Introduction
The Questions and Answers section was prepared after the request of several partners of the EU SHIPSAN ACT Joint Action in the General Assembly meeting that took place in Luxembourg in 17 of October 2014. The purpose is to provide answers to the questions received by public health authorities and shipping industry, based on evidence and according to the existing guidelines and knowledge. The content of answers in regards to the case definitions, the clinical and laboratory criteria and the management of contacts are based on the European Commission directives and the guidelines of the European Centre for Diseases Prevention and Control (ECDC).
The answers to the questions were prepared by the working group of the EU SHIPSAN ACT Joint Action, consisting of: Barbara Mouchtouri, Miguel Davila Cornejo, Mauro Dionisio, Martin Dirksen-Fischer, Finan Gallagher, Boris Kopilovic, Gordon Nichols, Diederik Van Reusel, Carmen Varela Martinez, Thomas von Münster, Christopher Bartlett, Christos Hadjichristodoulou. Moreover, the working group consulted the following persons: Cinthia Menel Lemos from the European Commission Consumers, Health and Food Executive Agency (CHAFEA), Emmanuel Robesyn, Diamantis Plachouras, Klaus Weist and Carmen Varela Santos from the European Centre for Diseases Prevention and Control (ECDC), Daniel Menucci and Ninglan Wang from the World Health Organization (WHO) and Antonino Di Caro from the EU Joint Action “Quality Assurance Exercises and Networking on the Detection of Highly Infectious Pathogens” (QUANDHIP).
Disclaimer: The answers provided are opinions of the working group. The content is based on the evidence available to the working group at the time of writing (5 December 2014). The working group recognises the possibility of missing evidence or changes in practices and knowledge in regards to the Ebola Virus Disease. The EU SHIPSAN ACT Joint Action has received funding from the European Union, in the framework of the Health Programme (2008-2013). Sole responsibility lies with the authors and the European Commission Consumers, Health and Food Executive Agency is not responsible for any use that may be made of the information contained therein.
Questions and answers for public health authorities
Personal protective equipment for port health officers going aboard a ship, which has come from an affected area, without having ill persons on board
Question 1
What personal protective equipment should be used by inspectors going aboard a ship, which has come from an affected area, without having ill persons on board?
Note: This is where there is no indication via the Maritime Declaration of Health that there is anyone ill on board.
Answer
- The port health authority should proceed according to the national and local guidance and policy (e.g. to board the ship and identify the health status on board or not to take any action).
- No special PPE are needed if there is no information about disease on board. Inspectors should follow the routine procedures for an inspection.
- However, if inspectors board the ship and identify the presence of a sick person on board with symptoms compatible with Ebola virus disease (see question 2), [1] they should not proceed if they are not trained to deal with a suspected case of Ebola virus disease or are without the appropriate personal protection. In this case, the inspector should seek immediate medical advice and continue as described in question 2.
Response measures by a competent authority when a ship arrives from an affected country with a traveller presenting clinical criteria compatible with Ebola virus disease
Question 2
What are the actions by the competent authority at port when a ship arrives from an affected country with a traveller presenting some of the clinical criteria compatible with Ebola virus disease?
Answer
Step 1: Trained personnel of the competent authority should board the ship and confirm if the clinical condition of the patient is compatible with Ebola virus disease.
a. The personnel should be trained in the use of PPE and the safe management of patient with Ebola virus disease.[2]
b. The clinical criteria for Ebola virus disease are: any person currently presenting or having presented before death with: fever ≥ 38.6°C, AND any of the following: severe headache, vomiting, diarrhoea, abdominal pain, unexplained haemorrhagic manifestations in various forms, multi-organ failure; OR a person who died suddenly and unexpectedly.[1]
Step 2: The competent authority should identify which of the following epidemiological criteria are fulfilled:
c. In the 21 days before the onset of symptoms: if the patient has been in an area with community transmission; OR has had contact with a probable or confirmed EVD case.[1]
d. In the 21 days before the onset of symptoms, if the patient fulfills any of the following high-risk exposure criteria:
• close face-to-face contact (e.g. within one metre) without appropriate personal protective equipment (including eye protection) with a probable or confirmed case who was coughing, vomiting, bleeding, or who had diarrhoea; or had unprotected sexual contact with a case up to three months after recovery;
• direct contact with any material soiled by bodily fluids from a probable or confirmed case;
• percutaneous injury (e.g. with needle) or mucosal exposure to bodily fluids, tissues or laboratory specimens of a probable or confirmed case;
• participation in funeral rites with direct exposure to human remains in or from an affected area without appropriate personal protective equipment;
• direct contact with bats, rodents, primates, living or dead, in or from affected areas, or bushmeat.[1]
Step 3: Based on the above clinical and epidemiological criteria, the traveler should be classified as:
• Person who does not meet any of the criteria for EVD.2 If the traveller has only the clinical criteria, but: a) did not go ashore in the affected area; or b) no port worker or other person presenting symptoms of EVD boarded the ship while being at the port of the affected country (to answer this question, clarification is needed whether screening of persons, including port workers, entering the port and/or the ship in the affected country is taking place); or c) does not meet the high risk exposure criteria, then the person does not fulfil any of the criteria for EVD.
