Download the EU SHIPSAN ACT JA - Newsletter: Issue 16 in .pdf format

Editorial

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Dr Rimantas Pilipavicius, Lithuania

Dear readers,

Summer vacation is over. Therefore, I would like to invite all of You with new energy to continue the SHIPSAN ACT activities.
The experts of the European Agency for Safety and Health at Work (EU-OSHA) identified occupational exposure to ultraviolet radiation (UVR) as important, with work-related physical risk. According to different surveys, seafarers belong to a higher risk group compared to the general population and much more often suffer from occupational diseases, such as actinic keratosis, skin cancer and others. About UVR and its impact to seafarer’s health You can read in article written by Dr. Marcus Oldenburg. More about Occupational health in maritime transport You could learn during the Webinar, on the 25th of November, 2015.

In this Newsletter Mr. Martin Walker finished his mini-series about ballast water management, exchange and treatment. I hope that You can use this knowledge in Your practical activities.

Mr. Paul Harold, Mr. David Russell and Mr. Andrew Kibble is presenting a European funded project ARCOPOL (Atlantic region Coastal Pollution Response) which aim is to further improve maritime safety in the Atlantic area and reinforce the protection of the coastal regions from maritime pollution. Taking advantage of this opportunity, I would like to suggest to all EU SHIPSAN ACT Joint Action partners to disseminate the information about this project, the possibility to use the deliverables and e-learning material to the companies transporting radioactive and chemical cargo and coast port authorities.
And traditionally, I would like to invite You to “take a tour” and visit a wonderful, ancient sprawling port of Constanta, in Romania.

I hope that you will find this Newsletter both interesting and informative.

Enjoy reading. 

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News from the leadership 

 
Prof Christos Hadjichristodoulou, SHIPSAN ACT Joint Action Coordinator
Dr Barbara Mouchtouri, SHIPSAN ACT Joint Action Manager

In this issue we are pleased to give you an update on the progress in achieving the objective of the EU SHIPSAN ACT Joint Action to facilitate implementation of IHR by supporting core capacities of Annex 1b and IHR provisions for Ship Sanitation Certificates.

The SHIPSAN ACT Information System improves preparedness and response at ports by strengthening capacities for event detection and response and by sharing of information and avoiding duplication of efforts and repetition of actions in event management. To date, a total of 27 public health events on 24 ships (1800 cases) were followed up by competent authorities using the web-based Communication Network (http://www.shipsan.eu/comnet/) facilitating the communication in real time within and between countries. At the same time, the Information System for recording/issuing IHR Ship Sanitation Certificates (http://ssc.shipsan.eu) was used to issue 7139 certificates by 197 registered inspectors from 12 EUMS.

Moreover, a total of 69 short-notice (48hr) inspections in 38 ports in 18 EUMS are scheduled for 2015. To date, 37 inspections were conducted in 25 ports of 14 countries according to the standards of the European Manual, by trained port health officers in accordance with a pre-agreed annual inspection programme at European level by Ministries of Health of 18 EUMS.

In the following months, the SHIPSAN ACT Information System, which is currently being upgraded, as well as the revised version of the European Manual for Hygiene Standards and Communicable Diseases Surveillance on Passenger Ships will be available and disseminated to all interested parties.

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Thematic Sections 

Environmental health and hygiene on ships

Ballast water exchange

Martin Walker, Port Health Officer, Suffolk Coastal Port Health Authority, Felixstowe, England

Key Message:

Explaining the concept of ballast water management and what Port Health Officers may find during inspection.

Introduction
Continuing from the last 2 months topics about the risks from ballast water, I wanted to conclude this mini-series about ballast water by looking at systems of ballast water management. In particular, the typical processes that can be used and how they can help control public health risks under the International Health Regulations 2005 (IHR)¹ together with meeting the requirements within the WHO Technical Handbook².

The Ballast Water Convention
From the previous article about ballast water exchange, readers will recall that there was a phased timetable for compliance with either the D1 (exchange standard) or D2 (performance standard) requirements of the Ballast Water Convention.3 For newer vessels, ballast water management should become the norm.

