Cruise Ship Rapid Immunization Response

State: FL Type: Model Practice Year: 2007

Brevard County is centrally located along 72 miles of Florida’s eastern coastline with higher than average density per square mile. It is well known for its beaches and nearby tourist destinations, such as: Kennedy Space Center, Port Canaveral, Disney World, Sea World, and Universal Studios. Port Canaveral is second in size only to Miami as a cruise ship destination in the United States. Due to the global nature of the traveling public, sea ports are particularly vulnerable to disease transmission. Health officials in these communities must be vigilant and aggressive in their epidemiologic surveillance and response methodologies. Vaccine-preventable illnesses, such as measles, mumps, rubella, and varicella are life-threatening and can result in serious complications including: encephalitis, heart damage, blindness, deafness and death. Fortunately, in the United States, these diseases have been significantly reduced due to routine childhood vaccination programs; however, they are still widespread in other countries. Because cruise lines are commonly based in foreign countries, they maintain foreign-born crews that may not be immunized. Due to the confined nature of a cruise ship and duration of a voyage, viral infections can spread quickly and easily among crew members and un-immunized passengers, and eventually, to the communities where they port, and beyond. In 1997, the Centers for Disease Control and Prevention (CDC) published in the MMWR that this environment also represents a special risk to pregnant women and women of child-bearing age and they recommend that these women be immunized before traveling by cruise ship. As part of its overall mission to protect the health and welfare of citizens, tourists, and visitors in Brevard County, the Brevard County Health Department (BCHD) serves as a community leader by bringing together local, state, and federal-level partners to create an effective model to ensure a rapid multi-agency response to address disease outbreaks on cruise ships. This model ensures the immediate containment and immunization of crew, notification of passengers, counseling and education, protection of the port and community, and serves to promote prevention strategies by the cruise industry in the future.
It is critical to identify and respond to symptoms of infectious disease quickly to confirm a diagnosis, interrupt further transmission, and provide vaccinations to prevent an outbreak. In 2006, a foreign-born visitor reported to a local hospital with a rash that was serologically diagnosed as positive for rubella and reported to the local health department (LHD). It was determined that the individual was a crew member of a cruise ship destined to Miami. The LHD notified the Centers of Disease Control and Prevention (CDC) quarantine station in Miami where a case of active rubella among crew-member foreign nationals were verified through serological testing as the ship headed back to Port Canaveral. Information continued to be collected and it was revealed there was also a suspected case of measles. Reports confirmed a measles outbreak in the Ukraine, as well as, a rubella outbreak in the Philippines at that time. Based on this information, the health department deemed it prudent to screen and vaccinate all crew members in order to contain the outbreak once it docked in Cape Canaveral. The ship carried approximately 3,200 passengers and 1,180 crew members. Conference calls were conducted between the health department, the CDC’s Quarantine Service, CDC Child Vaccine-Preventable Disease Branch, the cruise line, and state authorities to systematically implement the methodology outlined above. Challenges included: logistics of limited space, time constraints of porting ship, personnel requirements, vaccine supplies, laboratory sample processes, documentation requirements, and parking and port security issues. The LHD and CDC epidemiologists boarded the ship at initial docking. Once the diagnoses were confirmed, passengers were notified and the entire crew was screened and immunized. A total of 1,151 were immunized in 5 hours, or 230 doses per hour. This rapid and efficient response effectively curtailed further outbreaks and protected the individuals involved from future exposures. Nationally, preparedness plans are underway to respond to terrorist attacks and natural disasters, but standardized plans to coordinate the activities necessary to respond to the very real threat of contagious disease via cruise ships is not the norm. Historically, foreign-flag cruise ships have borne the responsibility of responding to contagious disease within their confines. Although their medical personnel strive to isolate and treat disease in a manner consistent with their professional standards, they do not have the public health responsibility to contain and prevent further transmission at port. Both the CDC and the Florida Department of Health have commended Brevard County’s approach as a model of cooperation and collaboration and have recommended that it be shared through via grand rounds, publications, and other venues so it may be replicated by other port communities. Similar to Incident Command System models, it establishes jurisdictions, roles and responsibilities, security procedures, establishes personnel and skill levels, dictates logistics of space and materials, and establishes agreements between cruise lines and state, federal, and local authorities to ensure the appropriate response is ever-ready for quick implementation. Cruise lines cooperation and participation is critical to logistics, medical assistance, documentation, and monitoring of positive cases that remain onboard. Pre-planning lays the groundwork for positive relationships and clear communication. This results in quick action in response to an immediate threat and the ability to safeguard the public without disruption of ship itineraries or negative impact on local tourist relations. Once the model is adopted, these activities also serve as an opportunity to test off-site pod processes to meet a variety of potential threats that require immunization, such as Avian Bird Flu Response, as part of an overall preparedness plan.
