Systematic Review on Outbreaks of SARS-CoV-2 on Cruise, Navy and Cargo Ships

Microbiome and virome on indoor surfaces of an Antarctic research ship

BACKGROUND

Few studies have focused on microbial diversity in indoor environments of ships, as well as the role of the microbiome and its ecological interconnections. In this study, we investigated the microbiome and virome present on the internal surfaces of a polar ship in different stages (beginning, during, and at the end) of the Brazilian Antarctic expedition in order to evaluate abundance of microorganisms in different periods.

OBJECTIVES AND METHODS

We used shotgun metagenomic analysis on pooled samples from sampling surfaces in the ship's interior to track the microbial diversity.

FINDINGS

Considering the total fraction of the microbiome, the relative abundance of bacteria, eukaryotes, viruses, and archaea was 83.7%, 16.2%, 0.04%, and 0.002%, respectively. Proteobacteria was the most abundant bacterial phyla, followed by Firmicutes, Actinobacteria, and Bacteroidetes. Concerning the virome, the greatest richness of viral species was identified during the middle of the trip, including ten viral families after de novo assembly: Autographiviridae, Chrysoviridae, Genomoviridae, Herelleviridae, Myoviridae, Partitiviridae, Podoviridae, Potyviridae, Siphoviridae, and Virgaviridae.

MAIN CONCLUSIONS

This study contributed to the knowledge of microbial diversity in naval transportation facilities, and variations in the abundance of microorganisms probably occurred due to factors such as the number of passengers and activities on the ship.

The Cornell COVID-19 Testing Laboratory: A Model to High-Capacity Testing Hubs for Infectious Disease Emergency Response and Preparedness

The unprecedented COVID-19 pandemic posed major challenges to local, regional, and global economies and health systems, and fast clinical diagnostic workflows were urgently needed to contain the spread of SARS-CoV-2. Here, we describe the platform and workflow established at the Cornell COVID-19 Testing Laboratory (CCTL) for the high-throughput testing of clinical samples from the university and the surrounding community. This workflow enabled efficient and rapid detection and the successful control of SARS-CoV-2 infection on campus and its surrounding communities. Our cost-effective and fully automated workflow enabled the testing of over 8000 pooled samples per day and provided results for over 2 million samples. The automation of time- and effort-intensive sample processing steps such as accessioning and pooling increased laboratory efficiency. Customized software applications were developed to track and store samples, deconvolute positive pools, track and report results, and for workflow integration from sample receipt to result reporting. Additionally, quality control dashboards and turnaround-time tracking applications were built to monitor assay and laboratory performance. As infectious disease outbreaks pose a constant threat to both human and animal health, the highly effective workflow implemented at CCTL could be modeled to establish regional high-capacity testing hubs for infectious disease preparedness and emergency response.

Attack Rate for Wild-Type SARS-CoV-2 during Air Travel: Results from 46 Flights Traced by German Health Authorities, January-March and June-August 2020

Background

Evidence on the risk of SARS-CoV-2 transmission during air travel is scarce. We aimed to estimate the attack rate for wild-type SARS-CoV-2 to improve the evidence base for the adaptation of nonpharmaceutical intervention (NPI) strategies aboard airplanes.

Methods

In collaboration with German Public Health Authorities (PHA), we conducted a follow-up of in-flight SARS-CoV-2 contact persons. We included those contact persons whom the Emergency Operations Centre at the Robert Koch-Institute had forwarded to PHA between January to March 2020 (before masking on flights became mandatory) and June to August 2020 (after the introduction of mandatory masking). We retrospectively collected data on whether these contact persons had been successfully contacted, had become symptomatic and had been tested for SARS-CoV-2, and whether alternative exposures other than the flight were known.

Results

Complete data that allowed for the calculation of attack rates were available for 108 contact persons (median age of 36 (IQR 24-53), 40% female), traveling on 46 flights with a median flight duration of 3 hours (IQR 2-3.5). 62 of these persons travelled after masking on flights became mandatory. 13/87 developed symptoms, 44/77 were tested (no data for 21 and 31). 13 persons (9 of whom had been SARS-CoV-2 positive) were excluded from the analysis of attack rates due to a likely alternative exposure. We thus identified 4 probable in-flight transmissions (2 of which occurred after the introduction of mandatory masking). The overall attack rate resulted in 4.2% (4/95; 95% CI: 1.4%-11.0%). Considering flights after mandatory masking, the attack rate was 3.6% (2/56, 95% CI 0.6%-13.4%), before masking 5.1% (2/39, 95% CI 0.9%-18.6%).