The process of Ballast Water Management
Ballast Water Management is a general term used for ships carrying out an approved form of treatment of the ballast water rather than merely practising deep water exchange. The specific processes are often referred to as ballast water treatment. Here, the aim is to ensure that discharged ballast water meets the performance standard for the number of viable organisms per cubic meter and the number of viable organisms (Toxicogenic Vibrio Cholerae, Escherichia Coli and Intestinal Enterococci). (These levels are set out in Area 11 of the WHO Technical Handbook³).

At it’s simplest, ballast water treatment is separated into 2 types of treatment: solid-liquid separation, and disinfection. The first stage is separating out suspended solid material from the ballast water (which may include larger micro-organisms). Processes include, hydrocyclone, surface filtration or coagulation/flocculation. The second stage of disinfection can be achieved by chemical treatment (e.g. Chlorination, Ozonation, Hydrogen Peroxide, Menadione (vitamin K)), physical treatment (UV radiation, heat, cavitation (ultra sonic energy)) or asphyxiation of micro-organisms through deoxygenation. Lloyds Register Marine produce a useful manual called “Understanding ballast water management” which includes a table highlighting the types of treatment currently available, together with their benefits and other considerations^.4

The figure below shows how filtration and hydocyclone physical separation methods work:

Source: globallast⁵

Most of the treatments used for disinfection will probably be familiar to readers. However, in researching this article, Menadione /Vitamin K was a method that was new to me. A proprietary name for this that you may see is SeaKleen 80. Menadione appears to be toxic to invertebrates and applied as a chemical dosing system but I cannot establish its availability as the website reference I found was unavailable. Perhaps readers have further information about whether it is commercially available? The other method that was new to me was cavitation. The process works by the formation and growth of micro bubbles in water, followed by the violent collapse of these bubbles which generates a high intensity pressure leading to microbial cell disruption. It may be used in conjunction with a secondary form of disinfection. Interestingly, this concept has it’s source in the ocean. The humble Alpheidae “Snapping Shrimp” uses cavitation to stun it’s prey.⁶

Available Ballast Water Systems
Ballast Water treatment systems require approval by the IMO under the Ballast Water Convention3 (regulation D-3). In addition, there are a number of regulations by various national bodies, of which the most influential appears to be the United States Coast Guard (USCG). A useful spreadsheet of current systems can be found via a link at Lloyds register⁷. It includes information about the manufacturers, techncial specifications, type approvals, separation methods and disinfection methods.

Conclusions
This series of articles can only serve as an introduction to ballast water and the controls available. I hope that it has given readers a useful steer towards the principles involved and reference material for use during ship sanitation inspections. I will finish with a reminder that a free e-learning about operational Aspects of Ballast Water Management is available on the GloBallast website8 and I would encourage readers to sign up for it.

References:
¹ International Health Regulations 2005 Second Edition, World Health Organization, Annex 3, http://whqlibdoc.who.int/publications/2008/9789241580410_eng.pdf

² “Handbook for Inspection of Ships and Issuance of Ship Sanitation Certificates”, World Health Organization 2011, http://whqlibdoc.who.int/publications/2011/9789241548199_eng.pdf?ua=1

³ International Convention for the Control and Managment of Ships’ Ballast Water and Sediments http://www.imo.org/en/About/Conventions/ListOfConventions/Pages/International-Convention-for-the-Control-and-Management-of-Ships'-Ballast-Water-and-Sediments-(BWM).aspx

⁴ “Understanding Ballast Water Management”, Lloyds Register Marine, http://www.lr.org/en/_images/213-35824_Understanding_Ballast_Water_Management_0314_tcm155-248816.pdf

⁵ “Ballast water treatment technologies and current system availability”, (Part of Lloyd’s Register’s Understanding Ballast Water Management Series), http://globallast.imo.org/wp-content/uploads/2015/01/BW-Treatment-Technology-Sept.-2012.pdf

⁶ “Alpheidae”, https://en.wikipedia.org/wiki/Alpheidae

⁷ “Available ballast water treatment systems”, http://www.lr.org/en/marine/consulting/environmental-services/ballastwatermanagement.aspx

