sanitary organisations can enhance collaboration in order to implement integrated hygiene programmes and prevent the occurrence of communicable diseases aboard passenger ships. Key words: passenger ship, diseases surveillance, prevention 50 Executive summary During 2008, the industry carried an estimated 13.05 million passengers on cruises around the globe (Cruise Lines International Association, 2009). The worldwide population of sea- farers serving on internationally trading merchant ships was estimated to be about 466,000 officers and 721,000 ratings in 2005 (IMO, 2009). Ships are closely related to public health in many ways: they may provide the place for disease transmission from person to person; they may be the source of infection (e.g. con- taminated food, surfaces, water), or they may act as a means through which infections or vectors may be transmitted internationally. While travelling on a cruise ship or ferry may be associated with some specific infection risks (e.g. Norovirus), the overall rate of foodborne outbreaks (for example) on such ships may be lower than equivalent shore based facilities. However, comparisons of ship and shore related infections and outbreaks are difficult be- cause of differences in surveillance between ship and shore and because ascertainment differs between countries. In particular, the larger cruise ship operators usually maintain information on reported passenger ill health that is not commonly held for shore based holidays. As a result, some outbreaks will be detected on ships that would not be detected on land. Some outbreaks on ships may be due to shore visits while others are due to specific bad management on board an individual ship. The scope of this report is to review all passenger ship associated diseases and outbreaks and to describe legislation and practices on sanitation and disease surveillance related to ships internationally. Some relevant historical information about infections on merchant ships is provided as well. The methods used to develop the state-of-the-art report included a scientific literature review, and an extensive and thorough search of the websites of organisations and government de- partments. A considerable effort was made to capitalise on previous experience in the field. In particular, for the literature review, a total of 158 scientific articles were used including 91 full papers and 67 abstracts, 7 guidelines published by the WHO, and 13 guideline documents published by other organizations. A total of 14 main websites are referenced in this report. Moreover, 5 international conventions relevant to passenger ships were identified. The results revealed that the infections/outbreaks occurring on passenger ships included: cholera, cyclosporiasis, diphtheria, E. coli infection, Hepatitis A, influenza, Legionnaires’ disease, measles, meningococcal meningitis, rubella, salmonellosis, scabies, shigellosis, sexually transmitted diseases, trichinosis, tuberculosis, varicella, and viral gastroenteritis. The pathogens that most often caused outbreaks were: Norovirus, Legionella spp., Salmo- nella spp., E. coli, Vibrio spp., and influenza A and B virus. The modes of transmission included person to person, waterborne, foodborne, airborne, and vectorborne, and shore excursions were responsible for some of the outbreaks. The factors which contribute to such outbreaks are often preventable, or can be reduced by means of sanitation measures, training the crew members, and advising passengers. At the international level, public health issues related to ships are regulated by the revised International Health Regulations (2005). These regulations have changed ship sanitation certification, disease surveillance, and response to public health threats that may constitute an emergency of international concern. Other conventions of the International Maritime Organization regulate safety onboard ships and waste and ballast water management, while conventions of the International Labour Organization regulates issues related to working conditions onboard ships. European legislation directly applied to ships includes safety rules and standards for pas- senger ships, border measures for public health purposes, and the welfare of animals in 51 Int Marit Health 2010; 61, 2: xx–xx transit. Except for
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