1. The EU SHIPSAN TRAINET Project Assoc. Prof. Christos Hadjichristodoulou Project Leader University of Thessaly, Greece

2. Shipsan Trainet Project Leadership :University of Thessaly, Larissa, Greece Scientific Coordination :National School of Public Health, Athens, Greece DG HEALTH & CONSUMERS PUBLIC HEALTH PROGRAMME 2003-2008 Priority Area Responding to health threats rapidly and in a co-ordinated manner (HT 2007) Action Health security and strategies relevant to communicable diseases control SHIPSAN TRAINET Duration30 months Duration : 30 months : November 2008 Start : November 2008 : May 2011 End: May 2011SHIPSAN Duration24 months Duration : 24 months : December 2006 Start : December 2006 : December 2008 End: December 2008

3. Shipsan Trainet Health Protection Surveillance Centre, IRELAND Health Protection Agency, Centre for Infections, UNITED KINGDOM Institute of Public Health of the Republic of Slovenia, SLOVENIA National Centre for Epidemiology, SPAIN Health Protection Inspectorate, ESTONIA Klaipeda Public Health Centre, LITHUANIA Hamburg Port Health Centre, GERMANY Consulting Management Training (C.M.T.) Prooptiki Athens, GREECE Technological Institute of Athens, Faculty of Health and Caring Professions, GREECE Medical university of Gdansk, Interfaculty of Maritime and Tropical Medicine POLAND Ministry of Health, Section of Communicable Diseases Surveillance, BULGARIA The National Board of Health and Welfare, Unit of Communicable Disease Prevention and Control, SWEDEN Associated Partners 11 EU countries

4. Shipsan Trainet 17 Collaborating Partners National Institute for Public Health and the Environment, THE NETHERLANDS Ministry of Health, Department of alert, response and preparedness, FRANCE Ministry of Public Health, BELGIUM Ministry of Health, Medical and Public Health Services, CYPRUS Ministry of Health - Department of Preventive Hygiene, ITALY Ministry of Health, PORTUGAL Centre of Environment, FINLAND Association of Port Health Authorities, UNITED KINGDOM Spanish Ministry of Health, SPAIN Ministry of Health, Department of alert, response and preparedness, FRANCE Carnival Cruise Lines, UNITED KINGDOM Ministry of Health, PORTUGAL Ministry of Health, Department of alert, response and preparedness, FRANCE Spanish Ministry of Health, SPAIN Ministry of Health, PORTUGAL Ministry of Health, Department of alert, response and preparedness, FRANCE Ministry of Health - Department of Preventive Hygiene, ITALY Spanish Ministry of Health, SPAIN Ministry of Health, PORTUGAL Ministry of Health, Department of alert, response and preparedness, FRANCE Ministry of Public Health, BELGIUM Ministry of Health - Department of Preventive Hygiene, ITALY Spanish Ministry of Health, SPAIN Ministry of Health, PORTUGAL Ministry of Health, Department of alert, response and preparedness, FRANCE National Institute for Public Health and the Environment, THE NETHERLANDS Ministry of Public Health, BELGIUM Ministry of Health - Department of Preventive Hygiene, ITALY Spanish Ministry of Health, SPAIN Ministry of Health, PORTUGAL Ministry of Health, Department of alert, response and preparedness, FRANCE National Institute for Public Health and the Environment, THE NETHERLANDS Ministry of Public Health, BELGIUM Ministry of Health - Department of Preventive Hygiene, ITALY Spanish Ministry of Health, SPAIN Ministry of Health, PORTUGAL Ministry of Health, Department of alert, response and preparedness, FRANCE Centre of Environment, FINLAND National Institute for Public Health and the Environment, THE NETHERLANDS Ministry of Public Health, BELGIUM Ministry of Health - Department of Preventive Hygiene, ITALY Spanish Ministry of Health, SPAIN Ministry of Health, PORTUGAL Ministry of Health, Department of alert, response and preparedness, FRANCE ANEK Ferries, GREECE Centre of Environment, FINLAND National Institute for Public Health and the Environment, THE NETHERLANDS Ministry of Public Health, BELGIUM Ministry of Health - Department of Preventive Hygiene, ITALY Spanish Ministry of Health, SPAIN Ministry of Health, PORTUGAL Ministry of Health, Department of alert, response and preparedness, FRANCE Hellenic Centre for Infectious Diseases Control, GREECE Ministry of Health and Social Solidarity, GREECE Centre of Environment, FINLAND Passenger Shipping Association, UNITED KINGDOM National Institute for Public Health and the Environment, THE NETHERLANDS Ministry of Public Health, BELGIUM Ministry of Health - Department of Preventive Hygiene, ITALY Spanish Ministry of Health, SPAIN Ministry of Health, PORTUGAL Ministry of Health, Department of alert, response and preparedness, FRANCE Carnival Cruise Lines, UNITED KINGDOM MINOAN Lines, GREECE Bluestar Ferries, Superfast Ferries, GREECE Hellenic Association of passenger ships, GREECE 9 country authorities, 5 associations, 5 shipping companies European Centre for Diseases Control and Prevention World Health Organization CDC Vessel Sanitation Program International Maritime Organization Turkey Jordan Israel Lebanon