⁸ “Operational Aspects of Ballast Water Management e-learning course”, http://globallast.imo.org/

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Occupational health on ships:

UV-induced damages of the seafarers’ skin
Marcus Oldenburg, Institute for Occupational and Maritime Medicine, Hamburg, Germany

Several studies have described a significantly increased risk of UV-induced skin damages in outdoor workers compared to indoor workers and found a dose-effect relationship with increasing lifetime UV radiation exposure. Seafarers are episodically exposed to UV radiation to an extraordinary high level. In a recent study, solar erythemal UV irradiance and exposure were measured on merchant vessels operating along typical international routes at low latitudes. Measured data showed very high noontime UV index values up to 19 with clear sky, and up to 22 due to cloud scattering. Furthermore, the latter study showed that eight hours erythemal exposure values were more than double of typical mid-latitude summer values (Feister et al. 2013). In total, seafarers can be regarded as typical outdoor workers with an extraordinarily high lifetime UV exposure. Consequently, skin photodamages and skin cancers can be considered as work-related diseases in this occupation. Correspondingly, some studies have reported on a growing number of seafarers with skin cancer in the past years (Kaerlev et al. 2005; Pukkala & Saarni 1996).

According to a recent German cross-sectional study, the examined 514 seafarers had worked cumulatively more than 20 years at sea; that means a median lifetime tropics-weighted exposure of almost 14,000 sun-hours. The median UV radiation exposure during the seafarers’ home leave within the past 5 years was 450 sun-hours. In the dermatological examinations, on average 4 extrinsic skin ageing symptoms according to Vierkötter et al. (2009) were documented among the seafarers. Teleangiectasis, coarse wrinkles and lentigines solares were most frequently observed. The lentigines solares were mainly distributed on the face/back of the neck (38%), scalp and hands (each approximately 5%) (Oldenburg et al. 2013 (A)). The number of increased skin ageing symptoms (more than 4 symptoms) was not significantly different between Caucasians and non-Caucasians (42.5% vs. 30.0%; p=0.089). This was surprising as a higher proportion of an elevated number of skin ageing symptoms was expected in the rather fair-skinned Caucasian than in the darker-skinned non-Caucasian seafarers. In regard to the working place, a higher tendency towards skin ageing symptoms was observed among seafarers with higher work-related sun exposure (deck personnel (41.5%) and the galley staff (54.2%)) than among the engine room personnel (37.1%) mainly working in areas without UV exposure (p=0.084).

Furthermore, actinic keratosis was significantly more frequently diagnosed among seafarers compared to the general population ashore (Oldenburg et al. 2013 (B)). Unexpectedly, the engine room personnel displayed significantly more often actinic keratosis than the more sun-exposed deck personnel or the galley staff examined. It is unclear if this finding is caused by their work-related high exposure to polycyclic aromatic hydrocarbons (PAH). Additionally, the latter study demonstrated that only half of the examined seafarers were aware of their elevated risk of UV-induced skin lesions.
In total, an increased risk for skin ageing symptoms and for actinic keratosis (and likely also for UV-induced skin cancers) was found among seafarers compared to the general population. Therefore, more effort is needed to raise awareness about the effects of sunlight exposure both during working time at sea and during home leave. In addition, appropriate organisational, technical and secondary preventive measures should be initiated to protect from high work-related UV radiation.

References
Feister U, Meyer G, Kirst U. Solar UV exposure of seafarers along subtropical and tropical shipping routes. Photochem Photobiol. 2013: 89: 1497-1506.

Kaerlev L, Hansen J, Hansen HL, Nielsen PS. Cancer incidence among Danish seafarers: a population based cohort study. Occup Environ Med. 2005: 62: 761-765.

Oldenburg M, Kuechmeister B, Ohnemus U, Baur X, Moll I. Actinic keratosis among seafarers. Arch Dermatol Res. 2013 (A): 305: 787-796.
Oldenburg M, Kuechmeister B, Ohnemus U, Baur X, Moll I. Extrinsic skin ageing symptoms in seafarers subject to high work-related exposure to UV radiation. Eur J Dermatol. 2013 (B): 23: 663-670.

