CDCs Vessel Sanitation Program

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CDCsVessel Sanitation Program
Viruses Impactingthe Restaurant and Foodservice
Industry ConferenceAtlanta GeorgiaAugust 15,
2007
CAPT Charles S. Otto, III, RS, USPHS / CDC / EHSB
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Mission

• Prevent the introduction, transmission, or spread
  of communicable diseases into the U.S.
• Assist cruise ship industry develop and implement
  comprehensive sanitation programs in order to
  minimize the risk for gastrointestinal diseases.

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VSP Staff

• Atlanta (N 7)
• CAPT Jaret Ames
• CAPT George Vaughan
• CAPT Brian Cagle
• L isa Beaumier
• Dr. Elaine Cramer
• Stephanie Lawrence

• Ft. Lauderdale (N 6)
• CDR Laura Rabb
• CDR Julia Chervoni
• CDR Don Ackerman
• LT Hien Nguyen
• LTJG Tim Albright
• Susan Perez

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Vessel Sanitation Program Inspection Fees - FY
2007
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VSP Program Components

• Inspections

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• Cruise vessels that
• Carry 13 or more passengers
• International Itinerary
• Call on U.S. Ports
• FY 2006
• - 150 vessels
• 10 million passengers in No. America

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SAME STANDARD
ArabellaLength 50 mGRT 91Pax 40Crew
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Freedom of the Seas Length 339
m GRT 158,000 Pax 3,600 Crew
1,360
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• Based on
• Previous VSP Ops Manual
• FDA 2005 Model Food Code
• WHO Guide to Ship Sanitation

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VSP Program Components

• Inspections
• Surveillance Outbreak Investigations

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Surveillance

• Syndromic surveillance
• Gastrointestinal illness defined as
• Diarrhea (3 or more loose stools in 24 hour
  period or
• Vomiting and 1 additional symptom
• loose stool
• abdominal cramps
• aches head or muscle
• fever
• Case reports (disease specific)

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Surveillance Reports

• Item - 4 points
• Routine reports
• 24 - 36 hours prior to arrival at a U.S. port
  from a foreign port
• Additional cases 4 hour update report
• Outbreak reports
• Special report GI illness 2
• Electronic reporting
• Email
• Web
• Phone
• Fax

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Confirmed Outbreaks of GI Illness Cruise Ships,
2000-2006
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Have There Been MoreCruise Ship Outbreaks?

• True increase in absolute outbreaks
• Increase in passenger-days and ships
• More sensitive immunoassays
• Expanded surveillance

Following slides provided by CAPT George
Vaughan, CDC, VSP
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Gastroenteritis Incidence Among Passengers on
Cruise Ships, 2001-2006, Vessel Sanitation
Program, CDC

Source VSP GI Surveillance System Consecutive
cruise outbreaks counted as one outbreak
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Acute Gastroenteritis Outbreaks, 2001-2006
Vessel Sanitation Program, CDC

Source VSP GI Surveillance System
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What do we expect, 2006?

Median number of passengers on a 7-day voyage
2,173
Source VSP GI Surveillance System
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Acute Gastroenteritis Incidence Among Passengers
by Cruise Length, 2000-2006, VSP, CDC

Source VSP GI Surveillance System
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Cruise Ship-Associated OutbreaksAmong Passengers
by Pathogen 2001-2006, VSP, CDC

Source VSP
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Laboratory-confirmed Cruise Ship Outbreaks by
Pathogen Type, 1990-2006, Vessel Sanitation
Program, CDC
Source VSP E. Cramer, et al, unpublished data
Median inspection score 94-95
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Results Symptom Profiles(All Ships)

Note Number passengers ill prior to boarding
5-13
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Results Reasons why cases did not report their
illness to the ships infirmary

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Results Summary of KAPs (Cases)

• More likely to be exposed to
• Ill contacts
• Vomitus or diarrhea
• Many cases did not report illness
• Illness not perceived serious
• Self-treatment
• Self isolation
• Less likely to believe in/practice
• hand washing
• hand sanitizer use
• Less likely to believe isolation is an effective
  disease control strategy
• Less likely to be aware of hand sanitizer
  presence before or after outbreak notification