• Person under investigation: when the traveller meeting the clinical and the epidemiological criteria; or with high-risk exposure and any of the clinical symptoms, including fever of any grade.[1]
• Probable case: a person meeting the clinical and high-risk exposure criteria.[1]
Step 4: If the traveller has been classified as person under investigation or probable case, then the competent authority should proceed as described in Questions 3 and 4. See Figure 1: Response Phase 1 - Algorithm for decision making of the public health competent authorities in response to an event of a suspected case of Ebola virus disease on board ships.
Step 5: Measures taken on board should also be noted on the Ship Sanitation Certificate (IHR Annex 3).[3]
Transportation of a patient, meeting the criteria for the person under investigation or probable case, from the ship to the medical facility
Question 3
In the event of a patient meeting the criteria for the person under investigation or probable case on board a ship (see question 2), what are the actions by the competent authorities at ports in regards to transportation of patient to a medical facility?
Answer
Legal provisions: according to Annex 1b of the IHR, a designated port must have the capacity a) at all times to provide access to equipment and personnel for the transport of ill travellers to an appropriate medical facility and b) for responding to events that may constitute a public health emergency of international concern, to provide access to specially designated equipment, and to trained personnel with appropriate personal protection, for the transfer of travellers who may carry infection or contamination and to provide appropriate public health emergency response by establishing and maintaining a public health emergency contingency plan.[3]
If a patient meets the criteria for a person under investigation or a probable Ebola virus disease case on board a ship, competent authorities must guarantee timely and secure transportation of the patient to a medical facility suitable for Ebola virus disease treatment according to the national plans. The port public health contingency plan must be activated. All the details for the procedure including the use of PPE should be part of the public health emergency contingency plan of the port. Guidelines for the development of a contingency plan are given in the International health regulations (2005): a guide for public health emergency contingency planning at designated Points of entry. World Health Organization 2012.[4]
Available guidance for the transportation of suspected EVD patients can be found at:
Interim Guidance for Emergency Medical Services (EMS) Systems and 9-1-1 Public Safety Answering Points (PSAPs) for Management of Patients with Known or Suspected Ebola virus disease in the United States. October 28, 2014.[5] Available from: http://www.cdc.gov/vhf/ebola/hcp/interim-guidance-emergency-medical-services-systems-911-public-safety-answering-points-management-patients-known-suspected-united-states.html
If the ship is away from land, then emergency air medical evacuation might be necessary.
Actions by the competent authority in the event of a patient meeting the criteria for the person under investigation or probable case on board a ship
Question 4
In the event of a patient meeting the criteria for the person under investigation or probable case on board a ship, what are the actions by the competent authorities at ports in regards to the ship and travellers on board until the laboratory results of the patient who meet the criteria for the person under investigation or probable case are available (confirming or not confirming the EVD case).
Answer
After implementing steps 1 to 4 as described in Question 2, samples from the patient will be collected and tested to confirm infection at the appropriate medical facilities. If specimens are taken within 48 hours after the onset of symptoms, then the sampling should be repeated at day 3 after the symptoms onset or after 24 hours in a patient with a high risk exposure.[6] In that case, until the laboratory results of the second sampling are available, the ship should not depart from the port (see Figure 1 : Response Phase 1 - Algorithm for decision making of the public health competent authorities in response to an event of a suspected case of Ebola virus disease on board ships). Measures taken on board should also be noted on the Ship Sanitation Certificate (IHR Annex 3).[3]
Actions by the competent authority in the event of a traveller on board a ship meeting the criteria for a confirmed case of Ebola virus disease
Question 5
In the event of a traveller meeting the criteria for a confirmed case of Ebola virus disease, what are the actions by the competent authorities at ports in regards to the ship and travellers on board?