Pukkala E, Saarni H. Cancer incidence among Finnish seafarers, 1967-92. Cancer Causes Control. 1996: 7: 231-239.

Vierkötter A, Ranft U, Krämer U, Sugiri D, Reimann V, Krutmann J. The SCINEXA: a novel, validated score to simultaneously assess and differentiate between intrinsic and extrinsic skin ageing. J Dermatol Sci. 2009: 53(3): 207-211.

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Chemical and radiological issues on ships:

ARCOPOL - Enhancing Shoreline Response to Maritime Incidents

Paul Harold, David Russell and Andrew Kibble. Public Health England, Centre for Radiation, Chemical and Environmental Hazards (CRCE Wales)

Key Points / Messages

• Atlantic Region Coastal Pollution Response (ARCOPOL) is a European funded Atlantic Area project aimed at enhancing shoreline response to maritime incidents through the development of open access resources and materials.
• The project provides a coordinated and holistic approach to emergency planning and preparedness to reduce the public health impact of maritime events.

As maritime transport of bulk and packaged chemicals continues to rise globally, and in view of the potentially catastrophic impact of oil and chemical releases at sea and also within ports, the need for effective planning and a state of preparedness for such events has become a major consideration. ARCOPOL (Atlantic Region Coastal Pollution Response), a European funded project framed in the EU Atlantic Area aims to enhance shoreline planning and response to maritime incidents through technology transfer, training and innovation. 

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People from the project 

Iuliu Laurentiu Todea, Romania
My name is Iuliu Laurentiu Todea, I am 64 years old and I live in Bucharest, Romania.
  
Education:

• 1971-1977 Medical Farmaceutical Institute Cluj – Napoca, Romania
• 1980-1983 resident in communicable diseases and epidemiology medical specialty
• 1984 specialist in epidemiology and infectious diseases and from 1990 year, senior epidemiologist

My professional experience of 30 years, in public health includes the following:
1977-1980 - General Practitioner in a communal dispensary, Braila County, Romania
1981-1996 work in contagious diseases medical ward, in the Municipal Hospital Braila.
1981-1996 chief epidemiologist at the Center for Preventive Medicine in Braila County.

Experience in:

• immunization programs of infant and adult population, in the county;
• surveillance and control of infectious diseases programs in the county; 
• surveillance programs and control of nosocomial infections in county hospitals; 
• Sanitation Control for the river Danube boats.

From 1996 until 2003 I was head of the department of non-communicable diseases, biostatistics and health promotion, in Center for Preventive Medicine of the Ministry of Transportation.

Experience in:

• organization management;
• epidemiological surveillance of diseases related to the transportation; 
• coordination of health promotion for transport workers.

2004 - 2006 Director of Public Health Departament of the Public Health Agency of Transportation Ministry.
2006 - 2013 Office worker in the Public Health Department of the Ministry of Health.
2013-2014 Office worker in NATO and Speciall Problems Department .
2014-2015 Office worker in Helthcare and Public Health Departament of the Ministry of Health.
Since 2012, I have been actively participating at the process of implementation of the International Health Regulations (WHO 2005) in Romania.

Since February 2013, I represent MoH of Romania in the EU SHIPSAN ACT Joint Action project.
I fully support SHIPSAN project and I am very pleased to be involved in the EU SHIPSAN ACT Joint Action.

Legionnaires' Disease in Hotels and Passenger Ships: A Systematic Review of Evidence, Sources, and Contributing Factors.
Mouchtouri VA, Rudge JW.
J Travel Med. 2015 Sep; 22(5):325-37.
http://www.ncbi.nlm.nih.gov/pubmed/26220258 

Abstract
BACKGROUND: Travel-associated Legionnaires' disease (LD) is a serious problem, and hundreds of cases are reported every year among travelers who stayed at hotels, despite the efforts of international and governmental authorities and hotel operators to prevent additional cases.

METHODS: A systematic review of travel-associated LD events (cases, clusters, outbreaks) and of environmental studies of Legionella contamination in accommodation sites was conducted. Two databases were searched (PubMed and EMBASE). Data were extracted from 50 peer-reviewed articles that provided microbiological and epidemiological evidence for linking the accommodation sites with LD. The strength of evidence was classified as strong, possible, and probable.