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Discussion Hand washing

• Proper hand washing is key
• Easy access to facilities
• Hand sanitizers use
• When hand washing impractical
• Not a replacement for proper hand washing
• Appropriate concentrations and contact time
• Gel vs liquid
• Frequent reminders needed

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Discussion Isolation

• Encourage reporting of illness
• Onboard surveillance system
• Disease control efforts triggered by amount of
  illness
• Sick cabins receive special treatment (e.g.
  fogging)
• Encourage compliance withisolation procedures
• Provide room service
• Provide entertainment
• Credit for isolation period

Neri 2006
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Discussion Sanitizer Location

• Food outlets
• Gangways
• Jewelry shops (?)
• Hand washing facilities unavailable (e.g.,
  transport vehicles)
• Accompany with strong handwashing messages
• Daily announcements
• Daily printed materials
• Hand hygiene fact sheets

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Discussion Control

• Written Outbreak Prevention/Response Plans
• Reasonable isolation periods
• Foodhandler 48 hours / Non-foodhandler 24 hours
• Passengers 24 hours
• Effective disinfectants (conc./contact
  time/compatible)
• Handwashing Campaign
• Daily printed materials

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Summary

• Plan for outbreak response OPRPs
• Establish strong housekeeping/infection control
  procedures
• Ensure proper cleaning/disinfection protocols
• Train personnel in proper PVI/PDI incident
  response
• Establish surveillance procedures (examples)
• Excess cases
• PVI/PDI incidents
• Passengers (guests) missing events/meals/shore
  excursions

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Summary (contd)

• Establish a good hand hygiene program
• Use appropriate isolation/cohorting of
  case-patients
• Understand dynamics of disease spread and human
  involvement (behaviors) in disease spread
• Educate/communicate with everyone

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VSP Program Components

• Inspections
• Surveillance Outbreak Investigations
• Construction

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VSP Consultation Plan Review
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Vessel Sanitation Program - Yard Inspection
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VSP Program Components

• Operational inspections
• Surveillance/outbreak investigations
• Construction inspections
• Training
• Consultation

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VSP Training 2007

• 21-23 Feb
• 18-20 Apr
• 6-8 Jun
• 15-17 Aug
• 26-28 Sep

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VSP Consultation

• Health Canada
• WHO International Health Regulations
• Intl Olympic Committee
• National Football League
• FDA Interstate Travel Program
• Others (e.g., hotel industry)

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www.cdc.gov/nceh/vspvsp_at_cdc.gov
Warning Views are those of the presenter and do
not necessarily represent official policies and
procedures of CDC/ATSDR or the US DHHS
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Acknowledgments

• Vessel Sanitation Program
• CAPT Jaret T. Ames, Chief
• CAPT George Vaughan
• Dr. Elaine Cramer, Medical Epidemiologist
• VSP Inspection Staff (N 8)
• Mr. David Forney, Former Chief
• Dr. Ciara OReilly
• CAPT Andy Dannenberg
• CAPT Hugh Mainzer
• CAPT Dan Harper
• LT Antonio Neri, MD, EIS

Warning Views are those of the presenter and do
not necessarily represent official policies and
procedures of CDC/ATSDR or the US DHHS
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• Contact Information
• CAPT Charles S. Otto, III, RS, USPHS
• Centers for Disease Control and Prevention
• National Center for Environmental Health
• Environmental Health Services Branch
• 4770 Buford Highway NE MS F28
• Atlanta GA 30341-3724
• USA
• v. 770.488.7303
• 770.488.7310
• e. cotto_at_cdc.gov
• www.cdc.gov/nceh/ehs

Additional Acknowledgements Cruise Lines
andtheir Dedicated Crews
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CDCsVessel Sanitation Program
Viruses Impactingthe Restaurant and Foodservice
Industry ConferenceAtlanta GeorgiaAugust 15,
2007
CAPT Charles S. Otto, III, RS, USPHS / CDC / EHSB