CDC Vessel Sanitation Program (VSP) – An Exercise in Cooperation

CDC Vessel Sanitation Program
(VSP) – An Exercise in Cooperation
2014 Emergency Preparedness Training
Workshop
June 4, 2014
CAPT Jaret Ames
CDC/NCEH
Chief, Vessel Sanitation Program
National Center for Environmental Health
Vessel Sanitation Program
Mission

Prevent the introduction, transmission, or spread of
communicable diseases into the United States

Assist cruise ship industry in developing and
implementing comprehensive sanitation programs to
minimize the risk for gastrointestinal illnesses
2
3
VSP Program Components
 Inspections
 Operations
 Construction
 Training
 Consultation with international groups







Australia
Brazil
CARPHA
China Quarantine
EU SHIPSAN
Health Canada
WHO IHR
 Surveillance and outbreak investigation
4
VSP Staff

Atlanta
 4 Environmental
Health Officers
 1 Epidemiologist
 1 Admin Assistant
 1 IT Specialist

Ft. Lauderdale
 5 Environmental
Health Officers
 1 Admin Assistant
5
VSP History
1970-1975
Routine sanitation
inspections of all arriving
vessels
Significant risk
associated with cruise
ships
WHO Guide to Ship
Sanitation
6
VSP History
1970-1975
1975
Routine sanitation
Voluntary compliance to
inspections of
maintain
all arriving
minimum levels
vessels
of sanitation and
Significant risk
minimize threat of GI
associated with
illness
cruise
ships
Inspection results
WHO Guide to
available
Ship to the public
Sanitation
7
VSP History
1970-1975
1975
1986
Routine sanitation
VoluntaryFirst
compliance
overseastoconsultation on
inspections of
maintain
all arriving
construction
minimum levels
1986
vessels
of sanitation and
1980
Significant risk
minimizeInspections
threat of GI discontinued &
associated with
illness
cruise
industry “encouraged” to develop a
ships
Inspection
program
resultsof self-inspection using
WHO Guide to
available
Ship Vessel
to the public
Sanitation Inspection Manual
Sanitation
8
VSP History
1970-1975
1975
1986
1987
Routine sanitation
Voluntary compliance
First overseas
to In compliance
consulwith
inspections of
maintain
all arriving
minimum
tation on
levels
construction
congressional directive,
vessels
of sanitation 1986
and
1980reestablished with
VSP
Significant risk
minimize threat
Inspections
of GI
discontinued
following components:
associated with
illness
cruise & industry “encouraged”
Unannounced
inspections
ships
Inspection results
to develop a program
of
WHO Guide to
available
Ship to the
self-inspection
public  Follow-up
using
inspections
Sanitation
Vessel Sanitation
 Construction consultation
Inspection Manual
 Investigation of outbreaks
 Biweekly publication of
inspection scores
 Inspection reports on
request
9
VSP History
1970-1975
1975
1986
1987
1988
Routine sanitation
Voluntary compliance
First overseas
to In compliance
consulwith
inspections of
maintain
all arriving
minimum
tation on
levels
construction
congressional directive,
vessels
of sanitation 1986
and
1980reestablished with
VSP
Significant risk
minimize threat
Inspections
of GI
discontinued
following components:
associated with
illness
cruise & industry “encouraged”
Unannounced
inspections
ships
Inspection results
to develop a program
of
Cost
WHO Guide to
available
Ship to the
self-inspection
public = $0.03*/passenger/day
using
Follow-up
inspections
Sanitation
Vessel Sanitation
* 2014

Construction
consultation
Inspection Manual
User fees charged to support
100% of VSP budget
 Investigation of outbreaks
 Biweekly publication of
inspection scores
 Inspection reports on
request
10
Arabella
Length
50 m
Size
91 GRT
Passengers
40
Crew
8
Allure of the Seas
Oasis of the Seas
Length
360 m
Size
225,282 GRT
Passengers
5,400
Crew
2,165
11
12
13
Jurisdiction

Cruise vessels that
 Carry 13 or more passengers
 Have an international itinerary
 Call on U.S. ports

2013
 200+ vessels
 17+ million passengers*
* 2012 Forecast Cruise Lines International Association (CLIA)
14
Legal Authority