RESULTS: Three of the 21 hotel-associated events identified and four of nine ship-associated events occurred repeatedly on the same site. Of 197 hotel-associated cases, 158 (80.2%) were linked to hotel cooling towers and/or potable water systems. Ship-associated cases were most commonly linked to hot tubs (59/83, 71.1%). Common contributing factors included inadequate disinfection, maintenance, and monitoring; water stagnation; poor temperature control; and poor ventilation. Across all 30 events, Legionella concentrations in suspected water sources were >10,000 cfu/L, <10,000 cfu/L, and unknown in 11, 3, and 13 events, respectively. In five events, Legionella was not detected only after repeated disinfections. In environmental studies, Legionella was detected in 81.1% of ferries (23/28) and 48.9% of hotels (587/1,200), while all 12 cruise ships examined were negative.

CONCLUSIONS: This review highlights the need for LD awareness strategies targeting operators of accommodation sites. Increased standardization of LD investigation and reporting, and more rigorous follow-up of LD events, would help generate stronger, more comparable evidence on LD sources, contributing factors, and control measure effectiveness.

Infections on Cruise Ships.
Kak V.
Microbiol Spectr. 2015 Aug; 3(4).
http://www.ncbi.nlm.nih.gov/pubmed/26350312 

Abstract
The modern cruise ship is a small city on the seas, with populations as large as 5,000 seen on large ships. The growth of the cruise ship industry has continued in the twenty-first century, and it was estimated that nearly 21.3 million passengers traveled on cruise ships in 2013, with the majority of these sailing from North America. The presence of large numbers of individuals in close proximity to each other facilitates transmission of infectious diseases, often through person-to-person spread or via contaminated food or water. An infectious agent introduced into the environment of a cruise ship has the potential to be distributed widely across the ship and to cause significant morbidity. The median cruise ship passenger is over 45 years old and often has chronic medical problems, so it is important that, to have a safe cruise ship experience, any potential for the introduction of an infecting agent as well as its transmission be minimized. The majority of cruise ship infections involve respiratory and gastrointestinal infections. This article discusses infectious outbreaks on cruise ships and suggests preventative measures for passengers who plan to travel on cruise ships.

Ship's doctors qualifications required for cruise ships: Recruiter's comments on the German - Norwegian debate.
Christian Ottomann
International Maritime Health 2015;66(3):160-3. 

This contribution is intended to fertilise the current discussion of ship’s doctors qualifications required for cruise ships. Therefore 10 points are added to the debate containing different considerations focusing on the recommendations of the German Society of Maritime Medicine, the American College of Emergency Physicians (ACEP’s) Health Care Guidelines for Cruise Ship Medical Facilities and the different skills a ship’s doctor should have from the perspective of the recruiter.

http://czasopisma.viamedica.pl/imh/article/view/IMH.2015.0031/29777

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News and forthcoming dates 

EU SHIPSAN ACT Past events:
National training course titled “Inspections according to the European Manual and for the Issuance of the Ship Sanitation Certificates”
When: 31st August – 1st September 2015 Where: Dublin, Ireland
The EU SHIPSAN ACT training activities include European courses organised for port health officers and seafarers and National training courses for port health officers organised by the EUMS with the support of the EU SHIPSAN ACT Joint Action.
The 2-day National training course was organised by the Health and Safety Executive in Ireland with the support of the EU SHIPSAN ACT Joint Action.
In total, 20 port health officers from Ireland participated in the training course.

