CONTENTS

1 Trainer’s guide
1.1 Learning objectives
1.2 Training other crew members

2 Emerging epidemics
2.1 How diseases are transmitted
2.2 Epidemic diseases – symptoms, outcome, treatment and prevention:
2.3 Individual responsibilities
2.4 Master and ship responsibilities
2.5 Points to remember

3 Where to find out more

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1 TRAINER’S GUIDE
Important notes
The Healthy Living at Sea Series does not provide any form of medical or first aid training.
Nor is it intended for ships’ officers responsible for medical care or first aid as the content
is strictly non-specialist, although they may find it useful as a reference source or
refresher aid.

Advice about emerging diseases and their treatment changes rapidly and you should
check the latest information available from ship agents, national public health authorities
and the World Health Organization (WHO).

1.1 Learning objectives

After using this training package, you will know:
• why it’s important to know about the risks of disease in ports at which your ship
may call
• about the symptoms, treatment and precautionary measures for epidemic
diseases
• what you should do if you think you or a fellow crew member are developing
symptoms
• the importance of everyone playing their part in helping to keep themselves and
others safe from infection

For information on other serious diseases, see Part 2 Infectious Diseases and
Vaccination.

1.2 Training other crew members

If you are responsible for training others then you should aim to follow the instructions in
this section as closely as possible. It will help you to learn how to run effective training
sessions with the crew.

Preparation
Think about the group
How knowledgeable are your trainees about health issues?

Read the Reference

The Reference reinforces the key points from the video and contains reference material
that expands on the learning. You’ll also find lists of organisations’ websites where you
can find out more about the topics covered in the training package.

The training facilities

Make sure that the facilities are adequate for training.

Tips for running an effective training session

Make the best use of the video and Reference

Show the video and open up the session to general questions and discussion. If anyone
was unclear about a particular point, or you would like to reinforce a message, you can
re-play the relevant section(s) of the video and/or refer them to the material in the
corresponding section of the Reference.

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Ask questions throughout
Get your trainees to participate from the start by asking for questions. Encourage the
trainees to take an active part. At the end of the session you can use the Tutorial and
Test to check understanding and raise awareness of the issues in trainees’ minds.

2 EMERGING EPIDEMICS

The threat of disease

The ease of mass international travel may make the world a smaller place, but it also
makes it vulnerable to the easy movement of something no-one wants: disease.

In recent years we’ve been warned of possible pandemics, from swine flu to Middle East
Respiratory Syndrome (MERS), and more recently Ebola. Effective medical intervention
contained these outbreaks, but they haven’t gone away and the threat of similar diseases
remains high.

The shipping industry and seafarers have a major part to play in preventing the spread
of epidemics and in protecting themselves from the risk of becoming seriously ill.

Diseases are common in areas of dense population and poor sanitation and because it’s
likely that your ship may call at a port where they’re a risk, it’s worth knowing about them
before considering whether to go ashore. Be prepared for new types of well-established
diseases to emerge as well as entirely new epidemics to break out.

2.1 How diseases are transmitted

Diseases are spread to people through different routes (called ‘modes of transmission’).
In the future these could change in unexpected ways.

Modes of transmission
Water/foodborne In some places, water containing bacteria from human or
and faecal contact animal faeces is drunk or used in the preparation and

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 cooking of food. Untreated water is also dangerous if used
as ice cubes in drinks, or to wash salads and fruit.

Through poor personal hygiene, faecal bacteria can be

transferred on to surfaces or food and from there into the
mouth.

Examples: cholera, hepatitis A, typhoid.

Airborne This is when you breathe in droplets coughed or sneezed
into the atmosphere by an infected person.

Examples: tuberculosis, chicken pox, Severe Acute

Respiratory Syndrome (SARS), MERS, swine flu, avian flu.
Blood and body fluids Viral and bacterial infections transmitted, especially
through sexual contact, through needles used for drugs or
tattoos, and through medical procedures carried out
without adequate sterilisation or personal protection.

Examples: hepatitis B and C, HIV/AIDS, Ebola.

Mosquitoes and other Mosquitoes and other organisms spread a range of tropical
organisms diseases through biting and passing viruses or parasites
into the victim’s bloodstream.
Examples: malaria, yellow fever, dengue fever, Zika virus.
2.2 Epidemic diseases – symptoms, outcome, treatment and prevention
These are examples of diseases that have either recently re-emerged as epidemics or
are relatively new diseases that have started to spread rapidly.