Public Health Services Act
 42 U.S.C. Section 264. Quarantine & Inspection
• Regulations to control communicable disease
 42 U.S.C. Section 71.41. General Provisions, Foreign
Quarantine
• Requirements Upon Arrival at US Ports: Sanitary Inspection

No fines, civil or criminal litigation , but sailing can
be and is stopped or delayed thru “No Sail” process
on imminent health hazard identification.
15
VSP & Cruise Ship Industry

Joint Collaboration




Manuals
Training
Annual meetings
Consultation
• new concepts, technology
 Economic Cost of Outbreaks
 Per day delayed embarkation : $1.3 million to cruise line
 Per no sail day: $5 million to cruise line
 Media & residual impact
16
VSP Program Components

Operational Inspections
17
Operational Inspections





Majority of Program’s Work
Twice a year
Unannounced
Maximum score of 100
Minimum passing score is 86
18
Based on




Previous VSP Ops
Manual
Current FDA Model
Food Code
WHO Guide to Ship
Sanitation
Extensive References
19
Operational Inspections








GI Surveillance
Potable Water
Recreational Water
Food Safety
Pest Management
Housekeeping / Infection Control
Child Activity Centers
HVAC Systems
20
VSP Program Components

Construction
21
2011 Construction Guidelines
22
Construction






New builds
Renovations
Plan reviews
Yard Inspection
Final inspection
Equipment reviews
23
Plan Review/Construction Inspections
24
VSP Program Components

Training and Consultation
25
Training




Train-the-trainer course for cruise ship
supervisors
Six times per year
Miami and Seattle
700 industry personnel per year
26
VSP Program Components

GI Surveillance & Outbreak Investigations
27
Gastrointestinal Illness
(GI) Log

The main document of the VSP
surveillance system:




Listing of all REPORTABLE GI illness cases who
reported to the ship’s medical staff
Gather information to report cases to the VSP
Data for outbreak investigations
Maintained for each cruise/voyage
28
Reportable Case
Diarrhea (3 or more episodes in a 24-hrs or
what is above normal for the
individual)
- OR –
Vomiting + one other symptom (24-hrs)
-One or more loose stool
-Abdominal/stomach cramps
-Headache
-Muscle aches (myalgia)
F-ever (≥ 38°C or 100.4°F)
29
GI Surveillance

Use electronic reporting system
 Maritime Illness and Death Reporting System

Report 24 hours before arrival at a U.S. port

Submit a 4-hour update

Submit a special report when gastrointestinal illness
reaches 2% and again at 3%
30
GI Questionnaires

Demographic information

Activities before embarkation

Excursions & activities/meals ashore

Shipboard meals and activities for 72
hours
31
Isolation

Crew
 Food employee
• 48-hour minimum isolation period from last symptom
 Non-food employee
• 24-hour minimum isolation period from last symptom

Passengers
 Advised to remain isolated in cabins until well for a
minimum of 24-hours from last symptom
 Corporate Policy
32
Outbreak Prevention and Response
Plan

Pre-determined triggers and actions

Immediate reduction in GI cases




Removal of virus particles from surfaces
Limit movement of ill crew and passengers
Separation of ill and well crew members
Prevent spread to next cruise
33
Levels of Outbreak Response
CDC Epi-Aid
VSP epidemiological
investigation
Targeted environmental
health assessment
Consultation and
assessment
34
http://www.cdc.gov/nceh/vsp/surv/gilist.htm
35
Trends and Drivers for Outbreak
Investigations
 Increased incidence of GI illness
 Increasing rate of AGE outbreaks
 Industry concerns about outbreak trends
 Public concerns for health and safety (including
vulnerable populations)
 Public health obligation and expectation
36
Reasons for Investigating Outbreaks
 Primary
 Eliminate exposure to sources of infection
(Stop spread!)
 Develop strategies for control
(Recommendations)
 Describe new diseases/learn more about
existing diseases
 Secondary
 Evaluate existing prevention strategies
 Address public concern about the outbreak
 Teach/learn epidemiology
 Person
 Place
 Time
37
Case Studies
Case 1
38
Epidemic curve of all cases reported to medical
crew by illness onset, Ship A
350
300
Number of Cases
250
200
Ended voyage 2 days
early, disembarked in
Bayone, NJ
Embarkation,
Bayone, NJ
150
100
50
0
Crew
Passengers
21-Jan
22-Jan
23-Jan
24-Jan
25-Jan
26-Jan
27-Jan
28-Jan
29-Jan
30-Jan
31-Jan
21-Jan
0
2
22-Jan
2
139
23-Jan
25
283
24-Jan
11
86
25-Jan
8
54
26-Jan
3
38
27-Jan
2
26
28-Jan
3
5
29-Jan
0
1
30-Jan
0
0
31-Jan
0
0
39
Ship’s Itinerary
Date
Planned Itinerary
Actual Itinerary
January 21
Bayonne, NJ
Bayonne, NJ
January 22
At sea
At sea
January 23
At sea
At sea
January 24
Labadee, Haiti
San Juan, PR
January 25
San Juan, PR
San Juan, PR
January 26
St. Thomas, USVI
St. Thomas
January 27
St. Marteen, French VI
At sea
January 28
At sea
At sea
January 29
At sea
Bayonne, NJ (disembark)
January 30
At sea
Bayonne, NJ
(disinfection in port)
January 31
Bayonne, NJ
Bayonne, NJ
40
Lab Results

