G) Public Health and Infectious Diseases

G.8 Guidelines concerning Infectious Diseases Control on Ships

Details

Published: 09 January 2022

Occupational Health

International Labour Organisation (ILO)/International Maritime Organisation (IMO) Guidelines on the medical examinations of seafarers (30.9.2011) www.ilo.int and the concurrent national guidelines of maritime authorities.

These Guidelines document standards for the pre-employment fitness examinations of seafarers. Gastrointestinal diseases, Tuberculosis, HIV, sexually transmitted diseases, Hepatitis (A,B,C etc.) are specified in the document.

World Health Organisation (WHO), International Medical Guide for Ships, including the ship´s medicine chest. 3rd ed. World Health Organization - ‎2007.

This is a guide primarily aimed at the officer responsible for medical care on board a ship without a doctor. In addition it is useful for shipping companies, all other seafarers, ship supplying pharmacies, Telemedical assistance services (TMAS) and maritime authorities.

The chapters on infectious diseases in general and sexually transmitted diseases are detailed. It is especially useful for the treatment of Malaria and for infection control measures on board and includes cross-references to the International Health regulations 2005. 

There are several recognised, equivalent national guides for seafarers that include equipment lists and information on infectious diseases, for example:

• German Medical Guide for Ships: Manual for Captains and Ship's Officers https://www.deutsche-flagge.de/en/maritime-medicine/equipment-spaces
• UK – Ship’s Captain’s Medical Guide 23rd editionhttps://www.gov.uk/government/organisations/maritime-and-coastguard-agency
• Danish Guidelines: https://www.dma.dk/SoefarendeBemanding/Sygdomsbehandler/VejledningHjaelpemidler/Sider/default.aspx

Cruise ships

CDC Yellow Book

(online resource yearly updates) wwwnc.cdc.gov/travel/yellowbook

An up to date resource for clinicians giving pretravel advice.

The European Manual for Hygiene Standards and Communicable Disease Surveillance on Passenger ships; 2.4.2016

http://www.shipsan.eu/KeyResources.aspx

This manual outlines hygiene standards based on European Union (EU) legislation and best practice guidelines for passenger ships sailing within European waters. The manual is intended for passenger shipping companies and public health inspectors in European ports, who are responsible for passenger ship inspections. Specific guidelines are given for dealing with Influenza-Like Illness (ILI), general considerations for influenza pandemics, vaccine-preventable diseases, Legionnaires’ disease and gastroenteritis.

CDC Vessel Sanitation Program Manuals

https://www.cdc.gov/nceh/vsp/

This consists of an Operations Manual and Construction Guidelines to assist the cruise industry in management to prevent and control the introduction, transmission, and spread of gastrointestinal (GI) illnesses on cruise.

International Health Regulations 2005

Drawing on the experiences of the 2003 SARS CoV1 epidemic, the WHO adopted the current 2005 International Health regulations (IHR). 

In line with the IHR 2005 WHO published several guidance documents for ships and points of entry (Ports):

Guide to ship sanitation (third edition), 2011

https://www.who.int/water_sanitation_health/publications/2011/ship_sanitation_guide/en/

The guide is a useful reference material for regulators, ship operators and ship builders, as well as a checklist for understanding and assessing the potential health impacts of projects involving the design of ships. There is a detailed chapter on water sanitation.

WHO Handbook for inspection of ships and issuance of ship sanitation certificates 2011

https://www.who.int/ihr/publications/handbook_ships_inspection/en/

The handbook is intended as reference material for port health officers, regulators, ship operators and other competent authorities in charge of implementing the IHR (2005) at ports and on ships. It provides guidance for preparing and performing the inspection, completing the certificates and applying public health measures within the framework of the IHR (2005).

WHO Handbook for management of public health events on board ships 2016

https://www.who.int/ihr/publications/9789241549462/en/

This includes a literature review of common  infectious diseases events and summaries of disease specific measures for the following diseases: Anthrax, Botulism, Cholera, Dengue, Diphtheria, Gastroenteritis, Hepatitis A, B, E, Malaria, Measles, Meningococcal Meningitis, Mumps, Pertussis, Plague, SARS, Rabies, Scabies, Shingles, Staphylococcal poisoning, Tetanus, Trichinosis and Yellow Fever.

Others

Control of Communicable Diseases Manual, edited by David L. Heymann, MD Publisher: APHA Press

A very useful, practical and detailed book for communicable disease control.

G.6 Zoonotic – Environmental Cluster

Details

Published: 09 January 2022

Introduction

Infections in this cluster are transmitted by animals (zoonotic) or from agents in water and soil (environmental). Shipping is associated with the potential threat of the dispersal of microbes and their vectors, such as rodents and arthropods including cockroaches, mites or mosquitoes (1,2).  Vector-borne diseases on ships and the implication of spreading the vectors globally by travel and trade have long been a focus for international disease control programs overseen by the World Health Organization. The International Health Regulations 2005 regulate the surveillance of disease, disinfection, deratting and disinfection of ships and port areas as well as transported goods and health measures for travellers, including yellow fever vaccination (3). 

Beside the known risks of Yellow Fever and Malaria, emerging infections causing Chikunguya, Dengue fever or West Nile virus fever are recognized as travel related risks. Though no case reports are published from seafarers it is safe to assume that they are a population at risk.

Risk assessment

For centuries seafarers have been aware of the risk of being bitten by mosquitoes and acquiring disease when visiting areas where such disease is prevalent.

Seafarers and international travellers are at risk of developing disease once infected because they are non-immune and are frequently diagnosed late or misdiagnosed when returning home. Clinical manifestations of the disease may be evident on board when no medical doctor is available for diagnosis and treatment, or in ports where the reliability of a diagnosis may vary and is unknown to the seafarer. Seafarers may develop symptoms when they have ended their contract and returned to their home countries, sometimes to places where such diseases are not endemic and thus physicians may not consider the diagnosis when a seafarer presents with typical symptoms. Often, specialist tropical and diagnostic tools will not be easily available in the home areas of seafarers.

Risk management

Chemoprophylaxis, specific treatment or vaccination is available for some of these diseases. However no chemoprophylaxis can provide complete protection and specific therapies are not available for all. Hence measures to reduce the risk of mosquito bites are of paramount importance. 

There are specific measures that must be observed in relevant areas:

• Avoid being outdoors as much as possible and particularly between dusk and dawn
• Wear long-sleeved shirts and trousers when outside
• Systematic availability of insect repellent on board
• Air conditioning should be functioning and used at all times
• Window and door screens should be used or, if these are not available, living quarter doors and windows should be kept closed
• Use of an insecticide treated bed net when ashore
• Availability of anti-mosquito sprays or insecticide dispensers that contain tablets impregnated with pyrethroids to all cabins at night.

Indoor residual spraying is recommended only after consultation with a public health/tropical medicine expert who can judge on the epidemiological and entomological data. It should be performed by a professional pest management company

The WHO also promotes the ABCD for Malaria protection that also applies to seafaring:

• Be Aware of the risk, the incubation period, the possibility of delayed onset and main symptoms.
• Avoid being Bitten by mosquitoes, especially between dusk and dawn.
• Chemoprophylaxis, when appropriate.
• Immediately seek Diagnosis and treatment if fever develops one week or more after entering an area where there is a malaria risk. Fever may be delayed for up to 3 months, or occasionally longer.

The appropriate availability and use of rapid tests, medication and vaccination should also be considered in conjunction with TMAS and other shore based medical expertise.

Malaria - Human-infective Plasmodium species

Most malaria is transmitted by the bite of an infected female Anopheles mosquito that live in many tropical and subtropical countries (see map at www.who.int/ith/en). They are most active between dusk and dawn. Up to date information about the risk of acquiring malaria in a given port, is available at www.cdc.gov/travelregionalmalaria/index.htm. 

The period between the infective bite and the appearance of clinical symptoms is typically 9-14 days for Plasmodium falciparum, 12-18 days for Plasmodium vivax and Plasmodium ovale and 18-40 days for Plasmodium malariae. Some strains of Plasmodium vivax may have an incubation period of up to 12 months. Classic symptoms are fever, chills, diarrhoea, headache, fatigue or anorexia.

Malaria in seafarers

Numerous studies have investigated malaria among seafarers. Mouchtouri et al. concluded from these studies a varied incidence rate from 3 to 12/1000 seafarers (4).

Tomaszunas estimated the total number of malaria in international seafarers to be between 500 and 1000 each year. The disease was found to be contracted onboard or in ports (5).

Hansen et al showed in a longitudinal study from Denmark of 24.132 seafarers employed between 1986 and 1993 that the majority of the 25 malaria cases occurred in connection with trade to West Africa. Irregularity of malaria prophylaxis and chloroquin resistance was assessed to be of importance for risk of infection (6).

Port health authorities in Croatia reported 23 malaria cases in 19 sailors and 4 tourists on merchant ships arriving in Croatia between 1990 and 1993 (attack rate 0.3% (23/ 8379) (7).

Over 100 cases of malaria were reported to authorities in Japan between 1990 and 1997. It was estimated that approximately 5% of imported cases to Japan concerned seafarers (8).

In Klaipeda, Lithuania, malaria cases were registered from1973 to 1998. 99 of 113 cases occurred in seafarers and fishermen (9). In Italy, seafarers and airline personnel represented 21% all registered malaria cases (10).

Though, by the nature of their job, seafarers cannot avoid exposure to malaria there are well studied preventative measures that greatly reduces the risks of severe disease and death in sailors. The mainstay of prevention in ships sailing to malarious areas is chemoprevention (of note: there is by now no vaccination against Malaria).

