Communication of Public Health Events on Ships through the EU Common Ship Sanitation Database ^†

Abstract

The coordination of public health events related to ships presents a challenge to the port health authorities, and communication means and routes are not well established. The EU Common Ship Sanitation Database provides a platform for port-to-port communication of public health events on board ships. The last seven years of operation, 64 public health events were communicated through the system by port health authorities from seven EU countries. Although the usage of the platform has been appreciated, promoted, and legislated in several EU MSs, actions at the national and EU levels are needed to promote the use of the platform by all EU MS are necessary.

1. Introduction

Public health events onboard ships constitute a challenge for public health authorities because the ships are constantly moving from one port to another. In addition, the passengers disembark and may continue the trip to various other destinations; the next port of call may not be known, and authorities may not have enough time to take all the necessary actions. Coordination is required between local authorities in different ports and different countries in order to take action, and thus effective communication between authorities in different countries and different levels (local/port level and national level) is of great importance.

Port health authorities around the world are using different means and routes of communication and only a few of the events fulfill the criteria to be reported through already established international systems such as the Early Warning Response System (EWRS).

EU HEALTHY GATEWAYS joint action published the “Guidelines for inter-country communication and information flow in outbreak investigations on ships and public health event management” which provide suggestions on the means and channels of communication between the involved authorities [1].

A port-to-port communication form was available from 2011 in the SHIPSAN TRAINET COMMUNICATION NETWORK (comnet) and then from 2016 onwards in the EU Common Ship Sanitation Database (former EU SHIPSAN Information System—SIS). Through this form, the port health authorities could record data of public health events and share them with other port health authorities in the ship itinerary and with authorities at the national level. This form was initially named the N1-N2 form and allowed the detailed description and recording of the events, but in 2022, it was replaced with a simpler form (P2P communication form) that could be completed faster and easier.

This study presents information regarding the usage of the port-to-port communication form by the competent authorities through the EU Common Ship Sanitation Database from 2016 onwards.

2. Materials and Methods

Data from the port-to-port communication forms of the EU Common Ship Sanitation Database (both N1-N2 form and P2P communication form) were extracted and used for the analysis. A descriptive analysis of data in the submitted forms was performed and the frequencies were calculated per the time, the type of disease, and the reporting port.

3. Results

From 2016 to 2022 a total of 64 events have been submitted (53 through the N1-N2 form and 11 through the P2P form) corresponding to 57 (89.1%) public health events and seven (10.9%) communications for other information. The number of events submitted per year is shown in Figure 1. In total, 47 updates and 3 final updates were submitted. Most of the events (34) were updated one time, 18 were updated two times, 7 were updated three times, 3 were updated four times, and 2 events were updated five and six times.

The disease related to the events in most cases was COVID-19 (34.4%), followed by Gastrointestinal Illness (GI) (21.9%) (

Table 1. Diseases related to the events submitted through the EU Common Ship Sanitation Database.

Disease (Possible Diagnosis)	Number of Events	Percentage of Total (%)
COVID-19	22	34.4
Gastrointestinal Illness (GI)	14	21.9
None (other information)	7	10.9
Vaccine-Preventable	5	7.8
Tuberculosis	4	6.3
Legionellosis	4	6.3
Monkeypox	2	3.1
Scabbia	1	1.6
Influenza Like Illness (ILI)	1	1.6
Histamine intoxication due to tuna intake	1	1.6
Malaria	1	1.6
Listeria monocytogenes	1	1.6
Chickenpox, hand-foot-mouth disease, or other unclear viral disease	1	1.6

).

Table 2. Forms and updates submitted per port and country.