Five stool specimens sent to CDC’s Calicivirus lab

Specimens offloaded in St. Thomas, USVI on
January 26, 2014

All were positive for Norovirus GII.4 Sydney
41
Special Considerations

Requests for information during outbreak response:






Within CDC
Media
Port health officials
US Customs and Boarder Protection
US Coast Guard
Non-US Caribbean Island officials

Snow storm in Atlanta during voyage week delayed
specimen arrival at CDC

Super Bowl in Newark, NJ on turnaround weekend,
making alternate travel plans difficult
42
Findings

Health questionnaire distributed to all 3071
passengers with ~80% response rate

Epi-curve indicates exposure likely occurred on the
first day

VSP has received reports of people with illness who
disembarked January 21 from the previous voyage

Data analysis still underway, but have ruled out food
as a source
43
Case Studies
Case 2
44
Epidemic Curve of all cases reported to
medical crew by illness onset, Ship B
14
12
Number of Cases
10
8
6
Food
provisioned in
Peru
Crew
Passengers
4
2
0
Date of Self-Reported Symptom Onset
45
Assessment of self-reported food consumption
by cases in 48 hours prior to illness onset,
Ship B
Food Item
Date of onset
Day before onset
48 hours before
onset
n
%
n
%
n
%
Greens/Lettuce
12
50.7
15
52.2
13
49.4
Mixed fruit
18
34.2
9
28.1
8
34.8
Tomatoes
5
20.0
9
33.3
5
20.8
Seafood
8
29.6
11
35.5
6
27.3
Soup
10
37.0
12
38.7
9
32.1
Orange/juice
11
29.0
14
43.8
10
34.5
*Note: These data are from cases only. There is not well comparison group to determine relative risk, so it is difficult to know which
46
food items were just popular among both ill and well.
Lab Results



Ten clinical specimens sent to CDC’s Calicivirus lab
and Bacterial lab
Nine food samples sent to Bacterial lab
Tested specimens were negative for norovirus and
rotavirus
 Tested for rotavirus based on reports of community level illness
in port cities visited in South America


Two clinical specimens positive for ETEC
Romaine lettuce positive for ETEC
47
48
AGE Outbreaks by Pathogen and Year,
January 1, 1994 to December 31, 2013
NOTE: Includes only voyages with a cumulative case count of greater than or equal to 3% in either guest or crew populations
49
Cases Per 100,000 Passenger Days, 2001-2013,
Vessel Sanitation Program, CDC
50
Questions?
www.cdc.gov/nceh/vsp
National Center for Environmental Health
Vessel Sanitation Program
CAPT Jaret T. Ames
[email protected]
For more information please contact Centers for Disease Control and Prevention
Vessel Sanitation Program
4770 Buford Highway NE – MS 59
Atlanta GA 30341-3724 USA
1850 Eller Drive – Suite 101
Fort Lauderdale, FL 33316-4201 USA
Telephone:
Fax:
Telephone: 954-356-6650
Fax:
954-356-6671
770-488-3141
770-488-4127
Toll Free:
800-323-2132
TTY:
888-232-6348
Email: [email protected] / Web: www.cdc.gov/nceh/vsp
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position
of the Centers for Disease Control and Prevention.
National Center for Environmental Health
Vessel Sanitation Program

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