The International Medical Guide for Ships requires ships to carry the appropriate drugs as recommended by the World Health Organization or national guidelines for that specific region.

Before travel updated recommendations on the appropriate prophylaxis must be reviewed:

www.who.int/malaria/publications.html

or

www.cdc.gov/travel/regionalmalaria/index.htm

It will be in the responsibility of the ship owner to supply the appropriate drugs to their ships in sufficient amounts. However sailors often fail to use chemoprevention even if available on board, the ship master needs to to promote and facilitate the use of chemoprevention (5). It is well known that many seafarers avoid chemoprophylaxis due to unjustified fears of side-effects, thus necessitating appropriate medical counselling and written information.

All ships deploying to malarious areas must carry effective treatment. Provision of methods to confirm diagnosis by microscope, where staff have the skills to use it, or by using a rapid diagnostic test, is recommended.

The International Medical Guide for Ships (IMGS) recommends that ships carry the appropriate drugs as recommended by the World Health Organization or national guidelines for that specific region. It is the responsibility of the ship owner to supply the appropriate drugs to their ships in sufficient amounts. However, sailors often fail to use chemoprophylaxis even if it is available on board and the ship’s master needs to promote and facilitate its use (5). Many seafarers avoid chemoprophylaxis due to unjustified fears of side effects and appropriate medical counselling and written information is useful.

All ships deploying to such areas must also carry effective treatment. The provision of methods to confirm the diagnosis by microscope, where staff have the skills to use it, or by use of a rapid diagnostic test, is recommended. However, regardless of a test result, if a seafarer has travelled to a malarious region and develops typical symptoms of Malaria, not earlier than 6 days and typically 10-14 days or later after entering the area of risk, they should begin empiric full dosage treatment immediately. A positive rapid test will confirm the diagnosis but a negative result should not delay treatment and should be repeated after 24 hours. Management of these cases should be done in conjunction with TMAS or other shore based medical personnel. If symptoms persist after 3 days or the patient deteriorates, further medical assessment is necessary.

To date there is no available vaccine.

Use of a Malaria Rapid Diagnostic Test in the Ship Environment

Rapid tests are not currently listed as a part of the ship´s medicine chest in the IMGS. However they are increasingly carried on board to facilitate decision making in situations when a medical consultation ashore is not available. The advantage of the Malaria Rapid Diagnostic Tests is that they provide a quick result and are easy to use. However, the quality and performance of the many commercially available tests vary substantially and procurement must take into account product specifications.

Limitations of the tests

• Variabilty in their ability to detect specific malaria parasite densities and species by their target antigens. Some tests will detect P. falciparum or non-P. falciparum only, some detect both antigens. In some areas of South America, P. falciparum parasites do not express a certain antigen. If tests are based on this antigen, their sensitivity to detect P. falciparum from this region will be low - only tests that test pLDH will be effective in detecting P. falciparum in these areas of South America.
• Different tests are designed to detect infections in populations with different epidemiological situations of malaria, that is, countries where malaria is endemic as opposed to countries moving towards the elimination of malaria. Therefore, some tests are designed to detect low density infections, that is > 100 to 200 parasites /µl whilst others are designed for endemic countries and will detect high density infections only, that is > 2000 or 5000 parasites /µl.
• Tests continue to be positive in patients who have been treated with effective ant-malarial medicines within the last 5 - 14 days, depending on the test. This occurs because the test detects the antigen and not the parasite itself. Hence if a seafarer has recurrent or persistent signs and symptoms of malaria within 3 to 14 days after completing a recommend first line treatment, the rapid test may still be positive even if the treatment was successful and another cause of symptoms must be considered. But, it may also be that the treatment was not successful and second line therapy for Malaria may be required. In a seafarer who is not improving with first line therapy for Malaria, a blood film for malaria parasites is necessary to confirm the diagnosis and decide if this is treatment failure. However, if a patient develops symptoms and has a positive rapid test or blood smear for malaria parasites 14 days or more after initiation of first line therapy, with prior resolution of symptoms, this should be considered a new infection and the patient be treated with the first line drug.
• Depending on the test used, the test must be read 15 to 60 min after the buffer was added. After this time discoloration of the system appears and may result in false positive or false negative readings. Therefore, the rapid diagnostic test is not suitable for documentation of claims of a work related disease and in this situation it is recommended to use a blood slide for documentation, as described in the IMGS. This is a rather simple procedure that can be performed by a seafarer with minimal training.

Which test?

If purchasing a test for use on board, care must be taken to choose the appropriate test. Appropriate tests must:

• be heat resistant, if storage in a refrigerator in the ship’s medical centre is not possible at all times,
• detect parasites at a threshold of 100 to 200 parasites /µl with a high sensitivity and specificity,
• detect P. falciparum and non-falciparum and, if used for South-America travel detect pLDH Antigen,
• be easy to use and have an appropriate shelf-life.

The WHO has a product testing program for Malaria rapid detection tests that are commercially available and the results are published on the WHO website. This may be useful information to guide the procurement process.

(1) Tatem AJ, Hay SI, Rogers DJ. Global traffic and disease vector dispersal. Proc Natl Acad Sci USA 2006;103:6242-6247.

(2) Lounibos LP. Invasions by insect vectors of human disease. Annu Rev Entomol 2002; 47:233-266.

(3) World Health Organization. International Health Regulations (2005). Geneva: WHO, 2006. http://www.who.int/csr/ihr/en/  Last access August 2013.

(4) Mouchtouri VA, Nichols G, Rachiotis G, Kremastinou J, et al. For the SHIPSAN partnership: State of the art: public health and passenger ships. Int Marit Health 2010; 61, 2:49-98.

(5) Tomaszunas S. Malaria in seafarers. 1. The magnitude of the problem and the strategy of its control. 2.The status of malaria in large ports of the world. Protective measures against malaria in crews of ships. Bull Inst Marit Trop Med Gdynia 1998;49:53-61, 63-71.

(6) Hansen HL. Occupation-related morbidity and mortality among merchant seafarers with particular reference to infectious diseases. Esbjerg: South Jutland University Press, 1996.

(7) Nikolic N, Poljak I, Troselj-Vukic B.. Malaria, a travel health problem in the maritime community. J Travel Med 2000;7:309-313.

(8) Shoda M, Shimizu K, Nagano M, Ishii M. Malaria infections in crews of Japanese ships.Int Marit Health 2001;52:9-18.

(9) Scerbaviciene R, Pilipavicius R. Malaria among seamen in Klaipeda during 1973-1998. Int Marit Health 1999;50:7-13.

 (10) Herrador Aguirre J. El paludismo en los trabajadores del mar de Costa de Marfil. Med Marit 1996;1:112-117.

Dengue Fever and Dengue Haemorrhagic Fever

Dengue Type -1, -2, -3 and -4 viruses are transmitted by infected Aedes mosquitoes in areas where the winter temperature is above 10°C and the incubation time is commonly 4-7 days. Asymptomatic infection can occur. No direct person-to-person transmission occurs. Aedes aegypti mosquitoes are day-biting species, with increased biting activity for 2 hours after sunrise. The past 20 years have seen the spread of epidemic dengue fever and dengue haemorrhagic fever from South East Asia to the South Pacific Islands, the Caribbean and the Americas. Recent epidemics have occurred in Asia - Cambodia, China, India, Indonesia, Laos, Malaysia, Maldives, Myanmar, New Caledonia, Pakistan, Philippines, Singapore, Sri Lanka, Tahiti, Thailand  and Vietnam and in the Americas - Brazil, Colombia, Cuba, Ecuador, El Salvador, French Guyana, Guatamala, Honduras, Nicaragua, Puerto Rico, Surinam and Venezuela.⁶⁴ It is rare in African countries. Recovery from infection from one serotype provides lifelong immunity to that serotype only, but further infection with another serotype increases the risk of dengue haemorrhagic fever.

Dengue fever is an acute febrile viral disease characterized by the sudden onset of fever, intense headache, myalgia, arthralgia, retro-orbital pain, anorexia, nausea, vomiting and a generalized rash, often not seen in dark-skinned patients. Symptoms tend to last for 2-7 days. Dengue haemorrhagic fever and Dengue Shock Syndrome are serious courses of the infection characterized by acute febrile illness and haemorrhagic diathesis with abnormal blood clotting and increased vascular permeability causing petechia, echymosis or purpura with a tendency to develop hypovolemic shock. Immediate intravenous fluid therapy and further medical treatment is needed.

Studies estimate that the incidence of returning travellers with Dengue has risen from 2% in 1990 to 16% in 2005 (1 . No studies or reports were identified on the occurrence of Dengue and Dengue Haemorrhagic fever in seafarers, but cases are seen in clinical practice. Medical doctors caring for seafarers must be aware that seafarers, along with other frequent travellers, are at risk to acquire dengue fever and are at higher risk for more severe disease in the form of dengue haemorrhagic fever and/or dengue shock syndrome. However, the prognosis may be difficult to predict at the outset of the disease in an individual seafarer. There is no specific chemoprophylaxis or treatment medication and whilst vaccines are under development, they are not currently available.

Chikungunya Virus

Chikungunya is a virus that is transmitted to humans by the bite of infected Aedes mosquitoes. It is endemic in many South East Asian countries. It causes a febrile disease with symptoms of chills, headache, nausea, vomiting, joint pain, low back pain and rash. Despite the disease being increasingly recognized as a cause of fever in ill travellers (2), no reports have been published in seafarers to date.