Agency Community RolesThrough the years, the Brevard County Health Department has had a long-standing tradition of innovative programs and successful partnering between public and private organizations to meet the needs of citizens. This model is the result of past experiences and cooperation among local, state, and federal authorities, hospital and medical personnel, epidemiologists, port and security officials, and the cruise lines. Initial planning stages served as a needs assessment. Agreements were reached and roles, responsibilities, jurisdictional requirements, and special considerations such as logistics, costs, public relations, and cruise ship priorities were established. The LHD’s epidemiology department assumed the lead role to implement the model and coordinate activities between all parties. Roles and responsibilities include: The Department of Health Laboratory and local hospitals provide laboratory services and report positive cases to the health department per protocols. The Florida Department of Health’s Immunization Department ensures vaccine is shipped overnight to the local site. The CDC provides off-site and on-site expertise to identify the disease point of origin, provide letters of information to passengers, assist in obtaining serologic samples, and tracks cases. The LHD provides the medical response team to the ship, consisting of: vaccine and supplies, 2 clinicians, 10-15 nurses, 3-5 administrative staff, and 2-5 counselors. The cruise lines cover costs related to vaccine, and provide assistance with logistics of space, parking, and set-up of areas for triage, immunization, documentation, and counseling. The ship’s medical personnel assist in pre-docking plans, medical procedures, continued isolation and monitoring of positive cases, and issuance of immunization cards. ImplementationThis proactive response model has been successfully implemented four times by the Brevard County Health Department in 1997, 2002, and 2006. As the current model evolved, the health department has assumed the lead role in implementing the model and coordinating local activities on behalf of all partners. Pre-determined jurisdictions and procedures assure clear communication and rapid action by all involved to meet the challenges presented by cruise ship itineraries, transferring crew members, port security issues post-911, and response team logistics. Concurrent planning and investigations of illnesses with symptomatic rashes provide for early diagnosis, identification of incubation periods, and strategies for containment. The planned methodology assures clear communication and coordination among all entities and includes: Case definition: clear parameters as to what constitutes a positive case and who has authority to diagnose a verified case.  Data collection: processes to report a case of rash include name, date of birth, roommates and very close contacts, country of birth, vessel name, date of embarkation, place one month prior to embarkation, occupation, location of work area, vaccination history, onset date, clinical symptoms, date first seen in infirmary, date of isolation, place isolated, treatment received, and laboratory tests.  Active surveillance: requires daily surveillance of all crew members and crew transfers on all company ships for clinical symptoms and daily reports to the health department and CDC.  Prospective surveillance: involves the screening, blood samples, and isolation of all those presenting with a rash by ship medical personnel. Contacts are identified, isolated, and specimens for serology also collected.  Retrospective surveillance: requires medical record review to identify any crew member with rash illnesses during a specified period, the country of origin, and travel one month prior to boarding the ship. Passenger information: includes letters to all passengers traveling during the outbreak and incubation period on affected ships to notify them of possible exposure, signs and symptoms, and CDC contact names and phone numbers. Cases are reported nationwide via Epix and Florida Epicom.  Laboratory analysis: provides standardized testing and reporting procedures to determine positive cases of measles, rubella, and varicella.  Intervention strategy: include mass screening, counseling, and immunization when needed, of all crew members upon arrival at port. Pre-designated exemptions apply, such as pregnant women and those that are immune-suppressed. Also exempt are crew members that can provide proof of immunity, although second MMR immunizations are recommended and offered at that time.  
