Shipshape: Sanitation Inspections on Cruise Ships, 1990-2005, Vessel Sanitation Program, Centers for Disease Control and Prevention

Article excerpt

Background

In 1975, the then-Sanitation and Vector Control Activity (now the Vessel Sanitation Program [VSP]) at the Centers for Disease Control and Prevention (CDC) began surveillance for enteric diseases aboard passenger cruise ships. It did so in response to widespread findings of food-handling and water sanitation practice deficiencies that posed a significant potential for transmission of foodborne and waterborne diseases (Merson, Hughes, Wood, Yashuk, & Wells, 1975). To reduce the occurrence of outbreaks and identify unsafe sanitation practices, VSP also began conducting environmental sanitation inspections modeled on the Food and Drug Administration (FDA) Food Code (FDA, 2005), outlined in the Vessel Sanitation Program Operations Manual (Centers for Disease Control and Prevention, National Center for Environmental Health, 1989). Following 15 years of program implementation and development, an evaluation of the program between 1989 and 2001 reported a decline in foodborne outbreaks and gastroenteritis incidence rates on cruise ships associated with improved environmental sanitation performance by industry (Koo, Maloney, & Tauxe, 1993).

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Since 2002, however, with the emergence of noroviruses associated with person-to-person and environmental transmission of disease, there has been an associated rise in the incidence rates of gastroenteritis on cruise ships (Cramer et al., 2006; Isakbaeva et al., 2005; Widdowson et al., 2004). Concurrently, the fleet sizes of major cruise lines have grown, with increasing numbers of passenger embarkations per year and larger, more complex vessels at sea (International Council Cruise Lines, 2005). In the course of the successful collaboration of CDC with the cruise industry on reducing common source outbreaks (Cramer, Gu, Durbin, 2003; Lawrence, 2004; Rooney et al., 2004) and on the challenges associated with environmental decontamination of noroviruses, VSP has expanded training, education, and inspection programs. This article presents 15 years of VSP ship sanitation inspection data, evaluates ship characteristics associated with performance on environmental sanitation inspections, and assesses sanitation performance in specific inspection categories in the context of a burgeoning cruise ship industry.

Methods

Sanitation Inspections

VSP environmental health officers (EHOs) conduct twice-annual, unannounced sanitation inspections (called routine inspections) of cruise ships sailing from foreign to U.S. ports and carrying 13 or more passengers. These inspections, scored on the basis of a possible 100 points, evaluate sanitation performance in six major categories: disease reporting, potable-water maintenance and distribution, swimming pools and spas, food safety and handling, medical log maintenance and reporting, and environmental health practices (e.g., housekeeping, disinfection, maintenance of child activity centers). Significant violations identified during inspections result in a loss of points; minor violations are noted on the inspection report and may not result in point deductions.

Inspections are conducted in U.S. ports within one day or less by one to three inspectors, depending on the size and complexity of each vessel. For vessels that do not meet the minimum passing score of 86 or higher, an unannounced re-inspection within 45 days of a failed inspection is conducted. Immediately following the conclusion of each inspection, EHOs review the inspection findings and sanitation deficiencies with the ship's master and the senior management personnel on board each vessel. Cruise ships are asked to submit corrective-action statements to VSP in response to violations cited on inspection reports within 30 days of an inspection. Cruise lines may submit appeals of inspection scores to VSP for review. Inspection scores and violations associated with each ship inspection are recorded and stored in the VSP database at CDC in Atlanta, Georgia, and can be accessed at http://wwwn. …