Public Health Aboard - Prepation, Prevention and Response

PUBLIC HEALTH BOARD
Preparation, Prevention and Response
Moderator:
DR. KATE BUNYAN
Medical Director
CARNIVAL UK
MARIA PITTORDIS
Partner & Head of Marine Trade & Energy
HILL DICKINSON LLP
DR. PIERFRANCESCO LEPORE
Fleet Medical Director, Corporate Medical Services
MSC CRUISES
MEL SKIPP
Health Policy, Maritime Policy & Analysis
CARNIVAL CORP &. PLC

DR. KATE BUNYAN
Medical Director
CARNIVAL UK

Public Health
The Everyday Reality

Is it Inevitable?
• Maria Pittordis
• Before, during and after cruise measures to reduce the risk
• How to demonstrate the measures used and why it is so important
• Mel Skipp
• The role CLIA is playing helping the cruise industry to lead the world in management of illnesses like Norovirus
• Dr Pierfrancesco Lepore
• When it does happen, how is a typical cruise ship geared up to manage it?

MARIA PITTORDIS
Partner & Head of Marine Trade & Energy
HILL DICKINSON LLP

1. Recent Claim Trends
• Explosion in the number of claims
• Family or multi party actions to avoid small claims limits
• Mixed with quality complaints
• Not always for the same cruise or same illness
• Illness not specified “infective viral or bacterial GI illness”
• Always allege food and drink as a source coupled with alleged lack of hygiene
• Always claim they did not eat off the ship
• Claimant solicitors try to stop their medical experts answering Part 35.6 questions
• Claimant solicitors seeking extensive and disproportionate disclosure
• Explosion in number of claims management companies dealing with sickness claims

Why the increase in UK Claims?
• CFA / ATE insurance in run off for pre 1 April 2013 cases
• No win no fee and Qualified One way Costs Shifting
• No portal for illness / accidents outside the UK
• No fixed costs for Claimant legal costs
• Significant cost recovery / lucrative cases for Claimant solicitors

Recent developments

Reminder - Legal Liabilities Arising From
• Causing illness
• Failure to identify illness / outbreak
• Failure to have adequate procedures and or Outbreak Plan
• Failing to implement procedures or Outbreak Plan adequately
• Failing to comply with industry standards and relevant codes, Regulations etc.
• Difference in liability between viral claims and bacterial claims

2. Recent developments
• Wood v TUI 2017 S.4(3) Supply of Goods and Services Act 1982 and The Package
Travel Regulations 1992 food was held to be goods of “unsatisfactory quality”!
• Uniqueness of PLR / Athens Convention regime and Nolan v TUI 2015 judgment
and differences with Swift v Fred Olsen 2016
Relevance of Wood v TUI to cruise cases
• Shore excursions
• On board infection
• Importance of distinguishing between food poisoning and Norovirus
• Importance of random food testing
• Importance of identifying the pathogen

Some Science

3. What can the epidemiological curve and a GI log tell you?
Can provide information on
• Pattern of spread
• Magnitude
• Inferences about the outbreak's mode of spread
• Time trend
• Exposure and/or disease incubation period
• Whether single point of infection or person to person spread
• Possibly source of infection
• When it started and possibly from whom
• Whether it was brought on to the vessel at embarkation or during the cruise
• Whether illness was well controlled

Illness
Bacterial
/Viral
Where you get it form Symptoms Incubation Period
Salmonella, Bacterial Usually contaminated food Diarrhoea, stomach cramps, sometimes vomiting
and fever
Usually last for 4-7 days.
12 to 72 hours
E-Coli Bacterial Contaminated food, touching infected
animals, person to person, swimming in
contaminated water
Campylobacter Bacterial Usually contaminated food (typically raw
poultry can be found in unpasteurised milk
or untreated water). Can be passed on from
touching infected animals.
Diarrhoea, stomach cramps and occasionally fever.
About half of people with the infection will have
bloody diarrhoea. Can last up to 2 weeks.
Nausea, diarrhoea, vomiting., stomach cramps
and fever. Diarrhoea can be bloody. In most
people, symptoms are relatively mild and improve
within 2-3 days
Usually reported as 3 to 4
days, but may be as short as 1
day or as long as 10 days
Can be as short as one day or
as long as 11 days
Cryptosporidium Parasite It passes out in the faeces of infected
humans and animals. It can then be found
in soil, water, food, or on surfaces that have
been contaminated with the infected
faeces.
Watery diarrhoea with abdominal cramps,
vomiting, high fever and loss of appetite.
Symptoms usually last around 12 to 14 days but
can sometimes last for as long as one month
3 to 12 days
Shigella Bacterial Contaminated food or faecal oral route,
person to person.
Diarrhoea, fever, and stomach cramps. Usually
resolves in 5 to 7 days.
1 to 2 days

Epidemiological Graph of background levels of viral illness

Epidemiological Graph based on day of illness of a well controlled
Norovirus outbreak

Claims handling

4. Claims handling
• Robust claims handling
• Knowing when to settle and when to fight
‣Consider GI log and epi curve what story does it tell?
‣Quality of Implementation evidence re outbreak / GI procedures
‣Obtaining and testing Claimant’s factual allegations
‣Requiring contemporaneous evidence of illness when illness not reported on
the ship
‣Request lab test results and medical records from Claimant
‣Questions to Claimant’s medical experts
‣Resist Claimant applications for extensive and disproportionate disclosure
‣Provide adequate protocol reply on time with key documents if defendable
‣Settle before protocol reply is due if issues and avoid large settlements
‣Keep legal costs to a minimum