Conclusions

The risk of wild-type SARS-CoV-2 transmission during air travel seemed low, but not negligible. In order to formulate an effective, evidence-based NPI protocol for air travel, further studies considering the different transmissibility of SARS-CoV-2 variants of concern and vaccination status are needed.

Re-Starting the Cruise Sector during the COVID-19 Pandemic in Greece: Assessing Effectiveness of Port Contingency Planning

Coronavirus disease (COVID-19) outbreaks on board cruise ships early in the pandemic highlighted gaps worldwide in public health emergency contingency plans (PHECPs) for responding to unknown threats. To restart cruise operations in 2021 and respond to potential COVID-19 outbreaks, a major tourist-based Greek island port (Port A) developed a COVID-19 PHECP. We assessed plan effectiveness by reviewing epidemiological data and monitoring outcomes, followed by an intra-action review (IAR) analyzing three event responses. From May to December 2021, 118 calls from 23 cruise ships with 119,930 passengers were recorded, with 29 COVID-19 cases in 11 cruises on board 7 ships. No outbreak was recorded during the study period. Strengths of the introduced PHECP included commitment of senior management; a core multi-disciplinary team of local authorities/ship agents involved in design and execution; interoperability agreements for port and ships' PHECPs; cruise industry commitment to compliance; and pre-existing scenarios considering capacity needs. Central government coordination for preparedness planning at local ports is essential for successful responses. Monitoring local and country level response capacities is critical to inform planning, risk assessment, and decision-making. Immediately recording ports' response actions provides the basis to capture lessons and improve contingency plans. To facilitate communication and common response protocols between European and non-European ports, IARs should be conducted between countries.

Transmission of SARS-CoV-2 Associated with Cruise Ship Travel: A Systematic Review

Background: Maritime and river travel may be associated with respiratory viral spread via infected passengers and/or crew and potentially through other transmission routes. The transmission models of SARS-CoV-2 associated with cruise ship travel are based on transmission dynamics of other respiratory viruses. We aimed to provide a summary and evaluation of relevant data on SARS-CoV-2 transmission aboard cruise ships, report policy implications, and highlight research gaps. Methods: We searched four electronic databases (up to 26 May 2022) and included studies on SARS-CoV-2 transmission aboard cruise ships. The quality of the studies was assessed based on five criteria, and relevant findings were reported. Results: We included 23 papers on onboard SARS-CoV-2 transmission (with 15 reports on different aspects of the outbreak on Diamond Princess and nine reports on other international cruises), 2 environmental studies, and 1 systematic review. Three articles presented data on both international cruises and the Diamond Princess. The quality of evidence from most studies was low to very low. Index case definitions were heterogeneous. The proportion of traced contacts ranged from 0.19 to 100%. Studies that followed up >80% of passengers and crew reported attack rates (AR) up to 59%. The presence of a distinct dose−response relationship was demonstrated by findings of increased ARs in multi-person cabins. Two studies performed viral cultures with eight positive results. Genomic sequencing and phylogenetic analyses were performed in individuals from three cruises. Two environmental studies reported PCR-positive samples (cycle threshold range 26.21−39.00). In one study, no infectious virus was isolated from any of the 76 environmental samples. Conclusion: Our review suggests that crowding and multiple persons per cabin were associated with an increased risk of transmission on cruise ships. Variations in design, methodology, and case ascertainment limit comparisons across studies and quantification of transmission risk. Standardized guidelines for conducting and reporting studies on cruise ships of acute respiratory infection transmission should be developed.

COVID-19 outbreaks on ships: Analysis of three representative cases

Objectives

Coronavirus disease (COVID-19) outbreaks occurred on ships during the global pandemic of COVID-19. Investigation of the management and outcomes of these outbreaks will help guide future prevention and control strategies for respiratory infectious diseases on ships.

Study design

Non-systematic narrative review.

Methods

PubMed and Embase databases were searched using the keywords “ship”, “cargo ship”, “fishing boat”, “cruise ship”, “yacht”, “merchant ship”, “port”, “SARS-COV-2” and “COVID-19”, connected by “OR” internally and “AND” between two keywords. After review of the titles and abstracts, and exclusion of irrelevant articles, the infection situation and details of the response measures were recorded. Cases were subsequently selected for this study based on the detailed information and records available on the COVID-19 outbreak prevention and control measures and experiences.

