GI Surveillance & Employee/Passenger Health

1. General Sanitation Procedures: NORTH AMERICAShipboard Sanitation – MEDICAL GI Surveillance & Employee/Passenger Health

2. Gastrointestinal Illness Surveillance System (GISS)

3. What is a reportable case? Official VSP Definition • Diarrhea (3 or more loose stool in a 24-hour period), -or – • Vomiting and one of the following: • 1 or more loose stools • Fever (100.4°F or 38°C) • Abdominal cramps • Headache • Myalgia (muscle aches)

4. Gastrointestinal Illness Log(“GI Log”) • Base documentof the VSP surveillance system: • A line-listing of cases of GI illness reported to the ship’s medical staff • Used to gather information to report cases to the VSP • Critical to all outbreak investigations • Requiredfor each cruise/voyage

5. What is an outbreak?

6. Some Important Disease-causing Agents • ETEC • Ciguatera fish toxin • Legionella spp • Noroviruses Salmonella spp Shigellaspp Cyclosporaspp Hepatitis A virus

7. How do we detect outbreaks?

8. When do the outbreaks occur? • Early in short cruises • During cruise segments in long cruises • Across different regions of the world • Some seasonal variations • Across multiple cruises or cruise segments

9. Keys to PreventionFood Safety • No bare hand contact with ready-to-eat (RTE) foods • No ill workers handling food – ever! • Proper cooking/holding temperatures • Proper galley equipment maintenance • Ensure food is procured from reputable sources

10. Keys to PreventionPotable & Recreational Water • Bunker potable water from approved sources • Properly maintain potable and recreational water systems, including filtration systems • Properly maintain halogen and pH levels within the required ranges

11. Keys to Prevention Environmental Controls • Properly clean and disinfect public/private areas • Ensure public toilets are operational and fully stocked for proper handwashing • Promptly and completely respond to PDI/PVI events • Ensure response teams are properly trained, protected and equipped • Report any illness (especially diarrhea & vomiting) promptly

12. Keys to PreventionMedical Case Management • Properly manage all cases of illness reported to the medical staff • Follow prescribed isolation and quarantine procedures for passenger and crew • Ensure crew members are completely free of symptoms before allowing them to return to work

13. Keys to PreventionMedical Case Management • Provide written or electronic confirmation of return to work documents • Provide handwashing and personal hygiene sheets as required to all ill passengers and crew • Thoroughly evaluate new and returning crew members for diarrhea or vomiting symptoms

14. Keys to PreventionGeneral Procedures • Develop written OPRPs that incorporate prevention strategies • Ensure response personnel are familiar with their assigned response duties • Use effective cleaners, sanitizers and disinfectants

15. Employee Health • Illnesses/syndromes requiring food employee exclusion/restriction (FDA Food Code – 2009) • VSP isolation requirements • Return to work • Asymptomatic cabin mates and close personal contact evaluations • New/returning crew health assessments

16. Exclusionvs Restriction (FDA) • Exclusion: to prevent a person from working as an employee in a food establishment or entering as an employee • Restriction: to limit the activities of the food employee so that there is no risk of transmitting a disease that is transmissible through food and the food employee does not work with exposed food, clean equipment, utensils, linens or unwrapped single-service or single-use articles Source: U.S. FDA Food Code - 2009

17. Symptoms Food Employees Must ReportFDA Food Code, 2009 Symptoms Lesion containing pus Hands or wrists Exposed portion of arms Other parts of body • Vomiting • Diarrhea • Jaundice • Sore throat with fever

18. Diagnoses That Must Be Reported by Food Workers, FDA Food Code, 2009 • Norovirus • Hepatitis A virus • Shigella spp. • Enterohemorrhagic (EHEC) or Shiga toxin-producing E. coli (STEC) • Salmonella typhi Note: Recent past exposure history of some listed diagnoses require reporting as well

19. Exclusion/Restriction Table, FDA Food Code 2009

20. Diseases Among Food Employees Requiring Exclusion, FDA Food Code, 2009

21. Restrictions Not Related to Foodborne Illness Individuals experiencing… Cannot work with: Food Clean equipment Table linens Unwrapped single-use and single service articles • Coughing • Sneezing • Runny nose/discharge from nose or mouth

22. Comparison of Isolation and Restriction

23. Crew Isolation (VSP Operations Manual) Food employees Non-food employees 24-hour minimum (after the last symptom) 48-hour minimum (after the last symptom) Document isolation period and medical follow-up including date & time of last symptom and clearance back to work.

24. Verbal Evaluation with AsymptomaticCrew (VSP Operations Manual) • Conduct daily interviews to confirm health status for up to 48 hours after onset of ill crew members symptoms • Include initial within 8 hours of ill crew reporting to medical, 24-hr and 48-hr interviews depending on date individual reported illness • Advise of hygiene and handwashing • Document interviews

25. Health Assessment for New/Returning Crew(VSP Operations Manual) • Assess AGE symptoms for 72 hours prior to arrival • Yes to symptoms require GI log entry (even if currently symptom-free) • Keep documentation on crew with symptoms • Retain for 12 months

26. Encourage isolation 24-hour symptom-free Medical follow-up advised Personal hygiene reminder Handwashing and personal hygiene information sheet Must be written Passenger Health (VSP Operations Manual)