Management of evidence for trial

5. Management of evidence for trial
Documentary and witness evidence of:
• Epi curve coupled with microbiologist expert evidence
• Policies and procedures (Shipboard outbreak plan, medical manual, HACCP etc. )
• Food testing and swab tests (Salmonella, Shigella, Staphylococcus Aureus,
Enteropathogenic E-coli and Norovirus)
• General evidence of implementation of policies and procedures
• Ship’s Medical records including GI questionnaires, cabin confinement letters etc.
• Outbreak response (Cabin Confinement for 48hrs, GI Discussion Meetings)
• Training documents (syllabus and records of training)
• Information to passengers (Booking information, pre-boarding questionnaire,
pillow letters, outbreak letters)
• Onboard spend accounts / gangway records

The Future?

The Future?
• Small claims increase from £1000 to £5000 imminent?
• Persuade the MOJ to include illness / accidents outside the UK with a value of £1000
to £25,000 to qualify for the portal
• Fixed costs ( consultation for multi-track claims up to £250 000) 6 January 2017
• Persuade the MOJ to allow Defendants to recover costs in multi party actions not
just cases of fundamentally fraudulent claims
• Operational improvements?
• Structural changes?
• Education of passengers
• Technology ? chemicals / copper?

MEL SKIPP
Manager – Health Policy, Maritime Policy & Analysis
CARNIVAL CORP. & PLC

CLIA GI Task Force
The GI TF was created in 2014 with scope to:
• Harmonize industry approach to prevention and control
• Improve expertise in the cruise industry
• Review and collaborate in research with industry partners
• Help counter media and public perceptions - improve and align global
communications:
o Consistent industry wide messages
o Work with global health authorities to align communications
• Work to increase self reporting – education and messaging

Norovirus – The Key Challenge
• Number 1 cause of viral gastroenteritis
• Estimated 699 million cases a year
• Affects 1 in 15 people in US annually
• Small numbers (18 viral particles) may cause illness
• Symptoms of vomiting & diarrhea
• Survives on surfaces for long periods
• Easily spread in aerosol and by contact
• Hard to destroy

CLIA GI Task Force Progress
• Actions agreed to align/improve prevention and control
measures
• Review of member procedures and model “Outbreak
Prevention & Control Plan” (OPRP)
• Technology Panels – Science panel evaluation of products
• Workshop events
• Research and support – vaccine development etc.
• Communications Group – work to align
• Carnival Corporation – standard corporate procedures

CLIA GI Task Force Progress
Research & Evaluation of Products:
• Collaboration with NoroCORE – Technology Workshops & testing to evaluate
products
• CLIA/Carnival Corporation/North Carolina State University (NCSU):
o Test surface disinfectants, hand sanitizers and novel products
o Direct testing on human norovirus and range of innovative methods
o Looking for 4 log reduction in 5 minutes
o Aim to develop a harmonized approach to product evaluation
o Allow more confidence in efficacy

Testing Surface Disinfectants on Human
Norovirus
• Final results and conclusions to be shared with Task Force and published.
• Overall take home messages:
o Concentration and contact time are important
o Surface cleanliness really matters for disinfection - organic load
significantly reduces performance
o Use of different cleaning methods needs evaluation
• Started testing hand sanitizers now – preliminary results

Future Work – GI TF & Carnival Corporation
• Develop guidance on ship design and construction standards
• Work to change current real time outbreak internet posting by US
health authorities
• Review application of current prevention and control procedures –
look for opportunities to improve and new innovations
• Examine hand washing frequency and behaviours especially before
eating
• Continue research for example:
o Test cleaning/disinfection methods
o Evaluate residual surface products
o Evaluate other novel technologies

Novel Technologies for Surface Disinfection
• Residual products – claim continued effects
• Nanotechnology – surface coatings to enhance cleaning or residual effect
• Use of copper alloys, silver and other finishes

Novel Technologies for Surface Disinfection
• Ultra Violet (UV) – Pulsed Xenon or Mercury
• UV and hydroxyl radical technology
• Hydrogen peroxide gas

Thanks for Listening

DR. PIERFRANCESCO LEPORE
Fleet Medical Director, Corporate Medical Services
MSC CRUISES

• Ships are «floating towns» with unique risk factors from a
Medical and Public Health perspectives:
• Specific microenvironment
PUBLIC
HEALTH
ABOARD
• Many nationalities
• Different ports of call with own specific risk
• Itineraries of different length
• Shorex excursions

REGULATIONS

ON BOARD
MEDICAL
CENTRE

EQUIPMENT

EVIDENCE BASED APPROACH
STANDARD
OPERATING
PROCEDURES

Placing automated external defibrillators (AEDs) in key locations, and
making sure employees are trained to use them, can make the
difference between life and death
AEDs
IN PUBLIC AREAS

INFECTIOUS
DISEASE

HELICOPTER MEDEVAC
LIFEBOAT MEDEVAC
MEDEVAC
AT SEA

ITINERARIES

Time for Questions