Other past events
18th European Health Forum Gastein - Securing Health in Europe
Balancing priorities, sharing responsibilities
When: 30th September - 02nd October 2015 Where: Gastein, Austria
The conference covered topics such as sustainable health systems and health economics. The focus was on health system performance, pricing of medicines and health security, including health threat responses, European development aid and health policy development.
A poster of the EU SHIPSAN ACT Joint Action was displayed in the poster session.
http://ehfg.org/home.html

EU SHIPSAN ACT forthcoming events:
6th Live Webinar - Occupational health in maritime transport
When: 25th November 2015
The live webinar series organised by the SHIPSAN ACT partnership continues with a webinar on the Occupational Health in Maritime Transport.
Presenters:
• Dr Audrone Lavruvianec (Chief specialist of Communicable Diseases Prevention and Control, Klaipeda Public Health Center, Lithuania)
• Dr Brigita Kairienė (Chief specialist at Department of Infectious Diseases Prophylaxis and Control. Klaipeda Public Health Center, Lithuania
• Dr Raimonda Eicinaite Lingiene (Specialist, Institute of Hygiene, Lithuania)
• Dr Thomas von Münster (Specialist in Occupational Medicine, Institute for Occupational and Maritime Medicine, Germany)
• Dr Martin Dirksen-Fischer (Head of the Hamburg Port Health Center, Hamburg Port Health Center, Germany)

Visit the website to enrol to the webinar series: http://www.shipsan.eu/webinars.aspx

Other forthcoming events
Conference "lessons learned for public health from the Ebola outbreak in West Africa – how to improve preparedness and response in the EU for future outbreaks"
When: 12th – 14th October 2015 Where: Luxembourg
The SHIPSAN ACT Joint Action coordinator, Prof. Christos Hadjichristodoulou, will participate and give a presentation during the session: “Public Health in travel and transport and at ports and airports: - Support the dissemination of temporary recommendations of the IHR Emergency Committee and their coherent and cross-sectoral implementation across the EU based on Art. 15 of the IHR”.

8th European Public Health Conference
Health in Europe – from global to local policies, methods and practices
When: 14th – 17th October 2015 Where: Milan, Italy
The EPH Conference aims to contribute to the improvement of public health in Europe by offering a means for exchanging information and a platform for debate to researchers, policy makers, and practitioners in the field of public health and health services research as well as public health training and education in Europe. For further information: http://www.ephconference.eu/

Bridging epidemiology to public health security policy workshop
When: 10th November 2015 Where: Stockholm, Sweden
This is a side event to the ESCAIDE conference. The aim is to offer experts, project partners and other conference participants the opportunity to exchange information on their work in the field of preparedness and response and demonstrate how the outputs of the Health programme have been adopted at national/regional level.
The SHIPSAN ACT Joint Action coordinator, Prof. Christos Hadjichristodoulou, will participate and give a key note speech titled “Bridging health security knowledge from epidemiological studies to public health policy development - Key note speech”.
Moreover, a poster with the latest results of the EU SHIPSAN ACT Joint Action will be displayed in the World café of project session.
For further information: http://ecdc.europa.eu/en/ESCAIDE/programme/Pages/side-events.aspx

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Website statistics

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Quiz

In Romania was born in nineteenth century, a Romanian biologist, zoologist, speologist, explorer of Antarctica and the first biologist in the world to study the arctic life. He also is considered to be, together with René Jeannel, the founder of biospeology.
Will you find the name of this scientist?

Answer to the previous issue quiz:
Portugal’s jurisdiction SAR operation area comprises the Lisbon and Santa Maria Flight Information Regions (FIR), summing up to almost 5 800 000 square kilometers (which represents about 63 times the area of the country).

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Port in focus

PORT OF CONSTANTA ROMANIA
By Dr. Carmen Niculescu - Port Health Authority Constanta - epidemiologist
Dr. Mirela Gheorghita - Port Health Authority Constanta - epidemiologist

Constanta Harbour is the main Romanian port being located on the west coast of the Black Sea. 

The first archaeological evidence about the port dates from 6thcentury BC, when Greek seafarers founded Tomis, the ancient name of the current city and port.
The significance of Tomis Port has increased considerably in the time of Emperor Constantine the Great and since then, both the city and the port wear the Emperor’s name.
On October 16, 1896 King Carol I of Romania officially inaugurated the construction and modernization of the port which lasted until 1909 when it was officially inaugurated as Port of Constanta.

The port of Constanta continued to grow until 1937, when the cargo traffic has reached 6.2 million tons, which situated Constanta among the top European ports.