CentersforDiseaseControlandPrevention

NationalCenterforEnvironmentalHealth
VesselSanitationProgram

HealthPracticesonCruiseShips:TrainingforEmployees
Transcript

Housekeepingand Infection Control

TheCentersforDiseaseControlandPrevention's VesselSanitationProgramisproudto
bringtoyouthefollowingsession:HousekeepingandInfection Control. Whilethis
session isprimarily intendedforcruisevesselsunderthejurisdictionoftheVessel
SanitationProgram, it may beusedbyanyonewhois interestedinthistopic.Thissession
shouldnotreplaceexistinginteractivetraining,butshouldbeusedasanadjuncttoa
comprehensivetrainingprogram.
Housekeepingandinfectioncontrol.Routinehousekeepingandoutbreakmanagement.
Learningobjectives.Attheendofthissession, youwill beabletolistsomeofthe
proceduresthatmightchangebetween normaloperationsandoutbreakoperations,
describewhatshouldbeinahandwashingandpersonalhygienefactsheet,listsomeof
thewaystoencouragepassengerisolation,listsomeofthepublicareasonacruise
vessel,listsurfacesthatarefrequentlytouchedbyhands,listmethodstomakeexitsfrom
toiletsbarehandsfree.
Showerheads.Itisarequirementtodisinfectshowerheadseverysixmonths.This
disinfectionisprimarilyintendedtopreventthegrowthoflegionella.Individual
whirlpools.
Individualwhirlpoolsarenottobeconfusedwithpublicwhirlpools.Thesewhirlpoolsare
thosethatmightbelocatedinacabinorinacabinsuite, orawhirlpoolortherapytub
thatmightbeinaspa.Thesemustbedisinfectedbetweenoccupancies,orinthecaseofa
suiteoracabinwhirlpool,atleastonceeverysevendays.Thedisinfectionprocedure
shouldbeperthemanufacturer'srecommendations.
Publictoiletrooms. Asof2005,arequirementwasinstitutedintheoperations manual to
includeanexitfromtoiletsthatisbarehandsfree.This may bydoneinavarietyof
ways.One,theexitcouldbebypushingthedooropen.Two,theexitcouldbethroughan
electronicsensor. Andthree, if handsarerequiredtobeusedtoexit,paper towelsshould
beprovidedinthetoiletroom withawastereceptacleattheexitsothatthepapertowel
can beusedtoopenthedoor andcanbedisposedof neartheexit.
Routinecleaning.Itisvery importanttoconsidermanyofthearticlesthatareinacabin
whendevelopingacleaningprocedure. Thesecan includebeds,rugs,tables,desks,and
otherthingssuchasphones.Somerooms havepantries.Wecangoonandon ofthings
thatneedtobecleanedanddisinfected.Additionallywemustconsidersomevery

CentersforDiseaseControlandPrevention
NationalCenterforEnvironmentalHealth
VesselSanitationProgram

