Recommended procedures for prevention and management of probable cases of SARS on International Cruise Vessels
4 June 2003
In response to the outbreak of Severe Acute Respiratory Syndrome (SARS) in several countries, the World Health Organization has developed the following procedures for personnel on international cruise vessels and local port health authorities when there is a suspected or probable case of SARS on board. All individuals, groups and authorities involved in the cruise ship industry including crew, health care staff, cruise line operators, owners, and port health authorities should be aware of these procedures.
General Information and symptoms of SARS
All international travellers including crew and passengers of cruise vessels should be aware of the main symptoms and signs of SARS, which include:
Prior to boarding, all passengers and crew on international voyages originating in areas with recent local transmission of SARS2 should receive and complete a short pre-departure SARS Screening Form with questions as to symptoms, contacts, and recent history of travel to an area(s) with recent local transmission of SARS.
1) A person presenting symptoms compatible with SARS, should not travel until s/he is fully recovered. The local health authority should be notified and the patient must be assessed immediately.
2) A person reporting having been in close contact3 with a probable case of SARS in the last 10 days, but who is otherwise healthy, should not travel. S/he should be advised to be vigilant for SARS symptoms over the 10 days following exposure and continuously monitored by the local public health authority.
3) A person exhibiting none of the above symptoms, and who has not been in contact with a suspect or probable case/s of SARS over the previous 10 day period, should be provided with information on SARS and instructed to seek medical attention immediately if any symptoms consistent with SARS develop.
Managing passengers and crew
Following preliminary medical examination, if the ship's medical officer determines that there is a suspected or probable case of SARS on board, the following measures should be taken:
i) the suspected case should be isolated in an isolation ward, cabin, room or quarters with, if possible, an independent ventilation and toilet system.
ii) infection control measures including respiratory and standard precautions should be implemented4.
iii) designated staff taking care of the patient should wear a protective face mask5 , gloves and eye protection and wash hands before and after contact with the patient.
The officer in charge of the vessel should immediately alert the medical authority at the next port of call regarding the suspected case to determine if the necessary capacity for transportation, isolation , and care is available at the port. The vessel may be asked to proceed to another national port in close proximity if this capacity is not available or if warranted by the critical medical status of the suspected or probable SARS case.
For persons meeting the definitions of suspect or probable case of SARS, confinement to isolation ward, cabin, room or quarters with infection control measures should be continued until 10 days after the resolution of fever, provided respiratory symptoms are absent or improving. However, if the illness does not meet the case definition, but the individual has persistent fever or unresolving respiratory symptoms, the person should not be allowed to return to public areas of the vessel or interact with the public. Infection control precautions including confinement to isolation ward, cabin, room or quarters and further monitoring of symptoms should be continued. A decision as to returning to public areas can be reviewed in collaboration with the public health authority of the next port of call. All contacts (see below for details) on board should be identified and monitored.
While case management is in progress on board a cruise vessel, a high level of cleaning and disinfection measures should be maintained on the vessel. Cabins and quarters occupied by patients and contacts of SARS should be cleaned and disinfected according to WHO6 and local public health recommendations.
On arrival at the next port
1. No one may leave the vessel until a medical officer for the health authority has examined the suspect or probable case and has identified and examined all possible contacts on board.
2. If the medical officer for the port determines that the ill crewmember or passenger meets the SARS case definition, the crew member or passenger shall be removed from the vessel, using all necessary precautions, and transported to the nearest medical facility. If the patient is determined to be a probable case of SARS, his/her contacts should be asked to be in voluntary isolation and not permitted to travel until 10 days after the contact.
3. As soon as the suspected or probable case had been removed from the cruise vessel, the cabin or quarters where the SARS patient was isolated and managed should be thoroughly cleaned and disinfected (see below).
4. The local public health authority should provide information on symptoms and transmission of SARS to all passengers and crew.
5. The vessel may be allowed to proceed to its next port of call after the health authority has determined that none of the other crewmembers or passengers has symptoms consistent with SARS.
Procedures for contacts
All contacts of a suspected7 or probable8 SARS case should be provided with information on symptoms and transmission of SARS. They should be placed under active surveillance for 10 days and directed to observe voluntary isolation. Designated health staff on board should monitor and record the temperature of contacts daily. Both embarking and disembarking ports must be notified immediately of SARS contacts being on board and measures taken. If, after 10 days of voluntary isolation and observation, the contacts do not develop symptoms of SARS, then contacts can be discharged from the follow up.
Disinfecting the cabin or quarters occupied by a suspect or probable SARS case
Cleaning and hygiene staff should be well-briefed on infection control. Precautionary procedures should be observed when cleaning and disinfecting the isolation area(s) (ward, cabin room, or quarters) of the SARS patient. Persons cleaning the isolation area(s) should wear adequate personal protection (gloves, protective face mask5 , eye protection, disposable outer garments). These areas should be disinfected with sodium hypochlorite (bleach) and formalin9 , chloro meta xylenol, or an equivalent product. All surfaces and objects that the patient may have touched should be specifically targeted for cleaning. Materials, such as sheets and towels that have been used by the possible SARS case, should be thoroughly cleaned and disinfected. All cleaning equipment should be disinfected after use. Areas contaminated by body fluids from the suspect case (e.g. vomitus) should not be vacuumed unless a HEPA filter vacuum is available. Wet mopping with a disinfectant cleaner (hard surfaces) or steam cleaning (carpets) is recommended.
1See WHO web link for areas with local transmission
2See WHO web link for areas with local transmission
3Close Contact: having cared for, lived with, or had direct contact with respiratory secretions or body fluids of a suspect or probable case of SARS. SeeWHO web link
4See WHO web link
5 N/R/P 95/100 or FFP 2/3 or an equivalent national manufacturing standard (NIOSH (N,R,P95,99,100) or European CE EN149:2001(FFP 2,3) and EN143:2000 (P2) or comparable national/regional standards applicable to the country of manufacture.
6Lamoureux VB. Guide to Ship Sanitation. WHO. 1967
7 see WHO web link for definition of suspected case of SARS
8 see WHO web link for definition of probable case of SARS
9 Sodium hypochlorite diluted to a strength of 100 mg/1 and a 5% solution of formalin, which itself is a 40% solution of formaldehyde gas in water.