Answer
Legal provisions: Articles included in Part V of IHR and Annex 1b.[3]
Step 1: Information about the places that the patient visited and about his/her contacts since the onset of symptoms on board the ship or ashore should be collected in order to use this information for contact tracing.[7]
Step 2: At the same time, authorities should check if the appropriate measures have been implemented on the ship in regards to isolation and other measures, as recommended by WHO.[2;8]
Step 3: Based on this information, an assessment of the level of exposure to all travellers on the ship should be initiated. All travellers on board the ship should be classified as:
- contacts with high risk exposure, or
- contacts without high risk exposure, or
- non-contacts, or
- occupational exposure
Healthcare workers who have had contact with the patient will be dealt as high risk exposure.[7] The definitions of contacts are provided in the ECDC Technical report “Public health management of persons having had contact with Ebola virus disease cases in the EU”[7], available from:
http://www.ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx?List=4f55ad51-4aed-4d32-b960-af70113dbb90&ID=1200
Step 4: Since the traveller is a confirmed case of Ebola virus disease, health measures can be applied to travellers according to the national policy and taking into consideration the WHO Temporary Recommendations under IHR (2005) to reduce the international spread of Ebola, effective on 8 August 2014.[9]
An algorithm for the response measures can be found in Figure 2. An algorithm for Ebola virus disease contact management can be found at: European Centre for Disease Prevention and Control. Public health management of persons having had contact with Ebola virus disease cases in the EU, 7 November 2014. Stockholm: ECDC; 2014.[7], available from: http://www.ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx?List=4f55ad51-4aed-4d32-b960-af70113dbb90&ID=1200
Step 5: Measures taken on board should also be noted on the Ship Sanitation Certificate (IHR Annex 3).[3]
Question 6
In the event of a traveller meeting the criteria for a confirmed case of Ebola virus disease, what are the actions by the competent authorities at ports in regards to quarantine of asymptomatic contacts of a confirmed case of Ebola virus disease?
Answer
Legal provisions
1. The WHO Temporary Recommendations under IHR (2005) to reduce the international spread of Ebola, effective on 8 August 2014, indicates that:
There should be no international travel of Ebola contacts or cases, unless the travel is part of an appropriate medical evacuation. To minimize the risk of international spread of EVD[9]:
- Confirmed cases should immediately be isolated and treated in an Ebola Treatment Centre with no national or international travel until two (2) Ebola-specific diagnostic tests conducted at least 48 hours apart are negative;
- Contacts (which do not include properly protected health workers and laboratory staff who have had no unprotected exposure) should be monitored daily, with restricted national travel and no international travel until 21 days after exposure;
Probable and suspect cases should immediately be isolated and their travel should be restricted in accordance with their classification as either a confirmed case or contact.
2. According to IHR Annex 1b, the designated port must have the capacity to provide appropriate space, separate from other travellers, to interview suspect or affected persons; and to provide for the assessment and, if required, quarantine of suspect travellers, preferably in facilities away from the point of entry.[3]
3. According to IHR article 27, paragraph 2, if the competent authority for the point of entry is not able to carry out the control measures required, the affected conveyance may nevertheless be allowed to depart, subject to the following conditions: (a) the competent authority shall, at the time of departure, inform the competent authority for the next known point of entry of the evidence found and the control measures required; and (b) the evidence found and the control measures required shall be noted in the Ship Sanitation Control Certificate.[3] Any such conveyance shall be permitted to take on, under the supervision of the competent authority, fuel, water, food and supplies.
If the country implements the WHO Temporary Recommendation in regards to cases and contacts, then the contacts with high risk exposure should be monitored daily, with restricted national travel and no international travel until 21 days after exposure.[9]
Based on the above, there are two options for action in regards with the contacts with high risk exposure:
Option 1: The interviews can be conducted on board the ship, with the agreement of the captain/ship operator. The travelers should be classified as contacts with high risk exposure or contacts without high risk exposure or non-contacts.[7] The contacts with high risk exposure[3;9] and the health care personnel of the patient should not continue travelling,[7] they should disembark, be accommodated in ashore facilities and monitored daily until 21 days after exposure; they can travel internationally 21 days after exposure, provided that they did not develop any symptoms. The non-contact travelers and the contacts without high risk exposure could disembark and travel internationally after receiving advice for self-monitoring for EVD symptoms for 21 days after last exposure and monitoring of temperature and symptoms twice a day.[7] Health measures including disinfection should be conducted on the ship by trained personnel. After the disinfection of places where the symptomatic patient visited, passed or stayed, the appropriate disposal of waste and the disembarkation of all contacts with high risk exposure and the health care personnel, the ship can continue the travel.