importantitems,forexamplethetoiletroom,whichcanbeveryheavilycontaminated
withpathogenicmicroorganisms.Wealsomustconsiderhowoftenshouldweclean,
sanitize,disinfecticebuckets,glassesandmugs,andthedispensingoffoodand
beverages.Forice buckets,therequirementistowash,rinse,andsanitize between
occupancy,andforcruisesthatlastmorethansevendays,towash,rinse,andsanitizeon
dayseven,andthenagainonthedisembarkationday betweentheoldpassengersandthe
newpassengers.
Cleaningsequenceactivity.We'llnowtakeapausefromthelecture todiscussacleaning
sequenceactivity thatmightbeusedtobringoutkeypoints onhowacabinshouldbe
cleaned.Itisimportanttoconsiderthestepsandprocedures thatarefollowedonyour
cruisevesselforcleaningacabin.Wewillbeshowingaslidethatshowsacleaning
frequency andsequencebasedonthestepsthatwehavedeveloped.Keepinmindwhile
thissequenceissomethingwethinkiscorrect, theremaybemorethanonewaytocleana
cabin.Itisimportanttoconsider,however,somepoints.Oneishowlongofacontact
timeisrequiredforthedisinfectionmethodyouareusing.Two,therearecertain
activitiesthataregoingtobeperformedduringthiscleaningthatrequirecleanhands,
suchasrefillingicebuckets,restockingcabinetswithcleancupsandsnacks.Soplease
considerthoseitemsinthesequence,includingwhenarehandstobewashed,andwhere
cantheybewashed?
Outbreakmanagement.Pathogensassociatedwithcruiseshipoutbreaks,1986to2002.
Wecanseefromtheslide thegreenwhereparasitesaregenerallynotaproblem on
cruisevesseloutbreaks.However,initiallyfromthisslide,wecanseewherebacterial
outbreakswerehigherthanoutbreaksassociatedwithviruses.Thisbegantochange
around2000, wherein2001wecanseewherevirusesarethemajorcauseofoutbreaks
oncruisevessels,andthiscontinuestobetruetoday.Thevirusthatwe'regenerally
seeingoncruisevesselsiscalledNorovirus.
Norovirus:presentandfuture.Norovirusisthemostcommoncauseofacute
gastrointestinalillnessoutbreaksintheUnitedStates.Norovirusoutbreakswillcontinue
tohappen.
Norovirusactionplan.It'sveryimportanttodevelopaNorovirusactionplanforeach
cruisevessel.Whiletheseplanscanbedevelopedatthecorporateend,it'sveryimportant
tomakesurethatoncetheygetdowntothecruisevessellevel,thattheycanbetailored
ormodifiedtosuitwhat'sgoingononaparticularcruisevessel.Numberone,weneedto
developaplan.Secondly,weneedtotrainemployeesinthatplan,andweneedtohave
materialsonhandsothatwecanfollowtheplan.Thiscanincludedisinfectants,
procedures,factsheets,andanyassociatedequipmentsuchasfoggersandsprayers.
Criticaleyereviewtheplan.Well,whyarewedevelopingaNorovirusactionplan to
beginwith?Well,numberone,wewanttostop thepersontopersonspreadofNorovirus.

CentersforDiseaseControlandPrevention
NationalCenterforEnvironmentalHealth
VesselSanitationProgram

Andwhatareasareweprimarilyconcernedwith?Wheredoweneedtodothis?Well,we
needtodothisbothinpublicareasandwhatweconsidertobeprivateareascabins,
crewcabins,passengercabins.Andtheremaybeotherareasaswell.Andwhatdowe
wanttousetotakecareofNorovirus?Wewanttouseaneffectivedisinfectant.
Outbreakpreventionandresponseprotocol,OPRP.Indevelopinganoutbreakprevention
andresponseprotocol,therearesomekeypointsthatshouldbeincluded.Weneedto
knowwhatarethedutiesandresponsibilitiesofeachdepartment.Weneedtoknowwhat
arethetriggersforeachstep,action,orcodeintheplan.Forexample,codeyellow.Some
vesselsusethistoindicateahigherthannormallevelofillnessonthevessel.Whilenot
attwopercentoratthreepercent,whichiswhatisconsideredanoutbreaklevel,these
levelsarehigherthanwhatwouldbeexpected,andthevesselmayinstituteacode
yellow,whichmaybeacleaningfrequency ordisinfectionfrequencybeinghigherthan
whatwouldnormallybeused.Whendoesthevesselrevertbacktonormaloperations?
Thisisveryimportanttoincludeintheplan.Whendoyoustepdownfromacoderedor
acodeyellow? Forexample,wemaystepdownfromacodered oncethenumbersfall
underonepercentor1.5%,whateverthevesselhasdecidedtobethatlevel.Butdowe
alsostepdownfromcleaningfrequency ordisinfectionsusedincabinsthatwere
consideredtobesickcabins? Sothisisveryimportanttoconsiderwhendoweresume
normaloperations?Andadditionally,weneedtoconsideristheregoingtobeareview
aftertheoutbreak? Oncewereturntonormaloperations,maybeattheendofthiscruise
oratthebeginningofthesubsequentcruise,istohaveareviewoftheprocedures that
werefollowedduringthisoutbreak.Whatwentwell?Whatneedsmodification? Soan
outbriefingisveryimportantafteranoutbreak.
Informationandeducation.Itisveryimportanttopublicizecasenumbers.Now,thisdoes
notmeanthatyouhavetoannounceoverthePAsystemorthepublicaddresssystem
exactlyhowmanypeoplearesickeverygivenday.Butit'simportanttoletindividuals
know thatthere'sahigherthanexpectednumberofillnesscasesandthatfrequenthand
washingisveryimportant.Additionally,Norovirusfactsheetsareveryimportantto
distributetopassengersandcrewmemberstogivethemabackgroundonwhatNorovirus
isandhowitcanbeacquired.Wewanttoencouragemedical evaluation forsymptoms,
andthiscouldbejustassimpleasnotchargingpassengerswhoseekmedicalcare
becauseofgastrointestinalillnesssymptoms.Wewanttoencourageisolation.It'svery
difficulttogetpassengersorcrewmemberstostayintheircabins.Withcrewmembers,
it'seasier,becauseiftheydon'tstay intheircabins, youcandischargethematthenext
port. Thismaynotbesomethingthatyouwanttodowithapassenger,soperhaps
providingthemwithpaper menusof foodstheycangetdeliveredtotheircabins,perhaps
givingthemgamesoractivitiesthatcanbeusedandtakenhomewiththem orusedand
discardedaftertheycomeoutofisolation,oranyothersteporprocedurethatyouthink
mightencouragethesepassengerstoremain intheircabins.Additionally,wewantto
providefactsheetsonproperhandwashing.Anyfactsheets thataredistributedtocrew
membersorpassengersshouldbesimple,meaningful,andeasytounderstand.