Yellow fever

Yellow fever is caused by a flavivirus, transmitted by the infected Aedes mosquitoe and predominantly seen in tropical Africa, Central and Southern America. It presents as a febrile disease with fever, headache, jaundice, muscle pain, nausea, vomiting and fatigue that usually lasts 3 – 4 days. The incubation period is 3 – 6 days. Letality in hospitalized cases is high.  There is no specific treatment although the early and appropriate management of dehydration and fever improves the outcome.

A vaccine is available and Yellow Fever is currently the only disease expressly listed in the International Health Regulations (IHR) for which countries can require proof of vaccination from travellers as a condition of entry. Many countries do require proof of immunization to Yellow Fever in travellers to, or through, their territory. The vaccine provides immunity after 10 days and there is evidence that it produces lifelong immunity in most immunocompetent persons. This is recognised by the IHR in an amendment that came into force in July 2016.

No reports have been published on cases of yellow fever in seafarers, also no severe side effects of the vaccination are known in seafarers. Note: The Yellow -fever vaccination is contraindicated in pregnant women and severely immunocompromised persons-

Zika Virus

In 2014 the WHO declared a cluster of microcephaly and other neurologic disorders reported in Brazil to be a Public Health Emergency of International Concern. They were caused by the Zika virus, transmitted primarily by the Aedes mosquitoes, which bite during the day. Outbreaks and evidence of transmission soon appeared throughout the Americas, Africa, and other regions of the world. To date, a total of 86 countries and territories have reported evidence of mosquito-transmitted Zika infection. In addition, Zika virus can be transmitted through sexual intercourse. This is of concern due to an association between Zika virus infection and adverse pregnancy and fetal outcomes. Zika virus infection during pregnancy can cause infants to be born with microcephaly and other congenital malformations, known as congenital Zika syndrome.

Most people with Zika virus infection do not develop symptoms but those that do experience a fever, rash, conjunctivitis, muscle and joint pain, malaise or headache. Symptoms typically last for 2–7 days. An increased risk of neurologic complications is associated with Zika virus infection in adults and children, including Guillain-Barré syndrome, neuropathy and myelitis.

Advice for the shipping industry is available at http://www.imo.org/en/MediaCentre/HotTopics/Pages/Zika-virus.aspx  and the EU ShipSan project has published an Interim guidance on maritime transport and Zika virus disease (Mochtouri, www.shipsan.eu/Home/Zikavirus.aspx). They conclude that the introduction of human cases of Zika virus disease (seafarers or passengers, symptomatic or asymptomatic) to the EU through ship travel is considered very low. However, specific types of imported goods including used tyres and ornamental plants do introduce invasive mosquito species to EU and recommend integrated Pest Management Plans.

There is no specific treatment and no vaccine available. Protection against mosquito bites during the day and early evening is a key measure to prevent Zika virus infection.

Other diseases

No reports were identified on other diseases from the zoonotic-environmental cluster known to occur in travellers including West Nile fever, Leptospirae, Schistosoma, Sand flies or Helminths.

(1) Schwartz E, Weld LH, Wilder-Smith A, von Sonnenburg F, Keystone JS, Kain KC, Torresi J, Freedman DO, for the GeoSentinel Surveillance Network. Seasonality, annual trends, and characteristics of dengue among ill returned travellers, 1997-2006. Emerg Infect Dis 2008;14:1081-1088. http://www.cdc.gov/eid/content/14/7/pdfs/1081.pdfLast access  August 2013.

(2) Townson H, Nathan MB. Resurgence of chikunguya. Trans R Soc Trop Med Hyg. 2008;102:308-9.

[124] Drăgănescu N, Duca M, Gîrjabu E, Popescu-Pretor I, Răducanu S, Deleanu L, Totescu E. Epidemic outbreak caused by West Nile virus in the crew of a Romanian cargo ship passing the Suez Canal and the Red Sea on route to Yokohama. Virologie 1977;28:259-262.

[125] Woodford N. Unwanted Souvenirs: Travel and Multi-Resistant Bacteria. Journal of Travel Medicine 2011; Volume 18 (Issue 5): 297-298.

G.7 Risk based approaches to management of infectious diseases

Details

Published: 09 January 2022

As with all other forms of risk, the control of infectious diseases depends on a range of engineered controls, safe working practices and monitoring and surveillance. All are supported by training and by effective supervision. The diversity of infectious agents and routes of exposure means that precautionary measures sometimes need to be tailored to the characteristics of certain infections.

Environmental controls include safe storage of food and quality assured water supply. An additional aspect, where vector organisms transmit infections such as malaria is  preventing their access to those on board.

Work practices include safe food preparation, personal hygiene and sometimes separation of those suspected of being infected from others on board, or the use of personal protective equipment

Vaccination – see text at end of volume. This type of personal protection is sometimes effective enough to mean that other precautions need to be less stringent.

Practical aspects

To be effective, the control of infectious diseases needs clearly defined responsibilities. The responsible organisations and persons and their roles are included in Table 2.

Table 2: Roles and responsibilities in managing infectious diseases in the maritime environment

G.5 Droplet-Air-Cluster

Details

Published: 09 January 2022

Introduction

Seafarers and passengers on board, as well as contacts in ports, are common sources of respiratory infections for seafarers. Spread is largely by droplets, directly or indirectly when a person with a respiratory illness coughs or sneezes, spreading droplets into the air and onto objects and surfaces in close proximity. Other people breathe in the droplets or touch the objects or surfaces and then touch their eyes, nose or mouth. Infective aerosols can also be source of infection. Other infectious diseases such as varicella, rubella and measles are also spread in this way, attack rates vary.

Several longitudinal studies of the epidemiology of illnesses among passengers from medical log books on cruise ships described large outbreaks of Influenza A and B and currently  COVID-19. Acute respiratory infections and influenza-like illness are the most common cause of seeking medical attention by passengers and crew members aboard cruise and cargo ships (1,2,3,4).

Verbist reported that 12 % of attendances in a port clinic in Belgium can be attributed to respiratory diseases. The most frequent upper respiratory diseases were rhinitis, rhino-sinusitis and influenza, while lower respiratory infections, including exacerbations of chronic obstructive pulmonary disease were linked to cigarette smoking (5). 

Schlaich et al. (6) showed in a retrospective study based on medical log books from merchant ships under the German flag that respiratory infections are the most common causes of communicable diseases aboard cargo ships and may cause outbreaks of considerable morbidity. During more than 1.5 million person-days of observation, nearly one fourth of the visits to the ship’s infirmary were due to communicable diseases (45.8 consultations per 100 person-years). 33.9 crew members per 100 person-years sought medical attention for presumed acute respiratory infections. 68 outbreaks of communicable diseases were identified of which 66 were caused by acute respiratory infections and two by outbreaks of gastrointestinal infection.

In the pre-COVID.19 pandemic era seafarers and passengers alike often perceived the air-conditioning on board as a cause of their frequent upper respiratory infections and frequently neglected vaccination when it is offered to them.

Vaccination against airborne diseases (including Influenzy, SARS-COV2, Pneumococcal disease, pertussis, varicella, measles) must be a preferred strategy for ship -owners to protect crew an passengers (7).

Risk management

The authors of a systematic review of COVID-19 outbreaks on ships concluded: ”Problems in handling outbreaks resulted from a high number of asymptomatic infections, transportation issues, challenges in communication or limited access to health care. Responsible operators need to implement infection control measures which should be described in outbreak management plans for ships to prevent transmission risks, including, e.g., education, testing strategies, communication lines, social distancing and hygiene regulations“ (8).

Key elements for the prevention and control of respiratory outbreaks on cruise ships and large vessels with many crew include:

• active and/or passive surveillance using standard case definitions,
• use of targeted rapid testing where available and viral cultures to confirm cases of infection,
• isolation of all persons on board who meet the relevant case definition,
• use of antiviral agents or immunoglobulin as appropriate for treatment and, if indicated for prophylaxis,
• monitoring of the effects of intervention
• vaccination programmes including post exposure vaccination where available and appropriate.

Notification of the public health authorities in the next port of call through the Maritime Declaration of Health is mandatory.

Due to highly publicized outbreaks of respiratory illness, particularly influenza and COVID-19 on cruise ships, and the corporate and global planning for pandemic influenza, extensive recommendations by the World Health Organization, the US Centre for Disease Control and the EU ShipSan Project are available for prevention, surveillance and the control of respiratory illness, seasonal and pandemic influenza on board of merchant and cruise ships.

(1) Millman AJ, Kornylo Duong K, Lafond K, Green NM, Lippold SA, Jhung MA. Influenza Outbreaks Among Passengers and Crew on Two Cruise Ships: A Recent Account of Preparedness and Response to an Ever-Present Challenge. J Travel Med. 2015 Sep-Oct;22(5):306-11. doi: 10.1111/jtm.12215. Epub 2015 Jun 2. PMID: 26031322; PMCID: PMC4869710.

(2) Pavli A, Maltezou HC, Papadakis A, Katerelos P, Saroglou G, Tsakris A, Tsiodras S. Respiratory infections and gastrointestinal illness on a cruise ship: A three-year prospective study. Travel Med Infect Dis. 2016 Jul-Aug;14(4):389-97. doi: 10.1016/j.tmaid.2016.05.019. Epub 2016 Jun 15. PMID: 27320130.

(3) Willebrand KS, Pischel L, Malik AA, Jenness SM, Omer SB. A review of COVID-19 transmission dynamics and clinical outcomes on cruise ships worldwide, January to October 2020. Euro Surveill. 2022 Jan;27(1):2002113. doi: 10.2807/1560-7917.ES.2022.27.1.2002113. PMID: 34991781; PMCID: PMC8739343.