Implications for option 1: If the number of contacts is high, then it would be challenging to find ashore facilities to accommodate the travellers. The cost of accommodation should be also secured. According to IHR article 40: Nothing in these Regulations shall preclude States Parties from seeking reimbursement for expenses incurred in providing the health measures in paragraph 1 of this Article: (a) from conveyance operators or owners with regard to their employees; or (b) from applicable insurance sources.[3]
Option 2: Another alternative option could be to quarantine the ship at the port for 21 days, provided that it is not feasible to implement effectively the health measures described in the first option. It should be noted that there is no Temporary Recommendation issued by WHO for quarantine of conveyances, this action is considered an additional health measure according to IHR articles 42 and 43. Therefore, a State Party of WHO implementing additional health measures which significantly interfere with international traffic shall provide to WHO the public health rationale and relevant scientific information for it. WHO shall share this information with other States Parties and shall share information regarding the health measures implemented. Therefore, this alternative option could be considered only if option 1 cannot be implemented effectively:
The competent authorities should communicate with the ship operator to ensure cooperation, to consider the available resources and make the best decision for the effective implementation of health measures.
The non-contacts and the contacts without high risk exposure depending on the situation: both passengers and crew members could disembark and travel internationally after receiving advice for self-monitoring for EVD symptoms for 21 days after last exposure and monitoring of temperature and symptoms twice a day.[7] Alternatively, only the passengers could disembark and travel internationally after receiving advice for self-monitoring for EVD symptoms for 21 days after last exposure and monitoring of temperature and symptoms twice a day, but the crew members to be self-monitored on board the ship for 21 days under the supervision of medical staff.
The contacts with high risk exposure and the health care personnel of the patient, depending on the situation and the availability of resources aboard the ship and ashore: a) they could stay on board and monitored daily by medical personnel until 21 days after exposure, or b) they could disembark, be accommodated in ashore facilities and monitored daily until 21 days after exposure. They can travel internationally 21 days after exposure, provided that they did not develop any symptoms.
The competent authority should decide in cooperation with the ship operator on the best option to ensure effective monitoring of contacts with high risk exposure either aboard the ship or ashore.
An additional day or more as necessary should be dedicated for the thorough disinfection of the ship.
Measures taken on board the ship should be noted on the Ship Sanitation Certificate (IHR Annex 3).[3]
Question 7
In the event of a traveller meeting the criteria for a confirmed case of Ebola virus disease, what are the actions by the competent authorities at ports in regards to health measures on the conveyance (cargo or passenger ship)?
Answer
Legal provisions: Articles included in Part V of IHR and Annex 1b.[3]
Disinfection should be conducted in all the areas where the patient passed, visited or stayed during his or her symptomatic period. The ship should be cleaned and disinfected paying special attention to those areas related to the case, by trained personnel using the appropriate PPE.
Guidance for the disinfection are given in the WHO Infection prevention and control guidance for care of patients in health-care settings, with focus on Ebola, August 2014[10], available from: http://www.who.int/csr/resources/publications/ebola/filovirus_infection_control/en/
The list with Disinfectants for Use Against the Ebola virus[11] recommended by CDC can be found in the following link: http://www.epa.gov/oppad001/list-l-ebola-virus.html
Measures taken on board the ship should be noted on the Ship Sanitation Certificate (IHR Annex 3).[3]
Question 8
In the event of a traveller meeting the criteria for a confirmed case of Ebola virus disease, should the ship be placed on quarantine and if yes for how long?
Answer
Legal provisions: IHR articles 42 and 43.[3]
“Quarantine” means the restriction of activities and/or separation from others of suspect baggage, containers, conveyances or goods in such a manner as to prevent the possible spread of infection or contamination.[3] If: a) the patient with Ebola virus disease, b) the contacts with high risk exposure and c) the health care personnel of the patient disembark; and if disinfection and waste disposal has been conducted appropriately, then there is no reason to quarantine the ship and the ship can continue the voyage. However, if the contacts with high risk exposure and the health care personnel of the patient are monitored on board, then the ship should not be allowed to continue the voyage. Measures taken on board the ship should be noted on the Ship Sanitation Certificate (IHR Annex 3).[3] An algorithm is provided in Figure 2.