CentersforDiseaseControlandPrevention
NationalCenterforEnvironmentalHealth
VesselSanitationProgram

Theroleof handwashing.Handwashingisveryimportantinpreventingthespreadof
Norovirus.Numberone,itremovesthevirusparticlesfromourhands,andnumbertwo,it
preventsthecontaminationofsurfacessuchasdoorknobs,handrails,elevatorbuttons,
andany surfacethatmightbetouchedby hands.
Handwashingtips.Whenwashingourhands, it's very importanttofollowcertain
procedure. Theseincludewettingyourhands,applyingsoap,latheringfor20seconds,
payingspecialattentiontoareaswherebacteria,viruses,andparasites may be,suchas
underneath fingernailsandin between fingersandunderjewelrysuchasrings.Wewant
torinsehandsthoroughly withwarmrunningwater,dryhandswithdisposablepaper
towels,andusethatpapertoweltoturnoffthefaucet. Weshouldalsoholdontothat
papertowel sothatifweareinapublictoiletwecanuseapapertoweltoopenthedoor
andexit.
Handwashingtips.Whenshouldwewashourhands? Well,throughouttheday,we
shouldwashourhandsveryfrequently.Butitisveryimportanttowashourhandsafter
usingthetoilet,aftercoughingorsneezing,orafterengaginginanyactivity that might
havecontaminatedourhands. Weshouldwashourhands beforehandlingfood,before
eating,beforesmoking,drinking,orbeforeengaginginanyactivity thatrequires handto
mouthcontact.Wewanttowashourhandsuponreturningtoourcabins.Ifyou'vebeen
travelingshoresideorevenjustthroughouttheship, therearemanysurfacesthatyou
havetouchedinyourtravelsthatmay havecontaminatedyourhands.Sooneofthefirst
thingsthatshouldbedoneuponreturningtoacabin,whetheryou'reapassengerorcrew
member,istowashyourhandsthoroughly.
Handantiseptic.Handantisepticscan beusedasanadjuncttohandwashing,butshould
notbeusedtoreplacehandwashing.Itisimportanttonote thathandantisepticsremove
thepathogenloadthatisleftonyourhandsafterthoroughhandwashing.Ithasbeen
shownthatahandantisepticthatis60to80%ethanol,gelbased,canremove95%of
FelineCalicivirus.FelineCalicivirus isusedasasentinel toindicatewhatcanbedoneto
Norovirus.Wewanttomakesurethatweusethegelbasedsanitizersbecausetheytake
longertodry,andwewantacontacttimeof20seconds.Again,usingahandantisepticis
notasubstituteforhandwashing.
Cleaninganddisinfection.Wewanttomakesurethatweincludeinourcleaningand
disinfectionprocedureshowwearegoingtoclean wellcabinsandhowwe'regoingto
cleansickcabins.This isacabinwherepeopleinthecabin arenotill oracabin where
thepeopleinthecabinaresickorill. Wewanttomakesurethatwedonottake
contaminationfromacabinwhereindividualsaresickandtransferitintoacabinwhere
peoplearewell.This may bejustsavingthesickcabinstilltheend.Ifacabinattendant
has30cabinstoclean andfivecontainsickpassengers, theycansavethosefivecabinsto
theend.Orhavingahitteamorhitsquadthatonlycleanssickcabins. Wewanttomake