(4) Plucinski MM, Wallace M, Uehara A, Kurbatova EV, Tobolowsky FA, Schneider ZD, Ishizumi A, Bozio CH, Kobayashi M, Toda M, Stewart A, Wagner RL, Moriarty LF, Murray R, Queen K, Tao Y, Paden C, Mauldin MR, Zhang J, Li Y, Elkins CA, Lu X, Herzig CTA, Novak R, Bower W, Medley AM, Acosta AM, Knust B, Cantey PT, Pesik NT, Halsey ES, Cetron MS, Tong S, Marston BJ, Friedman CR. Coronavirus Disease 2019 (COVID-19) in Americans Aboard the Diamond Princess Cruise Ship. Clin Infect Dis. 2021 May 18;72(10):e448-e457. doi: 10.1093/cid/ciaa1180. PMID: 32785683; PMCID: PMC7454359.

(5) Carter T. Infection on board ships in the 21^st century; overview of IMHA workshop, Singapore 2010. Int Marit Health 2011; 62, 3: 160-163.

(6) Schlaich CC, Lucas K, Sydow S, Beyer E, Faesecke KP. Procedural aspects of COVID-19 vaccinations for seafarers on ocean-going vessels. Int Marit Health. 2021;72(3):179-182. doi: 10.5603/MH.2021.0034. PMID: 34604986.

(7) Mouchtouri VA, Lewis HC, Hadjichristodoulou C; EU SHIPSAN ACT Joint Action Partnership. A Systematic Review for Vaccine-Preventable Diseases on Ships: Evidence for Cross-Border Transmission and for Pre-Employment Immunization Need. Int J Environ Res Public Health. 2019 Jul 30;16(15):2713. doi:

(8) Kordsmeyer AC, Mojtahedzadeh N, Heidrich J, Militzer K, von Münster T, Belz L, Jensen HJ, Bakir S, Henning E, Heuser J, Klein A, Sproessel N, Ekkernkamp A, Ehlers L, de Boer J, Kleine-Kampmann S, Dirksen-Fischer M, Plenge-Bönig A, Harth V, Oldenburg M. Systematic Review on Outbreaks of SARS-CoV-2 on Cruise, Navy and Cargo Ships. Int J Environ Res Public Health. 2021 May 13;18(10):5195. doi: 10.3390/ijerph18105195. PMID: 34068311; PMCID: PMC8153346.

Legionellosis

Legionella species are known causes of travel related illness (1). It is a waterborne disease, spread of disease is via inhalation of aerosols. In certain conditions potable water systems (showers), air conditioning, cooling towers, evaporative condensers, humidifiers, whirlpool spas, decorative fountains and respiratory therapy devices may harbour Legionellosis. No person-to-person spread occurs.

It is an acute bacterial disease with two distinct clinical manifestations: Legionnaires disease (incubation period 2-10 days) and Pontiac fever (5-72 hours). Both conditions present with anorexia, malaise, myalgia, headache and fever. Abdominal pain and diarrhoea are frequent. Legionnaires disease is a common cause of pneumonia and is characterized by non-productive cough. Chest radiographs are variable and may show patchy, bilateral or focal areas of consolidation. The fatality rate remains at 15%. Pontiac fever is a self-limiting febrile illness that does not progress to pneumonia or death.

In a study on Legionellosis associated with ships from 1977 and 1997, being on board a ship was an established a risk factor for an infection with Legionella spp. Cases were found to be less common among crewmembers than among passengers (2). Poorly constructed or maintained water or air management systems involving the water supply, swimming pools and beauty areas are the sources of infection. Using the whirlpool spa on a cruise ship has been identified as a risk factor for passengers (3).

A case study from a cargo ship described two lethal cases of Legionellosis in two mechanics working with the pump of the ship´s contaminated water system on a ship under repair in the port of Barcelona (4).

A prevalence study was carried out on 7 ferries and 2 cruise ships docked in Sardinia, Italy in 2004. Water samples from critical sites were analyzed for the presence of Legionella spp. Legionella spp. was identified in samples of 6 out of 7 ferries (5).

A prevalence study of 276 water samples from 10 cruise ships and 21 ferries showed heavy colonization of water distribution systems on ferries (38% of hot water and 18% of cold water systems) (6).

In a study in UK 803 samples from 360 non-passenger vessels were cultured specifically for Legionella and 58% of vessels proved positive for these organisms with 27% of samples showing levels greater than the UK upper action limit (7).

In Turkey 18 ferries and cargo ships were sampled, it was determined that 11.4% of the water samples collected from the water systems of the ships docking in Mersin International Port were contaminated with Legionella species (8).

Generally, ships have been recognized as an at risk environment for Legionella colonization in the drinking water installation due to poor temperature control and other factors. Only few cases of Legionella disease in sefarares have been reported, the true magnitude of the the disease burden is unkwn. Underreporting is possible.

Proper maintenance and construction are of major importance for Legionella prevention. Regular sampling procedures is recommended (9).

If a case of Legionnaires disease in a sailor is confirmed, potable water sampling on the ship and assessment of the condition of the system are mandatory.  Legionellosis is a notifiable disease in most countries. A cluster of diseases warrants an epidemiological investigation with environmental sampling and active surveillance of contacts by public health authorities.

(1) European Surveillance Scheme for Travel Associated Legionnaires’ Disease and the European Working Group for Legionella Infections, ed. European guidelines for control and prevention of travel associated Legionnaires’ disease. 2005. http://www.ewgli.org/data/european_guidelines/european_guidelines_jan05.pdf  Last access August 2013.

(2) Rowbotham TJ. Legionellosis associated with ships: 1997 to 1997. Commun Dis Public Health 1998;1:146-151.

(3) Jernigan DB, Hofmann J, Cetron MS, Genese CA, Nuorti JP, Fields BS, Benson RF, Carter RJ, Edelstein PH, Guerrero IC, Paul SM, Lipman HB, Breiman R. Outbreak of Legionnaires’ disease among cruise ship passengers exposed to a contaminated whirlpool spa. Lancet 1996 347:494-499.

(4) Cayla JA, Maldonado R, Gonzalez J, Pellicer T, Ferrer D, Pelaz C, Gracia J, Baladron B, Plasencia A, Legionellosis study group. A small outbreak of Legionnaires disease in a cargo ship under repair. Eur Respir J 2001; 17: 1322-1327.

(5) Azara A, Piana A, Sotgiu G, Marco D, Deriu MG, Masia MD, Are BM, Muresu E. Prevalence study of Legionella spp. Contamination in ferries and cruise ships. BMC Public Health 2006, 6:100.

(6) Goutziana G, Mouchtouri A Karanika M et al. Legionellaspecies colonization of water distribution systems, pools and air conditioning systems in cruise ships and ferries. BMC Public Health 2008, 8:390.

(7) Collins SL, Stevenson D, Mentasti M, Shaw A, Johnson A, Crossley L, Willis C. High prevalence of Legionella in non-passenger merchant vessels. Epidemiol Infect. 2017 Mar;145(4):647-655. doi: 10.1017/S0950268816002715. Epub 2016 Nov 28. PMID: 27890040.

(8) Ülger M, Tezcan Ülger S, Bekçi A, Nar Ötgün S, Delialioğlu N, Aslan G. Gemilerin Su Sistemlerinden İzole Edilen Legionella Türleri ve Moleküler Karakterizasyonu [Legionella Species Isolated in the Water Systems of Ships and Their Molecular Characterization]. Mikrobiyol Bul. 2022 Jan;56(1):11-24. Turkish. doi: 10.5578/mb.20229902. PMID: 35088956.

(9) Mouchtouri VA, Nichols G, Rachiotis G, Kremastinou J, Arvanitoyannis IS, Riemer T, Jaremin B, Hadjichristodoulou C; SHIPSAN partnership. State of the art: public health and passenger ships. Int Marit Health. 2010;61(2):49-98. PMID: 21154293.

Tuberculosis

Tuberculosis is an infectious disease which damages one or more organs through a slowly multiplying bacterium. Infections of tuberculosis are acquired from human aerosol or droplets which the infected patient spreads while coughing and breathing.

Tuberculosis can express many different symptoms, which initially may not be very distinctive. Infection of the lung is the most frequent form and also the most important because of its potential for transmission of the disease (so- called “smear-positive Tuberculosis”). Pulmonary tuberculosis commonly presents with symptoms like cough, expectoration, feeling ill, and a slight temperature rise. Due to the insidious symptoms, the diagnosis of tuberculosis often is delayed. Therefore, contact between the patients and their families or other crew members are possible before a contagious patient is being diagnosed, isolated and treated.

Assuming lifelong infection, about one-third of humanity is infected with Mycobacterium tuberculosis. It occurs globally but is a major cause of death and disability in developing countries where the disease is closely linked to the HIV epidemic. The densely populated countries of Asia harbour the largest number of cases, many of them being major suppliers of seafarers to international trade: India, China, Indonesia, Bangladesh and Pakistan together accounted for about half of the world´s new TB cases in the last decade. While most of the burden of the disease is carried predominantly by Asian countries, it is sub-Saharan Africa and the former Soviet Union that showed the most striking increase in case load during the 1990´s (1).

 The resurgence of multidrug and extensively drug resistant tuberculosis in Eastern Europe, Asia and Southern Africa is of special concern.

Notwithstanding the enormous global burden of disease, the interaction between M. tuberculosis and humans is relatively benign. As a rule of thumb, untreated sputum smear-positive cases infect 5-10 other individual cases each year. In immunocompetent humans, as most seafarers are, only about 5% of infected individuals develop progressive primary disease following infection. Also, the progression time is slow, averaging 3-4 years. After 5 years, there is a low annual risk of developing tuberculosis by reactivation of the infection, which is then said to be latent. On the other hand tuberculosis has a high case-fatality rate among untreated or improperly treated cases. About 2/3 of untreated smear-positive cases will die within 5 to 8 years (1).