Country	Number of Forms and Updates Completed	Port	Number of Forms and Updates Completed	Percentage of Total (%)
Greece	44 (38.6%)	Achladi	2	1.8%
		Heraklion (Iraklion)	5	4.4%
		Itea	1	0.9%
		Kavala	1	0.9%
		Kérkira (Corfu)	2	1.8%
		Piraeus(Pireefs)	28	24.6%
		Rethymnon	1	0.9%
		Rhodes	4	3.5%
Spain	27 (23.7%)	Algeciras	2	1.8%
		Barcelona	18	15.8%
		Cadiz	3	2.6%
		Gijon	2	1.8%
		Palma de Mallorca	2	1.8%
Italy	17 (14.9%)	Abadia a Isola	13	11.4%
		Livorno	1	0.9%
		Messina	1	0.9%
		Venezia	2	1.8%
Belgium	11 (9.6%)	Antwerpen	1	0.9%
		Zeebrugge	10	8.8%
Netherlands	10 (8.8%)	Amsterdam	4	3.5%
		IJmuiden/Velsen	1	0.9%
		Rotterdam	5	4.4%
Not applicable	3 (2.6%)		3	2.6%
United Kingdom	1 (0.9%)	Port of Liverpool (England)	1	0.9%
Cyprus	1 (0.9%)	Limassol	1	0.9%

shows the number of forms submitted per country and per port. The events that were submitted were related to 61 ships. Apart from 11 cargo ships and two ferries, all of the ships were cruise ships.

A total of 287 ports (for 47 of the events) were selected in the database to be notified as the next ports of call. Respectively, 11 local authorities were selected to be notified for 6 of the events, and 23 authorities at the national level were selected for 15 of the events. In total 200 emails (including 17 text messages) were sent from the database for notifying inspectors, port health authorities, and public health authorities at the national level.

“Other information” forms included an event of low-level gastroenteritis activity, a patient with respiratory distress syndrome (RDS) diagnosed with influenza A/H3N2, a water sample found positive for faecal indicators, a case of Legionnaires’ Disease associated with a cruise ship (reported by ELDSNET), a ship connected to a case of Legionnaires’ Disease that was found with low hot water temperatures, a ship found with a high level of gastroenteritis activity, expired foods and in need of a lot of repairs, and a crew member that was diagnosed after disembarking with malaria.

4. Discussion and Conclusions

There is a noticeable drop in events communicated through the EU Common Ship Sanitation Database in 2020. This drop can be explained by the fact that cruise operations were banned due to the COVID-19 pandemic. During the next two years (2021 and 2022), the number of events increased again. This increase coincides with the restarting of cruise operations and may be attributed partially to the fact that port health authorities started to communicate COVID-19 events through communication forms. In fact, all of the events submitted during 2021 were related to COVID-19 cases. In March 2021, a multi-sectorial tabletop exercise at ports at the European level has been held in the framework of the EU HEALTHY GATEWAYS joint action and in order to test the “Guidelines for inter-country communication and information flow in outbreak investigations on ships and public health event management” [1,2]. All of the events in 2021 were submitted after the webinar, indicating that the development of the guidelines and the delivery of training courses may increase the awareness of the competent authorities and the number of events communicated through the database.

In April 2022, a new, more simplified form replaced the old one. The change, along with a short video tutorial, was communicated to the port health authorities registered in the system in order to increase participation [3]. These actions may have further increased involvement as the number of events communicated through the database in 2022 is expected to be even higher than those of 2021.

The number of events submitted through the database is generally considered low and probably represents only a small proportion of the events that occurred in Europe over the study period. Currently, nine public health authorities at the national level from eight countries, 127 port health authorities from 19 countries, and 593 inspectors from 24 countries are registered in the database. Only seven countries used the EU Common Ship Sanitation Database for communicating public health events, and most of the events were submitted by competent authorities in Greece and Spain. The limited use of the database may be attributed to the lack of legal framework for its use, the lack of time from the competent authorities, the limited awareness, and the fact that this procedure is not integrated into the official procedures of the port health authorities.

Communication of public health events through the EU Common Ship Sanitation Database may facilitate a coordinated response between different countries. By sharing information and the actions taken, each event will be managed similarly by the different competent authorities involved. The further awareness and involvement of more authorities will render the communication database even more facilitative to the public health authorities.