CentersforDiseaseControlandPrevention
NationalCenterforEnvironmentalHealth
VesselSanitationProgram

surethatweconsiderpublicareasinourcleaningprocedures. Thisincludescorridors,
lounges,toiletrooms,casinos,Internetcafes,andmanyotherareas.Wewanttomake
surethatwetakeintoaccountbodyfluidevents.Forexample,ifsomeonehasanepisode
ofpublicvomiting,howarewedoingtocleanthatup? Orifsomeonevomitsintheir
cabin,howarewegoingtocleanthatup? Youmayhaveahitsquadgointherewith
properprotectiveequipmentandaprocedureandadisinfectanttocleanuptheseevents.
Theseeventsshouldbeloggedifthey'republicevents,andasmuchasyoucan,make
noteoftheindividualswhoareinthatimmediateareawhenthevomitingincident
occurred.
"Hitsquad."It'sveryimportanttodevelopaprocedureifyouhaveahitsquad.This
procedureshouldbeclear,shouldfollowaflowdiagramformat. Itwouldbeagoodidea
toprintandlaminatethisprocedureandmakeitavailableforthehitsquadtotakewhen
theyactuallyhavetocleanupaneventofpublicvomiting.Wewanttomakesureifthe
hitsquadiscleaningsickcabins,thattheyenteronlysickcabins.Wewanttomakesure
againthatifwehaveaprocedure tocleanbodyfluideventssuchaspublicvomitingin
eitherpublicareasorcabins,thatthisprocedureisinwriting,simple,cleartofollow,and
laminatedordisposedof attheendofeachday.
Spreadingcontamination.It'simportantforustonotethatincleaningprocedures,we
mayactuallyexacerbateorworsentheproblem.Wemaytakecontaminationfromone
areaandspreaditalloverthevessel.Weknowthat thisissomethingwedonotwantto
do.
Vacuumingshouldnotbedoneonapublicvomitingevent. Ifitneedstobedone,it
shouldbedoneafterthevomithasbeencleanedupandtheareahasbeenthoroughly
disinfectedwithappropriatedisinfectantatthecorrectcontacttime.Redbags.Redbags
canbeusedtodisposeofcontamination.Soifwehaveapublicvomitingevent, that
materialshouldgoinaredbag.Ifsomeoneisinacabinandhasafecalaccidentintheir
bed,thatlinenshouldbeputinaredbag.Redbagsshouldbetakentotheincineratorarea
rightaway andkeptisolatedifitcannotbeincineratedimmediately.Individualsworking
inthegarbageroom shouldbethoroughlytrainedintheimportanceofwashingtheir
handsafterhandlingredbags.Handwashingproceduresareimportantforeveryoneon
thevessel,butespeciallyforindividualswhohavetocleanupcontaminatedsites.Inthe
laundryroom,wewanttobeverymindfulofspreadingcontamination.Ifwehavesick
cabins,youmaywanttoisolateonewashingmachineandonedryerforhandlinglinens
comingoutofsickcabinsorifyou'regoingtowashalllinenstogether, tomakesure
thatthecycleonthewashingmachineandthedryerissuitableforeliminatingNorovirus.
Inthegarbageroom,wewanttobeespeciallyconcernedagainwiththedisposalofred
bagsandhandwashing.