Systematic data on the prevalence of infection, occupational disease transmission and the occurrence of clinical disease in the population of seafarers is very limited. However, in our personal experience as practicing port physicians detection of pulmonary regularly occurs during seafarers fitness exams or in medical work up of chronic cough and/or hemoptysis.(“think Tb”!).

On a United States Navy amphibious assault ship, one person had cavitating tuberculosis in 1998 which resulted in extensive transmission. Of 3338 crew who were subsequently skin tested, 21% (n=712) had new latent infection and n=21 were found to have active tuberculosis (2).

A longitudinal study on tuberculin skin rates in over one million US Navy and Marine Corps personnel in the United States from 1999 to 2002 showed higher annual conversion rates in personnel of amphibious ships (1.76%) as compared to aircraft carriers (Relative Risk 3.33 95% CI 2.98-3.71. A surveillance programme has been in operation since 1992 for USA Seafarers` International Union members. This used tuberculin skin testing and showed a reduction in positive results from ca 15% in 1994 to ca. 4% in 1998. A higher prevalence rate was found in submarines and those working on cruise ships (3).

A systematic review of 78 seafarers referred to the Naval Hospital in Shanghai, China in 1990 found the majority of clinical symptoms in seafarers diagnosed with active TB to be cough and expectorations (71%) and haemoptysis (51%). Only 6 of the cases diagnosed with tuberculosis were smear-positive (4).

One retrospective longitudinal study from Denmark on the risk of tuberculosis in seafarers compared to the general Danish population was identified. Hansen et al. linked a national registry containing all reported cases of tuberculosis in Denmark with a research register on all seafarers on Danish ships. The study period was 1992 to 2003. All strains of tuberculosis were analysed using DNA subtyping. The risk of tuberculosis among male seafarers was 1.51 (1.10-2.01) compared with the general population. Only 7 out of 64 cases of tuberculosis were assessed to be likely or possibly shipping-related. The authors conclude that despite multi-cultural crews aboard, including many from high incidence countries, only limited transmission of Mycobacterium tuberculosis takes places among crew aboard or during shore leaves (5).

In another Danish study from hospital registers fishermen showed a higher rate of tuberculosis as compared to the  general population (6).

A case report of cavitating smear and culture positive tuberculosis in a 32 years old sailor from the Philippines aboard a United States aircraft carrier described the outcome of this incident in the year 2006. The patient and other air-wing sailors slept in an open-bay compartment with 120 bunks arranged in stacks of three; another compartment of the same size was adjacent and connected to the patient´s compartment. The ship sailed with over 5000 soldiers aboard. Despite several months of potential exposure in a high-risk setting as described above, results from screening of all sailors suggested limited transmission of Mycobacterium tuberculosis on the ship.  No secondary cases were identified. 13% of close contacts had latent tuberculosis. The authors concluded that tuberculosis transmission was minimal despite the sleeping arrangement (7)

These publications demonstrate the complexity of risk assessment for tuberculosis in seafarers. Individual risk factors leading to infection, and for progression, recurrence and adverse outcome of disease are: HIV infection, alcoholism, smoking, malnutrition, country of origin, social status and non-adherence to treatment. The living and working conditions in the country of origin and on the vessel (intimacy and duration of possible contacts, the ventilation in the shared environment) and the degree of contagiousness of the index case (smear-positive or negative, cavitating pulmonary lesion, multidrug-resistant TB etc.) must be considered.

Commonly, if a case of tuberculosis is detected among crew, the seafarer will be hospitalized as soon as possible and repatriated as soon as he is not infectious any more. If it is decided that the seafarer is to continue to travel on the ship, he must be isolated in his cabin if smear-positive or unknown. Infectivity is usually best controlled through prompt specific therapy, normally leading to disappearance of viable organisms in the sputum in 2-4 weeks and full clearance in 4-8 weeks.[84] The disease and the therapy cause a major reduction of the patient’s physical fitness and working ability. Furthermore, adverse reactions from the drugs like liver dysfunction must be checked for, with examinations every other week. Even a rapid recovery from the disease leads to a period of limited ability to work for at least 4-5 months. Before getting back to work on board, the X-ray of the lung should show obliteration of any pulmonary cavities and a significant reduction in the inflammatory changes.

While there are detailed recommendations of World Health Organization and the European Centers for Disease Control concerning risks of infection and contact tracing if disease has occurred on board for international air travel, no such recommendations exist for the ship travel. It is common practice that in the ship’s environment all crew members on cargo ships are to be classified as “close household” contacts and be followed up for infection and disease. In passenger ships this is a decision to be made by individual assessment of the living and work-place condition. It is usually admitted that a stay exceeding 8 hours in a restricted area like a domestic room should be classified as a “close contacts”. Furthermore, close contact should be considered after direct contact with respiratory, oral, or nasal secretions from a symptomatic case of smear positive pulmonary / laryngeal tuberculosis (e.g. an explosive cough or sneeze in the face, sharing of food, sharing eating utensils during a meal, kissing, mouth-to-mouth resuscitation or performing a full medical exam including examination of the nose and throat).

Contact Tracing in seafarers

Management of potentially exposed contacts to a source of tuberculosis infection (contact tracing in seafarers) (8):

1. For some years a special blood test, the interferon gamma release assay (IGRA), has been used to discriminate between an acute infection with mycobacterium tuberculosis and a vaccination-induced immune reaction. This method seems to be the most practicable for use in the maritime environment where passengers and crew may not reside at the place of investigation. The test should be performed not earlier than 8 weeks after exposure has ended because the organism needs this time to induce the specific lymphocytes that are measured. The cost of the test is slightly higher than the skin-test but it’s more practical and more specific. Local health authorities may initiate the tests in cooperation with the shipping company.

2. An X-ray on persons with a positive blood test will demonstrate any manifestations of pulmonary tuberculosis. A combination of a positive IGRA test and a negative X-ray indicates latent infection. But always consider extrapulmonary tuberculosis if cervical or axillary lymph nodes, pleural or pericardial effusion, ascites or abdominal para-aortic lymph nodes are detected. In latent tuberculosis, preventative treatment with Isoniazid for nine months may prohibit a later recurrence of the infection. Decision making for preventative treatment should involve a medical specialist to assess comorbidities and strict cehcks for possible contraindications, such as preexisting liver dysfunction.

3. The diagnostic skin-test is an alternative to IGRA to see whether the tested patient’s immune system has responded to the tuberculosis bacterium. Like the IGRA a time gap between exposure and a positive test result exists. This test cannot discriminate between a latent infection and a manifest affection. Hence, for persons who test positive, an additional X-ray is necessary. In immunosuppressed persons further tests to rule out extra-pulmonary diseases are warranted. Furthermore, the test cannot discriminate between an acute infection and an immune reaction from an earlier vaccination. Moreover, the skin test reaction has to be examined by a physician two days after the solution was injected. This may be a problem for seamen on ships with short port-calls. Overall, if available, the IGRA is the preferred screening method for the shipping industry.

An X-ray of the lung shows only well-developed pulmonary disease, latent infections cannot be identified. Using only this method without IGRA or a skin test, a second X-ray is necessary about two months after contact with the index patient, because of a delayed expression of the infection. X-ray is obligatory in symptomatic persons after contact with tuberculosis. Symptoms could be cough and expectoration, malaise or loss of body weight.

Overall, if screening of close contacts to a smear positive case of tuberculosis on a ship results in positive tuberculin skin or IGRA tests, the individual should be referred to a medical specialist with experience in global tuberculosis epidemiology and care. Seafarers should receive written information from the company or public health authority on the time and duration of contact to a tuberculosis index case and recommendations for follow up in their home country if their contract ends before testing was possible.

(1) Davies P DO, Barnes PF, Gordon SB. Eds.: Clinical Tuberculosis. 4 th edition, 2008. ISBN-13 9780340948408. Hodder and Soughton Ltd.

(2) LaMar JE II, Malakooti MA. Tuberculosis outbreak investigation of a US Navy amphibious ship crew and the Marine expeditionary unit aboard, 1998. Mil Med 2003;168:523-527.

(3) Bowman C, Bowman W, Bohnker BK, Riegodedios A, Malakooti M. US Navy  and Marine Corps conversion rates for tuberculosis skin testing (1999-2002), with literature review. Mil Med 2006;171:608-612.

(4) Yufeng J, Shengyuan J, Bohua C. A clinical analysis on 78 cases with pulmonary TB in seafarers.In: 9^th International Symposium on Maritime Health. Equity in maritime health and safety – development through research, cooperation and education. Book of Abstracts.Esbjerg, Denmark 3-6 June 2007.Poster 1-13

(5) Hansen HL, Henrik Andersen P, Lillebaek T. Routes of M. tuberculosis transmission among merchant seafarers. Scand J Infect Dis 2006;38:882-887.

(6) Kaerlev L, Jensen A, Hannerz H. Surveillance of hospital contacts among Danish seafarers and fishermen with focus on skin and infectious diseases-a population-based cohort study. Int J Environ Res Public Health. 2014;11(11):11931-11949. Published 2014 Nov 18. doi:10.3390/ijerph111111931

(7) Buff AM, Deshpande SJ, Harrington TA, Wofford TS, O´Hara TW, Carrigan K, Martin NJ, McDowell JC, Ijaz K, Jensen PA, Lambert LA, Moore M, Oeltmann JE. Investigation of Mycobacterium tuberculosis transmission aboard U.S.S. Ronald Reagan 2006. Mil Med 2008;173:588-593.