Question 9
What are the actions to be taken by the competent public health authority at port with regards to sharing of information about the health measures implemented on board a ship in response to an event of a suspected or confirmed case of Ebola virus disease?
Answer
Legal provisions: IHR articles 27 and Annex 3.[3]
The public health authority should immediately inform the IHR National Focal Point and other authorities within the country (at local, intermediate and central level) according to the national and local communication plans, about an event of a suspected case of Ebola virus disease on board a ship. Moreover, the competent public health authorities of the EU Member States, which have been designated officially by the government of their country as members of the Early Warning and Response System (EWRS) should be informed.
The information about the health measures implemented in response to an event of a case of Ebola virus disease should be shared with the next ports of call, according to the national and local rules and plans. Measures taken on board the ship should be noted on the Ship Sanitation Certificate (IHR Annex 3).[3] In addition to this, the information about the health measures taken on board the ship should be entered into the web-based information system of EU SHIPSAN ACT for recording and issuing Ship Sanitation Certificates.
Waste management (sewage) on ships
Question 10
Can the Ebola virus survive in sewage?
Answer
To our knowledge, there are no published studies examining the survival of Ebola virus in sewage.
Ebola virus has been isolated from stool specimens of patients during the acute phase of the disease and until 12 days after the onset of symptoms.[12]
Currently available studies show that the virus can survive in the environment only for few days (up to six days in controlled favorable environmental conditions).[13-15]
Dilution and the natural degradation of Ebola virus in sewage will reduce the risks of transmission from this source provided disposal is adequate.
Disinfection of sewage from a ship that has had a confirmed Ebola case is not mandatory, but is desirable.
In the event that a suspected Ebola patient has used the bathroom of a ship, investigation should identify if the ship has a sewage treatment unit that is capable of inactivating infectious agents.[16] If the ship has an approved sewage treatment unit (including a sewage comminuting and disinfecting system according to MARPOL standards) and the unit performs well and it is in compliance with MARPOL standards, then no further action is needed. However, if such a system is not in place, then the sewage needs to be disinfected prior to discharge to the port reception facility. If disinfection is not feasible on the ship, then sewage should be discharged at a port reception facility and then the waste should be safely transported to an appropriate sewage treatment facility. The port reception facility and/or related equipment should be disinfected after the transportation/connection. If the sewage is to be put directly into the local sewage treatment system in the port, then prior agreement with the appropriate authorities is needed. In any case, the final destination of the untreated ship waste is an appropriate sewage treatment facility with preferably tertiary treatment.[17]
National guidance in regards to waste management has been produced in the United Kingdom, The Netherlands and Australia, which can be found at the following links:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/377095/Ebola_guidance_for_individuals_at_risk_of_contact_with_human_waste.pdf
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/377082/Ebola_information_for_sewage_and_water_handlers.pdf
http://www.kwrwater.nl/Netherlands_Spread_of_Ebola_via_water_is_not_likely/
http://www.waterra.com.au/publications/latest-news/2014/ebola-virus-and-drinking-water-member-update/.
Questions and answers for shipping industry
Preparedness of port health authorities at the ports of EU countries
Question 11
What are the various European ports doing - in advance - to determine a calm and orderly response to the management of any suspected Ebola case on any maritime conveyance - cruise ship, ferry, cargo - arriving in their port, while developing a quarantine strategy that respects the rights of fellow guests and passengers and maintains free pratique of the ships per IHR guidelines? What role will WHO and SHIPSAN have in the development of these policies?
Answer
The designated European ports should have developed a Contingency Plan to respond to these events. The Contingency Plan should follow WHO recommendations (Guide for public health emergency contingency planning at designated points of entry)[3;4] and include all the details related to the management of the situation. In the General Assembly meeting conducted on 17 October 2014 in Luxemburg, an ad-hoc working group was composed by partners of the SHIPSAN ACT with the purpose to respond to inquiries about Ebola virus disease in relation to maritime transport in EU. The responses to questions will be composed by the working group after consulting personnel at CHAFEA, WHO and ECDC. The question and answer session will be available and updated on the SHIPSAN ACT website, and disseminated to the EU MS competent authorities and port health authorities.