Process evaluation is a function of a “plan, do, check, act” improvement process which includes documentation review and debriefing by all parties once the event has concluded. Opportunities for improvement are identified and new processes or agreements are formed. In-the-moment innovations and solutions are identified and incorporated into future plans. Lessons learned and successful processes are celebrated and confirmed. Cruise lines incorporate these plans and processes into their policies and procedures. Cruise lines are encouraged to participate in routine, mandatory vaccination of employees and to provide their employees with vaccination documentation. In 1997, 2002, and 2006, infectious diseases were identified onboard cruise ships at Port Canaveral and implementation of this model served to effectively respond and eliminate the public health threat. Furthermore, it reduced the future threat of disease by increasing numbers vaccinated and overall awareness of the importance of immunization for employees by the cruise ship industry. Over 85 million people from all over the world visited Florida in 2005 and overseas travel to Florida has increased to over 4.7 million in 2005. Many of these visitors come from countries without routine immunization programs. Also of concern are U.S. citizens who decline vaccinations for themselves or their children due to religious objections or personal fears. These individuals depend primarily on their herd immunity status. However, herd immunity can be weakened in relation to the nature of the disease threat. In epidemiologic terms, the infectious nature of a disease is referred to as its Rule 0 value. Flu, for example, has a Rule of 2, or, for every infected individual, they expose/infect two other individuals. In turn, these two individuals each infect an additional two, and so on, exponentially. By contrast, measles has a Rule of 11, and rubella a Rule 9. The public health threat is very clear. In a scenario such as that posed by the cruise ship response, it is easy to see what the impact of such an outbreak could be for a community, as well as, nationally and across international borders.
SustainabilityThis is a practical and easily sustainable model and additional funding is not required. Vaccine and hospital laboratory costs are covered by the cruise lines. The public health preventative services are absorbed by the state, federal, and local authorities as part of their primary mission. Because special funding is not required, as a prevention strategy, the result is a win-win outcome for all involved, and self-sustainability is assured for the future. Once established, this model can serve as an off-site pod for future training or to test actual responses. Further, as inroads are made with the foreign cruise industry, increase compliance with standard immunizations for employees is increasingly recognized as part of good business. Once agreements are reached and parameters have been established by all parties, it is ever-ready to implement as needed. The LHD performs a “plan, do, check, act” evaluation to improve the plan for future occurrences and performs documentation review and debriefing activities. Findings are shared with all parties involved and any new processes that may be required are established. The LHD encourages cruise lines to incorporate prevention practices into their policies and procedures to prevent reoccurrences. Lessons LearnedObjective: Screen, Vaccinate, Document Immunization Status of all ship crew within time parameters. Feedback: The LHD receives estimations of number of crew members with unknown immunization status or at-risk. Lessons learned: Pre-draw 100-dose supply of vaccine before arriving. Ideal team includes: 2 clinicians; 2 counselors; 1 epidemiologist; 3 administrative staff; and 10-12 nurses. Add traffic control cop to team. Required space for shipboard immunization clinic. The CHD must insist that utilizing the ship’s theatre is necessary to accommodate various tasks: triage, immunization, counseling, documentation. Time is of the essence while ship is in port. Bring experienced immunization nurses. Identify contact name for port security and communicate directly with this person to ensure no delay due to security issues. Objective: Contain Outbreak; Protect public. Feedback: Isolation cases progress are reported daily to LHD; CDC and LHD receive notifications of any new or suspect cases identified; and LHD notified of any related cases by CDC reporting systems. Lessons learned: Maintain a positive and decisive posture. Wavering adds to anxiety and concerns. Objective: Provide information and education to crew and passengers. Feedback: CDC receives responses to surveys and letters of notification; and LHD reports results in publications and poster presentations; reports post-event. Lessons learned: Provide educational material to ship medical personnel to distribute and educate crew in advance of on-board immunization clinic. Counseling in groups with Q&A sessions most efficient. 2 clinicians & 3 RN counselors ideal – split between women’s issues (pregnancy) and men. Immune compromised individuals need special counseling. Be prepared to answer questions about MMR and autism. Objective: Establish continuous improvement processes. Feedback: LHD reports on findings; publishes to CDC MMRW and other venues; and notifies cruise lines or partners of new processes or recommendations. Lessons learned: Ship medical staff must be involved in entire process. Port security issues must be clearly identified and resolved prior to an event.