(8) Heyman DL ed. Control of Communicable Diseases Manual. American Public Health Association. WHO. 19th Edition 2008. ISBN 0-87553-034-6.

Human Influenza and Pandemic Influenza

Influenza is an acute respiratory infection that rapidly spreads around the world in seasonal epidemics. It occurs in small outbreaks or epidemics. In annual influenza epidemics, 5-15% of the general population are affected with upper respiratory infections. Morbidity and mortality is highest in certain risk-groups, e.g. children, pregnant women, the elderly, chronically ill persons. The disease is spread from person to person through the air. Influenza is very contagious especially in crowded environments with close interpersonal contacts, like ships . Here, the clinical attack rates can reach to more than 50%. The incubation period averages 2 days (range 1-4), in adults, viral shedding and probable communicability is greatest in the first 3-5 days of illness. In young children and the immuno-compromised, virus shedding can occur for longer (up to 10 days).

There have been well documented outbreaks of influenza A and B on passenger and naval ships, mainly from the northern hemisphere. Several detailed outbreak studies have been performed. Attack rates among crew members were described to be between 0% and 42% for influenza-like illness and 1% and 13% for acute respiratory infections. For passengers attack rates for influenza-like illness were between 1% and 37% and for acute respiratory infection between 2% and 18(1,2,3,4).

 In one United States Navy ship the attack rate of influenza-like illness as was found to be 42% despite an influenza vaccination rate of 95% before the outbreak (5). 

The particular vulnerabilities of cruise ships to influenza include 1) large numbers of persons in semi-closed environment, 2) the short incubation time of influenza, 3) mixing of passenger and crew from northern and southern hemispheres, 4) high numbers of persons at risk for morbidity (elderly, pregnant women, children) (6).

Though comparability of attack rates between studies is limited by different methods of case finding, definition and control measures, rates in crew and passengers were within the same range.  Overall, influenza outbreaks among crew members and passengers on all types of ships pose a travel related risks for exposure to influenza viruses even if the vessel is in regions where influenza is not in seasonal circulation.

Due to highly publicized outbreaks on cruise ships and corporate and global planning for pandemic influenza, extensive recommendations by the World Health Organization, the Centers for Disease Control and the EU Project ShipSan Manual are available for prevention, surveillance and control of seasonal and pandemic influenza on board of cargo and cruise ships(7,8).

 Control measures during a recognized outbreak include clinical and virological surveillance, antiviral therapy with Rimantidin or Oseltamivir and post-exposure vaccination. Since influenza infections may be introduced to cruise ships by passengers or crew it is recommended that cruise lines should attempt to achieve at least an 80% vaccination rate among crew members among each ship each year (9).

 Travellers at high risk for complications who have not been vaccinated against influenza during the preceding fall or winter season should consider receiving influenza vaccine before travel.

Key elements for the prevention and control of Influenza outbreaks on cruise ships and large vessels with many crew members include 1) active and / or passive surveillance using standard case definitions, 2) use of targeted rapid influenza testing and viral cultures to confirm cases of influenza virus infection, 3) isolation of all crew members meeting the influenza-like illness case definition, 4) use of antiviral agents for treatment and, if indicated for prophylaxis, 5) monitoring of intervention results (10).

The 2009/2010 experience of Novel Influenza A H1N1

Global spread, high attack rates and high excess mortality characterize pandemic influenza. Occurrence of pandemic influenza is unpredictable and believed to arise when a genetically re-assorted virus reaches susceptible populations. The occurrence of pandemic influenza requires special considerations by ship owners and masters, such as active and passive surveillance, information flow between company and vessels, isolation facilities on board, vaccination of crew and passengers, antiviral agents for prophylaxis and treatment and personal protective equipment (11).

The 2009/2010 pandemic caused by Novel Influenza A H1N1 has resulted in detailed recommendations to the shipping industry by the World Health Organization, the International Maritime Health Association and the EU ShipSan project (12).

Several outbreaks of Influenza A H1N1 on passenger ships were reported in the press but assessments of the burden of disease in seafarers or formal outbreak investigations were not published.  The World Health Organization published a global study on infection control measures on ships and in ports. Of 31 companies that operated 960 ships, 32% experienced health screening measures by port health authorities. Twenty-six percent of ports performed embarkation screening and 77% of shipping companies changed procedures during the early stage of the pandemic. Four companies reported outbreaks of pandemic influenza A (H1N1) 2009 on ships, which were ultimately stopped through infection control practices. Public health measures did not interfere substantially with port and ship operations with the exception that some port authorities delayed embarking and disembarking procedures. However, in shipping companies’ experience, measures were inconsistent between port health authorities. Antiviral drugs and pandemic vaccine was not made available (13).

The USA cruise ship industry cooperated early in the pandemic, in accordance with Centers of Disease Control procedures. Their experience reinforced the importance of pandemic planning for governmental agencies and private industries alike, including the development of practical procedures in advance (14)

Avian Influenza (Influenza H5N1, “Bird Flu”)

The highly pathogenic avian influenza A (H5N1) causes epizootic animal outbreaks in Asia, Europe, the Near East, and Africa . So far, the spread of H5N1 virus from person-to-person has been very rare, limited and unsustained. No infections in association with seafaring have been reported. No risk factors for transmission on board passenger or merchant ships can be identified.

(1) Miller JM, Tam TW, Maloney S, Fukuda K, Cox N, Hockin J, Kertesz D, Klimov A, Cetron M. Cruise ships: high-risk passengers and the global spread of new influenza viruses. Clin Infect Dis 2000;31:433-438.

(2) Brotherton JML, Delpech VC, Gilbert GL, Hatzi S, Paraskevopoulos, McAnulty JM. A large outbreak of influenza A and B on a cruise ship causing widespread morbidity. Epidemiol Infect 2003;130:263-271.

(3) Centers for Disease Control and Prevention. Influenza B virus outbreak on a cruise ship – northern Europe 2000.MMWR Morb Mortal Wkly Rep 2001 50:137-140.

(4) Centers for Disease Control and Prevention. Outbreak of influenza A infection among travellers –Alaska and the Yukon Territory, May-June 1999.MMWR Morb Mortal Wkly Rep 1999;48:545-546.

(5) Earhart KC, Beadle C, Miller LK, Pruss MW, Gray GC, Ledbetter EK, Wallace MR. Outbreak of influenza in highly vaccinated crew of U.S. Navy ship. Emerg Infect Dis 2001;7(3):463-465.

(6) Ferson M, Paraskevopoulos P, Hatzi S, Yankos P, Fennell M, Condylios A. Presumptive summer influenza A: an outbreak on a trans-Tasman cruise. Commun Dis Intell 2000;24:45-47.

(7) Lim PL. Influenza and SARS: the impact of viral pandemics on maritime health. Int Marit Health 2011; 62, 3: 170-175.

(8) World Health Organization. WHO technical advice for case management of Influenza A (H1N1) International travel and health

(9) Bodnar UR, Fielding KL, Navin AW, Maloney SA, Cetron MS, Bridges CB, Fukuda K, Butler JC. Preliminary guidelines for the prevention and control of influenza-like illness among passengers and crew members on cruise ships. Atlanta: Centers for Disease Control and Prevention, National Center for Infectious Diseases, 1999.

(10) Mouchtouri VA, Nichols G, Rachiotis G, Kremastinou J, et al. For the SHIPSAN partnership: State of the art: public health an dpassenger ships. Int Marit Health 2010; 61, 2:49-98.

(11) Schlaich C. Betriebliche Influenzapandemieplanung – Ein Thema für die Schifffahrt? In: Baur X, Glensk E, eds. Ethische Fragen in der Arbeitsmedizin. Arbeitsbedingte Hautkrankheiten. Maritime Medizin – eine komplexe arbeitsmedizinische Herausforderung. 48. Wissenschaftliche Jahrestagung der Deutschen Gesellschaft für Arbeitsmedizin und Umweltmedizin e. V. in Verbindung mit ICOH Mid-term Meeting 2008. Hamburg 12.-15.3.2008. Aachen: DGAUM, 2008:129-134

(12)  Mouchtouri VA, Nichols G, Rachiotis G, Kremastinou J, et al. For the SHIPSAN partnership: State of the art: public health and passenger ships. Int Marit Health 2010; 61, 2:49-98.

(13) Schlaich C., Gau B, Cohen N, Kozima K, Marano N, Menucci D. Infection control measures on ships and in ports during the early stage of pandemic influenza A (H1N1) 2009Int Marit Health 2012;63; 1:7-23.

(14) Bunyan K. Pandemic planning in the shipping industry – lessons learnt from the 2009 pandemic. Int Marit Health 2011; 62, 3: 196-199.

SARS (Severe Acute Respiratory Syndrome)

CHAPTER IN PROGRESS

Chickenpox and shingles (Varicella-zoster virus)

The varicella-zoster virus causes both chickenpox (varicella) and shingles (herpes zoster). The latter is usually a disease found in the elderly. Chickenpox is a highly contagious illness with a characteristic rash transmitted by the airborne or droplet pathway and by person-to-person contact, with a usually incubation period of 14 (10-21) days. Secondary attack rates reach close to 90% in susceptible household contacts. While it is a usually a mild disease in healthy children, serious complications may arise in adults, those who are immunocompromised, pregnant women and infants.

Varicella zoster virus predominantly affects children in temperate countries, with near-universal seroconversion occurring by late childhood. However, the epidemiology is changing where vaccination has been introduced as a routine immunization, in countries such as Germany, United States, Uruguay, Quatar, Australia, Canada and South Korea. The epidemiology of chickenpox is even more complex in tropical and subtropical regions where seroconversion generally occurs in late adolescents and adults and may be less likely in rural areas than in urban areas.