Ships visiting ports in affected countries
Question 12
What are the general recommendations to the Captain, including checks (entry-screening) when port-workers in affected areas are entering the ship and measures implemented if a symptomatic port-worker is identified on board?
Answer
The instructions provided in the IMO Circular Letter No.3484, 2 September 2014 and the Circular Letter No.3485, 10 September 2014 should be followed by Captains.[18;19]
It is up to the ship operator to decide about screening measures for travelers boarding the ship. The template for the Traveller Public Health Declaration Form in Appendix 2 of the WHO Interim Guidance for Ebola virus disease Exit Screening at Airports, Ports and Land Crossings, published on 6 November 2014, can be used for such purpose.[20] However, if the port authority performs screening to any person entering the port, including the port workers, then this should be also considered when deciding on the implementation of additional screening measures on the ship.
If a symptomatic port worker is identified on board, then the person should be immediately transferred to an ashore facility for medical assessment and depending on the results, then any contacts should be identified, as well as the places visited or stayed since the onset of symptoms.
Recommendations to the captain of a ship departing from affected areas and going to an EU port
Question 13
What are the recommendations to the Captain of the ship departing from affected areas and going to EU port (including documentation for self-monitoring, e.g. some example of check-list, recommendation to perform a general cleaning and disinfection, using of PPE etc.)?
Answer
The instructions provided in the IMO Circular Letter No.3484. 2 September 2014 and the Circular Letter No. 3485. 10 September 2014 should be followed by Captains.[18;19] In addition to this, and if the competent authority at the port of departure in the affected area does not implement exit screening, then the ship operator may decide to implement screening measures such as the completion of a questionnaire (the template for the Traveller Public Health Declaration Form in Appendix 2 of the WHO Interim Guidance for Ebola virus disease Exit Screening at Airports, Ports and Land Crossings, published on 6 November 2014, can be used for such purpose)[20] to identify any suspect cases or contact and additionally, non-contact temperature measurement by any person boarding the ship.[12-15]
Plan for event management of a suspected case of Ebola virus disease on board ships
Question 14
What should be the content of the plan for event management of a suspected case of Ebola virus disease on board ships?
Answer
Legal provisions: According to IHR 2005, conveyance operators or officers of ships are responsible for: permanently keeping ships for which they are responsible free of sources of infection or contamination, (the application of measures to control sources of infection or contamination may be required if evidence is found); informing the port of destination before arrival of any cases of illness indicative of a disease of an infectious nature or evidence of a public health risk (arising from all types of hazards including chemical, radiological and other) on board; facilitating inspections, medical examinations of persons on board and application of other health measures; providing relevant public health information requested by the authority including a valid Ship Sanitation Certificate; complying with the health measures recommended by WHO and adopted by the country of the port of call; informing travellers of the health measures recommended by WHO and adopted by the country of the port of call (IHR articles 24, 28, 37 and Annex 7).[3]
It is advised that each ship has a written management plan available that can be activated in the event of a suspected case of Ebola virus disease on board, as described in the European manual for hygiene standards and communicable diseases surveillance on passenger ships (chapter 1, items 1.8, 1.9 and 1.11).[21] Crew members and officers should be trained to implement the plan. The plan should include description of the type of PPE according to the type of contact with the suspected case and provisions for training on the appropriate use of Personal Protective Equipment (PPE) to all crew members who will come in contact with the suspected case: health care providers, housekeeping, food service etc. Available guidance can be found in European Centre for Disease Prevention and Control, “Critical aspects of the safe use of personal protective equipment”.[22]
The plan should cover disease information for passengers and crew members, notification and communication and reporting to the next port of call, isolation of suspected cases and quarantine of contacts, treatment of cases until referral to specialized clinic on the next port of call, disinfection, cleaning, and waste management, taking into consideration the WHO interim guidance for the transport sector.[2]
Communication should address the procedures, the timing, the means (leaflets, infographics, brochures, posters, announcements, other communication materials) and the content of messages to travelers in regards to the prevention and the response to the Ebola Virus Disease depending on the situation. Companies are advised to prepare draft template messages in advance.
Reporting should include the requirements of the International Health Regulations and the European legislation as described in chapter 2, items 7 and 8 of the European manual for hygiene standards and communicable diseases surveillance on passenger ships. For reporting purposes, the use of European Commission case definitions is recommend (chapter 2, item 2.12 in the European manual for hygiene standards and communicable diseases surveillance on passenger ships).[21]
Questions and answers for port workers
Recommendation for port-workers in EU ports, dealing with cargo (e.g. cacao-beans) from affected areas
Question 15
What are the recommendations for port-workers in EU ports, dealing with cargo (e.g. cacao-beans) from affected areas in regards to PPE?