CentersforDiseaseControlandPrevention
NationalCenterforEnvironmentalHealth
VesselSanitationProgram

Disinfectants.We'regoingtobediscussingdisinfectants thatareeffectiveagainst
Norovirus.Wewanttoconsiderthetypeofdisinfectant,theapplication,the
concentration,andthecontacttime.
Effectivedisinfectants.Whenweusethisterm,"effective,"wearedecidingwhatis
effectiveagainstNorovirus.Inalaboratory,it'sverydifficulttogrowNorovirusandto
tryandtestdisinfectants.Sogenerallytheterm"FelineCalicivirus"hasbeenusedto
showwhetherornotadisinfectantwouldbeeffectiveagainstNorovirus.That'schanged
tothegeneraltermof"Calicivirus."Soinselectingadisinfectantthat'sappropriatefor
Norovirus,wewanttomakesurethatit'seffectiveagainstCalicivirus.Someofthe
disinfectantsthathavebeenshowntobeeffectivearechlorineat1,000PPM,phenolic
compounds,acceleratedhydrogenperoxidecompounds,parachlorometaxylenol,
peroxomonosulfate,andheatat70degreesCentigradeor170degreesFahrenheit.These
haveallbeenshowntobeeffectiveagainstCalicivirus.
Whatdisinfectantisbest? TheVesselSanitationProgramisnotgoingtochooseforyou
thedisinfectantwhichwouldbebesttouse. Youwould,however,wanttodosome
research andensurethatthemanufactureroftheproducthasperformedindependent
testingtoshowthatthisdisinfectantiseffectiveagainstCalicivirus.Youwantthatdatato
beavailableorthatstudytobeavailable.
Personalprotectiveequipment.Inselectingadisinfectant,it'sveryimportanttoreview
themanufacturer'sdetailstoshowwhatpersonalprotectiveequipmentisnecessary.It
maybemask,gloves,aprons,goggles,orinsomecases,ifyou'refogging,respiratory
equipment.
Materialsafetydatasheets.WhiletheVesselSanitationProgram doesnotspecifically
requirematerialsafetydatasheets,itisveryimportanttohavetheseonhand,available,
andhavethesethingsexplainedtotheindividualsusingthedisinfectant.Donotwait
untilanaccidenthappenstotrainyouremployeesonthesematerialsafetydatasheets.
Foodforthought. Indevelopinganoutbreakresponseplan,itisveryimportantto
considersomeoftheareasofthevessel.Forexample,selfservicebuffets.Duringan
outbreak,youmaywanttodiscontinueselfservicebuffets.Youmaywanttoprovide
crewmemberswhoservethefoodtothepassengers.Thismayhelppreventtheperson
topersonspread,becauseyounolongerhavepassengershandlingthefooddispensing
utensils.Youwanttosuspendgalleytours.Youwanttotakealookatyourshoreside
excursions.Becausewhilewepredominantlyfindpersontopersonspread occurringona
cruisevessel,therehavebeencaseswheretheshoresideexcursion,orspecificallyfood
servedduringtheshoresideexcursion,wasthecauseoftheoutbreak.Wewanttosuspend
portvisits.

CentersforDiseaseControlandPrevention
NationalCenterforEnvironmentalHealth
VesselSanitationProgram

Duringanoutbreak,youdonotwantyourcrewmemberstoleaveyourvessel andvisit
anothervessel.Youalsodon'twantashipthatdoesnothaveanoutbreak tovisit your
vessel.Wewanttomakesurethatweincludetendersinouroutbreakresponseplan so
thatwecancleananddisinfectthem aspartofourprocedure.Wewanttomakesurethat
wetakealookatchildactivitycenters,becauseagainwemustrememberthatthishasan
especiallyvulnerablepopulation.Andtheremaybesomeotherareasthatyouneedto
consider.
Handwashing.Let'snotforgetthathandwashingisthemostimportantthingthatwecan
do tostopthespreadofdisease.Thisconcludesthesession HousekeepingandInfection
Control.
Resourcesandreferences.Foradditionalinformation,pleasevisittheCentersforDisease
ControlandPrevention'sWebsiteatwww.cdc.gov.Formoreinformation ontheVessel
SanitationProgram,pleasevisitwww.cdc.gov/nceh/vsp.Forinformation onthe
EnvironmentalProtectionAgency,pleasevisitwww.epa.gov.