A cross- sectional serosurvey in 1533 US Navy and Marine Corps recruits was conducted in June 1989. Seronegativity was 6.7% for varicella (1).

In May 2008 the European Centres for Disease Control published a risk assessment when varicella transmission among crew members of a large Italian cruise ship was recognized. A total of eleven crew members were reported sick. No cases occurred in the passengers (2).

Between November 2007 and April 2008 five cases of chickenpox in four vessels were reported to the Hamburg Port Health Center from two passenger and two cargo ships. Cases originated from Indonesia (1), Philippines (2) and Sri Lanka (2). The majority of passengers were UK residents. Sources of infection were other crew members, passengers and persons in the home countries (3).

Idnani studied seroprevalence of Varicella immunity in Indian cruise ship employees. He found 17% of 121 Indian seafarers during pre-employment exams to be IgG negative (4).

Acevedo et al presented data on three outbreaks of varicella of Royal Caribbean Cruises Ltd. In 2009 three cruise ships of the company were affected and in 2010 5 ships (69 crew, 29 passengers). Crew members from 26 nations were involved, a total of 2085 contacts were vaccinated (5).

Rice te al from the CDC reviewed 967 reports of varicella and 13 reports of herpes zoster from cruise ships. (78.4% of varicelaa cases were crew members. Most often, cruise ship crew member case-patients were born in or held passports from Indonesia,Philippines, or India (6).

A large part of the work force on ships originates from (South-East) Asia and Eastern European countries. Port health doctors, ship doctors and shipping companies need to be aware that a substantial portion of their employees from Asia and Africa may be non-immune to varicella-zoster virus. Non-immune employees may introduce the disease from their home countries to the ship if they start a new contract within the incubation period and are at risk to be infected by children or other crew-members on board ships. It has been suggested that pre-employment serological screening and –if necessary vaccination- may be cost-effective as compared to the consequences of an outbreak at sea. [95] Certainly this is a serious consideration for crews on large passenger ships with children, immunosuppressed persons and pregnant women aboard.

If an outbreak at sea occurs the following measures are recommended:

-        isolation of the sick person in cabin until scabs resolve

-        person-to-person contact of the sick only with immune crew members

-        inform crew and passengers and alert them on typical symptoms, such as rash and fever to assist passive case-finding.

-        If appropriate, provide post-exposure vaccination within 72 hours

 -       On cruise ships, inform special risk groups (pregnant women)-

-        Notification of port health authorities

Oral aciclovir can reduce the duration of contagiousness and complications. Varicella vaccine is effective both for primary prevention and immediate post-exposure prophylaxis. Varizella zoster immunoglobulin is indicated only if there is high risk of complications, as in pregnant women and immunosuppressed persons.

(1) Struewing JP, Hyams KC, Tueller JE, Gray GC. The risk of measles, mumps, and varicella among young adults: a serosurvey of US Navy and Marine Corps recruits. Am J PublicHealth. 1993; 83:1717-20.

(2) European Centers for Disease Control.Risk Assessment – 12 May 2008. Risk assessment for varicella virus transmission of affectedcruise ship crew members to passengers.www.ecdc.europa. Last access 10/2008.

(3) Robert Koch Institut. Schlaich C., Kalkowski M, Hagelstein J-G, Oldenburg M. Windpocken an Bord. Epid Bull 2009.

(4) Idnani N. Varicella among seafarers: a case study on testing and vaccination as a cost-effective

method of prevention. Int Marit Health 2010; 61, 2:32-35-98.

(5) Acevedo F, Diskin A, Dahl E. Varicella Outbreaks on Cruise ships. 11^th International Symposium on Maritime Health. Book of Abstracts 2010: page 4. 

(6) Rice ME, Bannerman M, Marin M, Lopez AS, Lewis MM, Stamatakis CE, Regan JJ. Maritime varicella illness and death reporting, U.S., 2010-2015. Travel Med Infect Dis. 2018 May-Jun;23:27-33. doi: 10.1016/j.tmaid.2018.04.001. Epub 2018 Apr 3. PMID: 29621623; PMCID: PMC6624850

Rubella (German measles)

Rubella virus circulates worldwide in susceptible humans. Spread is via droplets or direct contact with infected persons.  Incubation period is from 14-17 days. Immunity is usually permanent after natural infection and probably life-long after immunization.

Risks of infection include non-compliance with childhood vaccination programs, contact with a case, crowded working and living conditions. Clinically, rubella is indistinguishable from febrile illness with rashes due to measles, dengue, parvovirus B 19, Herpesvirus 6, Coxsackie virus, Echovirus, Adenovirus or scarlet fever. Adults may experience a 1-5 day prodrome of low-grade fever, headache, malaise, mild coryza and conjunctivitis. Post-auricular, occipital and posterior cervical lymphadenopathy is the most characteristic clinical feature and precedes the rash by 1-5 days. Laboratory diagnosis of rubella is required since clinical diagnosis is often inaccurate.

Rubella transmission was reported among crew members of two different commercial cruise ships from Florida in the year 1997. In one ship 7 out of 900 crew members and 2000 passengers had disease consistent with acute rubella infection. Most of the crew members were born outside the United States and had no documented immunity. In a second cruise ship with 345 crew and 8400 passengers a cluster of illness with a rash among crew was notified to the Centers of Disease Control. A serosurvey confirmed Rubella in 16 (4%) of crew members an additional 25 (7%) had no immunity (1). In both cruises crew members represented 50 different countries. No passengers were infected with rubella during that outbreak, but 1% of approx. 3500 passengers surveyed were pregnant women

An outbreak of rubella was investigated aboard a ship of the German Navy in 1996. 20 cases out of 330 crew members over a period of 9 weeks were detected. The attack rate was 57% in non-vaccinated personnel (2).

Though Rubella infection in adult seafarers is a rare event, it must be included in the differential diagnosis of a febrile rash illness. Laboratory diagnosis must be used if in doubt.  

(1)  Centers for Disease Control and Prevention. Rubella among crew members of commercial cruise ships – Florida 1997. MMWR Morb Mortal Wkly Rep 1998;46;1247-1250.

(2) Ziebold C, Hassenpflug B, Wegner-Bröse H, Wegner K, Schmitt HJ. An outbreak of rubella aboard a ship of the German Navy. Infection 2003;31:136-142.

Measles

Spread of Measles is airborne or via droplets. It is highly communicable, with primary attack rates in susceptible individuals exceed 90%. The viral disease is clinically identified by the typical symptoms of prodromal fever, conjunctivitis, coryza, cough, and small spots with white or bluish-white centres with a erythematous base on the buccal mucosa (Koplic spots). A characteristic red blotchy rash appears on the third to the seventh day, the rash begins on the face, then becomes generalized, lasts 4-7 days, and sometimes develops with brown desquamations. Incubation period is about 10 days, but may be 7 to 18 days from exposure to onset of fever, and usually 14 days until the rash appears. The period of communicability is from 1 day before the beginning of the prodromal period (usually 4 days before rash appears) to four days after rash appearance.

Factors facilitating outbreaks are low immunization rates in seafarers or passengers.

A cross- sectional serosurvey in 1533 US Navy and Marine Corps recruits was conducted in June 1989. Seronegativity was 17.8% for measles (1).

Mitruka reported a cluster of rash illness in a cruise ship only among of crew members in 2006, rubella, measles and varicella disease was diagnosed (2).

If the disease is clinically suspected in a seafarer or passenger, laboratory confirmation is necessary. The detection of measles-specific IgM antibodies, present 3-4 days after rash onset, or a significant rise in antibody concentration between acute and convalescent sera, confirms the diagnosis. If available, virus isolation from nasopharyngeal swabs collected before day 4 of the rash or from urine before day 8 of the rash is helpful to ascertain the diagnosis.

If a case of measles is suspected or confirmed on a vessel, isolation measures, immunization of non-immune contacts up to 72 hours after contact is necessary. Contraindications for the administration of a live vaccine must be observed. Immunoglobulin are to be considered in persons with high risk of complications (contacts under 1 year of age, pregnant women or immunocompromised) or where the vaccine is contraindicated. Notification of public health authorities is mandatory to prevent the international spread of the disease.

All susceptible travelers and seafarers must be vaccinated before they start their travel, in accord with national recommendations.

(1) Struewing JP, Hyams KC, Tueller JE, Gray GC. The risk of measles, mumps, and varicella among young adults: a serosurvey of US Navy and Marine Corps recruits. Am J Public Health. 1993 Dec;83(12):1717-20. doi: 10.2105/ajph.83.12.1717. PMID: 8259801; PMCID: PMC1694921.

(2) Mitruka K, Felsen CB, Tomianovic D, Inman B, Street K, Yambor P, Reef SE. Measles, rubella, and varicella among the crew of a cruise ship sailing from Florida, United States, 2006. J Travel Med. 2012 Jul;19(4):233-7. doi: 10.1111/j.1708-8305.2012.00620.x. PMID: 22776384.

Mumps

Spread of Mumps is airborne, via droplets or by contact with saliva. The incubation period is about 16 to 18 days. It is an acute viral disease characterized by fever, swelling and tenderness of one or more salivary glands –usually the parotid and sometimes the sublingual or submaxillary glands.  Orchitis, most commonly unilateral, occurs in 20-30% of male cases. As many as 40-50% of mumps infections are associated with respiratory symptoms, aseptic meningitis occurs in up to 10%. Usually patients recover without complications, though many require hospitalization. Immunity is generally lifelong. Most countries have now introduced mumps in their childhood vaccination program. In countries were mumps vaccine has not been introduced, the incidence of mumps remains high, mostly affecting children under 5 years.