5. Shipsan Trainet What the SHIPSAN has achieved From 2006-2008 The most appropriate programme for the EU (based on best practice, experience, existing programmes etc) was explored Communicable diseases and outbreaks have been published from 1970 to 2006 on passenger ships were collated and included in the State of the Art report The European passenger ships market was examined and EU MS were categorised in four groups A study was conducted in the 32 countries and 176 authorities Identified the EU, national and international legislation applied by competent authorities in the EU Description of the current situation in the EU based on study findings (needs, gaps) Established a partnership which consists of experts scientists and intends to expand it Developed synergies with ECDC, authorities, the industry, key stakeholders and internationally recognised programmes

6. Shipsan Trainet Why SHIPSAN? The problem was first realised in 2001, during the preparation for the 2004 Olympic games - Hellenic vessel sanitation program 2006 SHIPSAN 2008 SHIPSAN TRAINET

7. Shipsan Trainet Increasing numbers of cruise ships and ferries in the EU: 66 cruise lines, 192 cruise ships The European market has grown by 41% over the past three years and has more than doubled over the last ten. Modern cruise liners designed to carry many more passengers and crew Approximately 320 million ferry passengers passed through EU MSs ports in 2007 Why SHIPSAN?

8. Shipsan Trainet In many countries different authorities (up to five) have the responsibility to enter a ship and conduct an inspection Quality of hygiene inspections of ships varies enormously between countries in Europe, even within countries, even within the same port Lack of knowledge, lack of training, overreaction at ports Introduction of the SSC has been a retrograde step in Europe especially on passenger ships Why SHIPSAN?

9. Shipsan Trainet Surveillance of disease associated with ships is inadequate Maritime Declaration of Health does not give adequate information to port health authorities for risk assessment and surveillance purposes Outbreaks and diseases on board – reported mainly to countries with specific surveillance systems: US VSP, Sydney, EU-ELDSNet, DIVINET, Southampton UK Lack of communication, duplication of investigations Why SHIPSAN?

10. Shipsan Trainet Large number of passengers in a confined space Infectious diseases may easily transmitted via person to person transmission Trans-national transmission may occur Passengers share food and water (foodborne and waterborne diseases) Ashore activities include risks The average age of passengers is a risk factor Public health importance of passenger ships

11. Shipsan Trainet Cruise ships vs. Land-based hotels 6,280,636 customer satisfaction questionnaires from 2000-2008 British tourists who returned from their holidays 24% of passengers reported illness during their holidays (11% nausea) 18% of tourists spent their holidays in hotels reported illness Frequency of reported symptoms: o stomach upset: passengers 5% and land-based 7% Lower risk for stomach upset was identified among passengers in comparison among land-based Source: Bryant N., Nichols G., Cartwright R., Lawrrence J., Jones J. and Hadjichristodoulou C. Northern self-reported illness in cruise ship travellers – focus on stomach upset. European Conference on Travel Medicine Abstract

12. Shipsan Trainet Cruise-based vs. Land-based holidays Stomach upset reporting on cruises appears to be reducing BUT: o Country specific rates vary o Spain accounts for 56% of customer satisfaction questionnaires Source: Bryant N., Nichols G., Cartwright R., Lawrrence J., Jones J. and Hadjichristodoulou C. Northern self-reported illness in cruise ship travellers – focus on stomach upset. European Conference on Travel Medicine Abstract