Results

Three representative cases were selected; the outbreak timeline and infection situation for these cases were summarised. Infection prevention and control measures and experiences for the three outbreaks were investigated in detail, including analysis of epidemic reports, and isolation, detection, screening, treatment and transportation procedures.

Conclusions

This study demonstrates that timely detection and intervention, exposure reduction, control of asymptomatic infections, treatment and transport of patients, preparation for prevention and control in advance, the communication and cooperation of various stakeholders, and the establishment of short-term and long-term response mechanisms are key elements to improve the efficiency of infection prevention and control on ships.

A Historical Review of Military Medical Strategies for Fighting Infectious Diseases: From Battlefields to Global Health

The environmental conditions generated by war and characterized by poverty, undernutrition, stress, difficult access to safe water and food as well as lack of environmental and personal hygiene favor the spread of many infectious diseases. Epidemic typhus, plague, malaria, cholera, typhoid fever, hepatitis, tetanus, and smallpox have nearly constantly accompanied wars, frequently deeply conditioning the outcome of battles/wars more than weapons and military strategy. At the end of the nineteenth century, with the birth of bacteriology, military medical researchers in Germany, the United Kingdom, and France were active in discovering the etiological agents of some diseases and in developing preventive vaccines. Emil von Behring, Ronald Ross and Charles Laveran, who were or served as military physicians, won the first, the second, and the seventh Nobel Prize for Physiology or Medicine for discovering passive anti-diphtheria/tetanus immunotherapy and for identifying mosquito Anopheline as a malaria vector and plasmodium as its etiological agent, respectively. Meanwhile, Major Walter Reed in the United States of America discovered the mosquito vector of yellow fever, thus paving the way for its prevention by vector control. In this work, the military relevance of some vaccine-preventable and non-vaccine-preventable infectious diseases, as well as of biological weapons, and the military contributions to their control will be described. Currently, the civil-military medical collaboration is getting closer and becoming interdependent, from research and development for the prevention of infectious diseases to disasters and emergencies management, as recently demonstrated in Ebola and Zika outbreaks and the COVID-19 pandemic, even with the high biocontainment aeromedical evacuation, in a sort of global health diplomacy.

Risk factors, immune response and whole-genome sequencing of SARS-CoV-2 in a cruise ship outbreak in Norway

OBJECTIVE

To improve understanding of SARS-CoV-2-transmission and prevention measures on cruise ships, we investigated a Norwegian cruise ship outbreak from July to August 2020 using a multidisciplinary approach after a rapid outbreak response launched by local and national health authorities.

METHODS

We conducted a cross-sectional study among crew members using epidemiologic data and results from SARS-CoV-2 polymerase chain reaction (PCR) of nasopharynx-oropharynx samples, antibody analyses of blood samples, and whole-genome sequencing.

RESULTS

We included 114 multinational crew members (71% participation), median age 36 years, and 69% male. The attack rate was 33%; 32 of 37 outbreak cases were seropositive 5-10 days after PCR. One PCR-negative participant was seropositive, suggesting a previous infection. Network-analysis showed clusters based on common exposures, including embarkation date, nationality, sharing a cabin with an infected cabin-mate (adjusted odds ratio [AOR] 3.27; 95% confidence interval [CI] 0.97-11.07, p = 0.057), and specific workplaces (mechanical operations: 9.17 [1.82-45.78], catering: 6.11 [1.83-20.38]). Breaches in testing, quarantine, and isolation practices before/during expeditions were reported. Whole-genome sequencing revealed lineage B.1.36, previously identified in Asia. Despite extensive sequencing, the continued transmission of B.1.36 in Norway was not detected.

CONCLUSIONS

Our findings confirm the high risk of SARS-CoV-2-transmission on cruise ships related to workplace and cabin type and show that continued community transmission after the outbreak could be stopped by implementing immediate infection control measures at the final destination.

A review of COVID-19 transmission dynamics and clinical outcomes on cruise ships worldwide, January to October 2020