A cross- sectional serosurvey in 1533 US Navy and Marine Corps recruits was conducted in June 1989. Seronegativity was 12.3% for mumps (1). No clinical cases of mumps in seafarers were reported in the literature.

Though underreporting may be possible, mumps is seemingly not occurring in seafarers on a significant scale. Most seafarers some from countries were mumps vaccine is part of the childhood immunization schedule. If the disease is suspected it can be confirmed by serological test and detection of virus by reverse transcription polymerase chain reaction (RT-PCR) from appropriate clinical specimen (throat swab, urine, cerebrospinal fluid). As a control measure, respiratory isolation for five days from onset of parotitis is recommended.

(1) Struewing JP, Hyams KC, Tueller JE, Gray GC. The risk of measles, mumps, and varicella among young adults: a serosurvey of US Navy and Marine Corps recruits. Am J Public Health. 1993 Dec;83(12):1717-20. doi: 10.2105/ajph.83.12.1717. PMID: 8259801; PMCID: PMC1694921.

Corynebacterium diphteriae and Bordetella pertussis

Both infections are transmitted by direct contact with carriers or a case of disease. No reports on diphtheria in seafarers were identified. Canals et al. questioned 505 seafarers during their pre-medical examination in Tarragona Spain and found that only 6.1% of seafarers were properly vaccinated against tetanus and diphtheria (1). One case of diphtheria was diagnosed in a 72 year old female British passenger who developed a sore throat during a cruise in the Baltic Sea (2).

(1) Canals ML, Pombo S. Follow up and intervention studies on Tetanus-Diphtheria Vaccination for seafarers. In: 9^th International Symposium on Maritime Health. Equity in maritime health and safety – development through research, cooperation and education..Book of Abstracts.Esbjerg, Denmark 3-6 June 2007. Paper 2-3.

(2) Communicable Disease Report. Diphtheria acquired during a cruise in the Baltic Sea: update. Comm Dis Rep CDR Wkly 1997;7:217.

Meningococcal Meningitis

Neisseria meningitits, Streptococcus pneumonia and Haemophilus influenza type b (HIB) cause more than 2/3 of all meningitis infections in adults. Meningococcal meningitis is unique among the major causes of bacterial meningitis in that it is both an endemic disease and also causes large epidemics. It is a severe disease with high case fatality rate: 8-15%.

Meningococcal Meningitis is characterized by a sudden onset of fever, intense headache, nausea and often vomiting, stiff neck and photophobia. A petechial rash may occur. Meningococcal sepsis is the most severe form of infection with petechial rash, hypotension, disseminated intravascular coagulation and multi-organ failure.

Transmission is via direct person-to-person contact, including respiratory droplets from the nose and throat of infected people. The incubation period is 2 to 10 days.

One case of a suspected meningococcal infection in a 24 year old sailor was reported in 2003 from a United States navy aircraft carrier. Chemoprophylaxis was given to 99 close contacts, no further cases occurred (1).

While meningitis on ships is rare, it may be a catastrophic event if a case is suspected in a sailor. It is a severe, life-threatening disease. Patients may rapidly deteriorate. If suspected on board, immediate antibiotic treatment, isolation measures and possibly chemoprophylaxis to all members of the crew are necessary steps. Close collaboration with the telemedical service is necessary. If confirmed, public health authorities must be notified.

The other significant point for the shipping industry concerns vaccination requirements. Although the disease is not covered by International Health Regulations, some countries may require a valid certificate of immunization against meningococcal meningitis as a condition of entry, e.g. Saudi Arabia. Further information can be found at www.who.int/topics/meningitis/en/.

Vaccines containing groups A, C, Y and W-135 meningococcal polysaccharides are available. Fairly new is a meningococcal B vaccine (MenB) used for special risk groups. The vaccines are effective for prevention.

Sailors in global shipping are a at risk groups due to their travel activity, living and working conditions on board and the limited access to medical and diagnostic care during their travel.

(1) Farr W, Gonzalez MJ, Garbauskas H, Zinderman CE, LaMar JE 2^nd. Suspected meningococcal meningitis on an aircraft carrier. Mil Med 2004;169:684-686.

Streptococcal Diseases

β- haemolytic Streptococcus  pyogenes (Group A streptococcus) infections cause a variety of diseases, the most frequently encountered conditions are invasive respiratory infections such as streptococcal pharyngitis/ tonsillitis (sore throat), pneumonia and otitis media and skin infections such as impetigo, pyoderma, or cellulitis.

Other conditions that arise from β-haemolytic streptococcal Group A infections that will not be discussed here are toxic syndromes (scarlet fever and streptococcal toxic shock syndromes) and post-infective conditions (rheumatic fever, glomerulonephritis and Sydenham´s chorea). Also, other groups of streptococci (β- haemolytic Streptococcus  pyogenes groups B-G and α-haemolysing groups) are not included in this review since they are of limited clinical relevance to seafaring (e.g. diseases of newborns, women, in pre-existing conditions such as valvular heart disease, dental caries of early childhood or asymptomatic colonization).

Streptococcal Sore Throat 

A sore throat is a common disease in both, the general population and in seafarers.[8] It is an inflammation of the throat (pharyngitis), resulting in pain on swallowing. It is transmitted by respiratory droplets or direct contact. Explosive outbreaks of streptococcal infection may follow ingestions of contaminated food. Milk and milk products, egg salad and similar preparations have been associated most frequently with food borne outbreaks. Incubation period is short, usually 1-3 days.

Most cases are due to respiratory viral infections (rhinovirus, coronavirus, adenovirus, influenzy virus, parainfluenza virus, respiratory syncytial virus), Epstein-Barr virus or coxsackievirus. Viral pharyngitis is a self-limiting condition that does not usually require a specific diagnosis and treatment.

Bacterial pharyngitis is less common. It´s single most frequent cause is Streptococcus pyogenes (Group A streptococcus). It is the cause of a sore throat in 10-15%. Other rare bacterial causes include Neisseria gonorrhoea, C. diphteriae or Mycoplasma pneumonia.

Patients with streptococcal sore throat typically exhibit sudden onset of fever, exsudative tonsillitis or pharyngitis (sore throat) and tender, enlarged anterior lymphnodes. Coincident or subsequent otitis media or peritonsillar abscess may occur. Possible non-suppurative complications include acute rheumatic fever and glomerulonephritis.

There are clinical scores available to differentiate between viral and bacterial sore throat infection. Also a rapid antigen detection test is used in outpatient settings of many countries to guide on the use of antibiotics.

The WHO International Medical Guide for Ships recommends using antibiotics in person with sore throat when three or more of the following symptoms are present:

-yellowish creamy material on the tonsil or back side of the throat

-tender, enlarged lymph nodes below the jaw

-fever

-cough

It is well recognized that the risk for spread of infection is increased in crowded living situations due to respiratory transmission and outbreaks from contaminated food. Epidemic infections with respiratory agents causing sore throat have been documented from settings with confined spaces such as military barracks or college dormitories.

No systematic studies to identify the risk and causes (by throat swabs and microbiological identification) of sore throat on ships were identified in the published literature. Also there are no reports on outbreak investigation on ships that included microbiological identification of causative agents.

One survey published from the Russian Federation investigated epidemic outbreaks of tonsillitis in 6 state fishery ships. The authors found that outbreaks of tonsillitis occurred in ships with more than 350 crew members. However the study did not include microbiological identification of causative agents (1)

A case report describes four cases of myocarditis including three fatalities caused by Coxsackie virus – a rare cause of sore throat- in a group of 18 stowaways who travelled in a shipboard cargo container. No fatalities were reported in the crew (2). However no conclusions on the risk of viral sore throat in seafaring can be drawn from this report.

In summary, due to the lack of specific data from the shipping environment, epidemiological data from the general population must be applied. Of note there are well recognized geographical differences on the frequency of pharyngitis/tonsillitis: The syndrome is more frequent in temperate than in tropical environments.

A pragmatic approach to the use of antibiotics in the shipping environment is the above described practice guidelines as given by the WHO Medical Guide of Ships. With this approach, antibiotic treatment will probably be initiated more frequently than in the outpatient setting ashore. This seems well justified to avoid invasive or toxic consequences that cannot be easily identified or treated during travel. Also, early antibiotic treatment will lower the risk of person-person transmission of bacterial disease on board.

Beyond early treatment WHO does not recommend to isolate persons with sore throat in the shipping environment unless he/ or she shows a febrile illness.

Explosive outbreaks of sore throats on ships must raise a high suspicion of contaminated food (milk, milk-products and eggs). People with skin lesion must be excluded from food handling. Carrying a rapid antigen detection test on board of passenger ships is well justified to adequately handle sore throat outbreaks in passengers and crew.

Some cruise ship companies require a throat swab for medical personnel and food-handlers to tule out streptococcal throat infection/colonization before embarkation.

(1) Obernikhin IM, Kolpakov SL, Iakovlev AA, Briko NI. Proiavleniia epidemicheskovo protsesa respiratornoi streptokokkovoi infekzii sredi ekipazhei sudov v usloviiach promyslovovo reisa.[The manifestations of an epidemic process in a respiratory streptococcal infection among ships´ crews under commercial sailing conditions].Zh Mikrobiol Epidemiol Immunobiol1994;5: 33-36.

(2) Li MK, Beck MA, Shi Q, Harruff RC. Unexpected hazard of illegal immigration: Outbreak of viral myocarditis exarcerbated by confinement and deprivation in a shipboard cargo container. Am J Forensic Med Pathol 2004;25:117-124.