Answer
Results from currently available studies show that the virus can survive in the environment only for few days (up to six days in controlled favorable environmental conditions).[12-15]
If the ship has no Ebola infection on board among the travelers or animals or other vectors, then it is unlikely that environmental surfaces or cargo are contaminated. Therefore, there is no need for the use of special PPE for the protection from Ebola. If there is no evidence of infection on board, then port workers in EU ports should use their usual PPE recommended on a routine basis.
The European Food Safety Authority has published a risk assessment on the transmission of Ebola virus via the food chain.[23]
Figures
Figure 1: Response Phase 1 - Algorithm for decision making of the public health competent authorities in response to an event of a suspected case of Ebola virus disease on board ships
Figure 2: - Algorithm for response of public health competent authorities to an event of a confirmed case of Ebola virus disease on board ships
Reference List
[1] European Centre for Diseases Prevention and Control. Ebola virus disease case definition for reporting in EU. 2014.
[2] World Health Organization. Travel and transport risk assessment: Interim guidance for public health authorities and the transport sector. 2014.
[3] International Health Regulations. Geneva: World Health Organization, 2005.
[4] World Health Organization. International Health Regulations (2005): a guide for public health emergency contingency planning at designated points of entry. 2012.
[5] Interim guidance for Emergency Medical Services (EMS) systems and 9-1-1 Public Safety Answering Points (PSAPs) for management of patients with known or suspected Ebola virus disease in the United States. 2014.
[6] European Centre for Diseases Prevention and Control. Algorithm for Ebola virus disease laboratory diagnosis. 2014.
[7] European Centre for Diseases Prevention and Control. Public health management of persons having had contact with Ebola virus disease cases in the EU, 7 November 2014. Stockholm: ECDC, 2014.
[8] World Health Organization. Interim guidance for Ebola event management at points of entry. 2014.
[9] Statement on the 3rd meeting of the IHR Emergency Committee regarding the 2014 Ebola outbreak in West Africa. WHO Statement. 2014.
[10] World Health Organization. Infection prevention and control guidance for care of patients in health-care settings, with focus on Ebola. 2014.
[11] Disinfectants for use against the Ebola virus recommended by CDC. 2014.
[12] Bausch DG, Towner JS, Dowell SF, et al. Assessment of the risk of Ebola virus transmission from bodily fluids and fomites. J Infect Dis 2007 Nov 15;196 Suppl 2:S142-S147.
[13] Centers for Diseases Control and Prevention. Interim guidance for environmental infection control in hospitals for Ebola virus. 2014.
[14] Sagripanti JL, Rom AM, Holland LE. Persistence in darkness of virulent alphaviruses, Ebola virus, and Lassa virus deposited on solid surfaces. Arch Virol 2010 Dec;155(12):2035-9.
[15] Sagripanti JL, Lytle CD. Sensitivity to ultraviolet radiation of Lassa, vaccinia, and Ebola viruses dried on surfaces. Arch Virol 2011 Mar;156(3):489-94.
[16] World Health Organization. Interim infection prevention and control guidance for care of patients with suspected or confirmed Filovirus haemorrhagic fever in health-care settings, with focus on Ebola. 2014.
[17] ISO 16304 Ships and marine technology - Marine environment protection - Arrangements and management of port waste reception facilities. 2013.
[18] International Maritime Organization. Circular Letter No.3484, 2 September 2014. 2014.
[19] International Maritime Organization. Circular Letter No.3485, 10 September 2014. 2014.
[20] World Health Organization. Interim guidance for Ebola virus disease exit screening at airports, ports and land crossings. 2014.
[21] EU SHIP SANITATION TRAINING NETWORK - SHIPSAN TRAINET PROJECT (2007206). European manual for hygiene standards and communicable disease surveillance on passenger ships. 2011.
[22] European Centre for Diseases Prevention and Control. Critical aspects of the safe use of personal protective equipment. Stockholm: ECDC, 2014.
[23] European Food Safety Authority. An update on the risk of transmission of Ebola virus (EBOV) via the food chain. 2014;12(11):3884,25pp. EFSA Journal 2014;12(11):3884-25pp.