BackgroundCruise ships provide an ideal setting for transmission of SARS-CoV-2, given the socially dense exposure environment.AimTo provide a comprehensive review of COVID-19 outbreaks on cruise ships.MethodsPubMed was searched for COVID-19 cases associated with cruise ships between January and October 2020. A list of cruise ships with COVID-19 was cross-referenced with the United States Centers for Disease Control and Prevention's list of cruise ships associated with a COVID-19 case within 14 days of disembarkation. News articles were also searched for epidemiological information. Narratives of COVID-19 outbreaks on ships with over 100 cases are presented.ResultsSeventy-nine ships and 104 unique voyages were associated with COVID-19 cases before 1 October 2020. Nineteen ships had more than one voyage with a case of COVID-19. The median number of cases per ship was three (interquartile range (IQR): 1-17.8), with two notable outliers: the Diamond Princess and the Ruby Princess, which had 712 and 907 cases, respectively. The median attack rate for COVID-19 was 0.2% (IQR: 0.03-1.5), although this distribution was right-skewed with a mean attack rate of 3.7%; 25.9% (27/104) of voyages had at least one COVID-19-associated death. Outbreaks involving only crew occurred later than outbreaks involving guests and crew.ConclusionsIn the absence of mitigation measures, COVID-19 can spread easily on cruise ships in a susceptible population because of the confined space and high-density contact networks. This environment can create superspreader events and facilitate international spread.

Mental health and wellbeing of seafaring personnel during COVID-19: Scoping review

OBJECTIVES

We aimed to synthesize published literature on seafarers' mental health and wellbeing during the COVID-19 pandemic.

METHODS

This scoping review searched four electronic databases for literature on the mental health and wellbeing of seafarers during the COVID-19 pandemic.

RESULTS

Fourteen studies were included in the review. Few reported on the prevalence of mental health conditions. Only one compared mental health data gathered during the pandemic to pre-pandemic matched samples, suggesting symptoms of depression and anxiety were greater during the pandemic. There was some evidence that mental health worsened with longer stays on board during the pandemic and being on board longer than expected. Crew exchange difficulties forced many participants to extend their contracts or delay repatriation, often with little information as to when they might get to go home, leading them to feel they had no control over their lives and causing concern about fatigue and the potential for accidents and injuries. Participants described other challenges such as denial of shore leave; concerns about finances and future employment; loneliness and isolation; fears of COVID-19 infection; limited access to essential supplies; and feeling unsupported by management.

CONCLUSIONS

Maritime organizations must understand how best to support their staff in the aftermath of the COVID-19 pandemic and in any other prolonged crises that may arise in the future. Recommendations include ensuring that staff feel valued by their organization; enhancing work-related autonomy; ensuring that communication is accurate, consistent, and timely; and using lessons learned from the COVID-19 pandemic to inform emergency preparedness policies.

[Prevention and management of COVID-19 outbreaks on merchant ships]

Hintergrund

Eine Pandemie ist eine besondere medizinische Herausforderung für Seeleute, die ohne Arzt/Ärztin an Bord unterwegs sind. Gleichzeitig ist es eine Notwendigkeit für die weltweite Bekämpfung der COVID-19-Pandemie, Warenströme durch eine widerstandsfähige Handelsschifffahrt aufrechtzuerhalten. Für die Infektionsprävention und das Infektionsmanagement an Bord benötigen Verantwortliche ein Portfolio von Schutzmaßnahmen, die auf Schiffen angewendet werden können.

Fragestellung

In der Übersicht wird der Fragestellung nachgegangen, welche technischen, organisatorischen und persönlichen Schutzmaßnahmen auf einem Handelsschiff angewandt werden können, um COVID-19-Ausbrüche an Bord zu verhindern oder bewältigen zu können.

Material und Methoden

Richtlinien, Informationen und Arbeitsschutzstandards aus dem maritimen Setting, aber auch aus anderen Arbeitsbereichen wurden gesichtet, damit Verantwortliche diese angepasst an die Lage (z. B. Schiffsgröße, Ausstattung, Witterung, Betriebszustand, Arbeitsanforderungen, Kontakt mit Schiffsfremden, medizinische Probleme) variabel einsetzen können.

Ergebnisse

Eine Handreichung, die konkrete, im maritimen Kontext erklärte technische, organisatorische und persönliche Schutzmaßnahmen für Crews zur anlassbezogenen Nutzung enthält, wurde erstellt. Kombinationsmöglichkeiten und Timing von Sicherheitsbarrieren werden darin zielgruppenorientiert erklärt.

Fazit

Eine Fülle der aus arbeitsmedizinischer Literatur und den Erfahrungen des Hafenärztlichen Dienstes in Hamburg abgeleiteten Schutzmaßnahmen sind auf hoher See umsetzbar. Handelsschiffe sollten in Pandemiezeiten vorausschauend ausgestattet (z. B. mit Schnelltests) und Verantwortliche ermächtigt werden, begründete Infektionsschutzmaßnahmen angepasst an die Situation an Bord einzusetzen. Seeleute sollten unabhängig von ihrer nationalen Herkunft prioritäre Impfangebote erhalten.