13. Shipsan Trainet Destination as a determinant of risk Odds ratio of stomach upset in various countries, compared to Spain Source: Bryant N., Nichols G., Cartwright R., Lawrrence J., Jones J. and Hadjichristodoulou C. Northern self-reported illness in cruise ship travellers – focus on stomach upset. European Conference on Travel Medicine Abstract

14. Shipsan Trainet SHIPSAN TRAINET Networks Research Manual Training

15. Shipsan Trainet SHIPSAN TRAINET Objectives EU SHIPSAN Integrated Programme Common standards Common training Communication Training material and Training modules for port health professionals and seafarers Training network with expert scientists Web-based Port to port Communication Manual for surveillance and inspections

16. Shipsan Trainet Manual Manual consists of two parts European Manual for Hygiene Standards and Communicable Diseases Surveillance on Passenger Ships Part A includes the following chapters: Chapter 1: Medical facilities Chapter 2: Communicable diseases surveillance aboard ships Chapter 3: Food safety Chapter 4: Potable water safety Chapter 5: Recreational water safety Chapter 6: Pest management Chapter 7: Housekeeping and facilities Chapter 8: Hazardous substances Chapter 9: Waste management Chapter 10: Ballast water management

17. Shipsan Trainet Manual Part B includes the following guidelines for :  The prevention and control of influenza-like illness on passenger ships  The prevention and control of gastroenteritis on passenger ships  The prevention and control of legionellosis on passenger ships

18. Shipsan Trainet SHIPSAN TRAINET Timetable of SHIPSAN TRAINET Manual versions Version 1Version 2Version 3Version 4 May 2010September 2010December 2010January 2011 Before “Seafarers Training Course” in Barcelona, Spain Deliverable 9After “Seafarers Training Course” in Barcelona, Spain and before meeting with the industry After meeting with the industry

19. Shipsan Trainet Outline of inspections Standardised inspection forms (inspection outlines) will be used during the inspection They are considered necessary in order to: o ensure consistent implementation of inspection procedures o avoid subjective implementation of standards o record the inspection findings in a consistent manner.

20. Shipsan Trainet Training Pool of trainers (35 trainers) 2 training courses o One 2-day “train the trainers” course and 3-day training course for seafarers (62 participants) in Barcelona, Spain (September 2010) o One 4-day course including practical training for Port Health Officers (34 participants from EU and 16 from EuroMed countries) in Athens, Greece (January 2010) E-learning platform: pre-reading tool and distance learning

21. Shipsan Trainet E-learning platform

22. Shipsan Trainet

23. Benefits from SHIPSAN

24. Shipsan Trainet Pilot phase Inspections based on the manual Ship-to-port reporting of diseases using the web-based network Port-to-port communication using the web-based network One selected competent authority from each designated country will participate in the network and carry out inspections It has been proposed that the following countries will participate in the pilot phase: o Greece o United Kingdom o Cyprus o the Netherlands o Germany o Spain o Poland o Estonia

25. Shipsan Trainet Pilot phase At least 2 cruise ship and 2 ferry companies Passenger ship/ship: Any seagoing or inland passenger ship (with more than 12 passengers) sailing within the EU waters, providing accommodation and/or food to passengers, and/or potable water from the ship water distribution system to passengers, with a duration of voyage of more than 6 hours.

26. Shipsan Trainet We have to acknowledge The most of the cruise lines are enforcing high hygiene standards They have quality management systems in place Outbreak plans and management teams in place They use surveillance on pre-embarkation and during the voyage Many other control measures However, there is always space for improvement for both port health authorities and the industry

27. Shipsan Trainet Legal frame Options EU Directive (legislation) Memorandum of Understanding among EU MSs Code of practice Future permanent implementation

28. Shipsan Trainet Future permanent implementation Who will operate a future programme? Coordinating centre ??? o Maintenance of EU database including inspection, laboratory and surveillance data o Data collection and dissemination among all parties o Network update o Auditing coordination o Training network coordination (SHIPSAN trainet) o Coordinate surveillance o Coordinate outbreak investigation o Evaluation and review of the network Decisions upon European Commission and EU Member States

29. Shipsan Trainet Next steps o Discussion with DG MOVE o European Maritime Safety Authority (EMSA) o ECDC advisory board o EWRS focal points of EU MSs Future permanent implementation

30. Shipsan Trainet Collaborate with industry: Training Consultation Research SHIPSAN partnership commitment

31. Shipsan Trainet Thank you for inviting me and I wish to everybody safe trips!!!