Cholera

Mode of transmission Water/foodborne and faecal contact

Description An acute diarrhoeal infection transmitted by water or food
contaminated by human faeces that contain cholera
bacteria.

It is found in parts of the world with poor sanitation and

may be present in densely populated port cities. In
2010-2014, major cholera epidemics were reported in
the Americas with Haiti and the Dominican Republic,
Central and West Africa and the Pacific region with
Papua New Guinea.

World Health Organization (WHO) figures show that

every year up to 142,000 people die from cholera.

Symptoms Usual symptoms are:

• severe, watery diarrhoea

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 • nausea and vomiting
• stomach cramps
Outcome Incubation is rapid, between two hours to five days. The
dehydration resulting from the diarrhoea and vomiting
can cause you to go into shock and can kill within hours
if left untreated. However, treatment with fluid
replacement is successful in many cases.
How it’s treated Urgent treatment with Oral Rehydration Therapy (ORT) or
with intravenous fluids is essential to replace the fluids and
minerals (e.g. potassium) that you lose when you become
dehydrated as a result of the vomiting and diarrhoea.

Antibiotics are also sometimes used.

Continuing to eat should help restore your normal intestinal

function.
How to protect You should also follow the basic precautions for protecting
yourself and others against food and waterborne diseases:
from it • Don’t use the local water to drink, or even to clean
your teeth
• Use sealed bottles of water from a commercial
producer, preferably with gas as they’re less likely
to have been filled from the tap. Check the seal is
unbroken before opening and drinking the contents
• Don’t eat or drink:
o ice in drinks or in contact with food
o salads
o peeled fruit (unless you peel it yourself)
o cooked dishes kept warm, not hot
o food exposed to flies
o dishes containing uncooked egg
o shellfish, especially uncooked
o undercooked or raw meat and fish
o unpasteurised dairy produce
o ice cream
o food from street traders

Norovirus

Modes of
transmission Water/foodborne and faecal contact

Description A highly contagious viral infection that spreads rapidly,

especially where people live in confined spaces, such as
ships. It can affect people of all ages.

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 Symptoms Vomiting and/or diarrhoea
How you get it Usually brought on board by someone already carrying
the virus, it’s spread by vomit, faeces and unclean hands.
Outcome Norovirus is normally quite mild and passes in a couple of
days.
How it’s treated There's no specific cure for Norovirus, so you have to let it
run its course.

Dehydration is a risk, so it’s important to drink plenty of

fluids (e.g. water, fruit juice, soup).

When you feel like eating again, choose light, plain foods
like rice or bread/chapatis instead of fatty or spicy foods.
Avoid large meals: eat little and often.
How to protect Hygiene is the best way to prevent or contain any outbreak
yourself and others and everyone on board can help by following obvious
from it guidelines, such as always washing hands after using the
toilet, and before and after eating.

Anyone who is ill or possibly infectious (especially food

handlers) should stay in their cabins.

Shipboard management must ensure that galley hygiene

is strictly observed, all surfaces promptly and effectively
disinfected and any risk of cross contamination eliminated.

Throughout the ship, any surfaces that people may touch

with infected hands must be wiped clean.

Anyone clearing up vomit must wear full PPE, and should

use suitable disinfectants to protect other people from
infection.

SARS (Severe Acute Respiratory Syndrome) and

MERS (Middle East Respiratory Syndrome)

Mode of transmission Airborne

Description SARS is caused by a coronavirus and it caused a
significant worldwide epidemic in 2002 and 2004.

More recently, MERS, caused by a related virus, has been

reported in 26 countries since 2012.

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 The SARS virus is spread in small droplets of saliva that
an infected person coughs or sneezes into the air and
which are then breathed in by another person. The primary
source of MERS isn’t yet known.

Instances of coronavirus infections spreading to other

people have mainly taken place in settings such as
hospitals and homes where there’s close contact between
patients and health workers or family members.
Symptoms • Fever (temperature >38ºC)
• Headache
• Feeling chilled
• Aches and pains
• Loss of appetite
• Diarrhoea
Outcome The virus may attack the lungs and airways, and the
person may suffer from breathing difficulties, coughing and
loss of oxygen, which can result in death.
How it’s treated So far there's no cure for SARS or MERS. If a crew
member is suspected of having been in a place where
these viruses are present and then developing respiratory
syndrome they should be transferred as soon as possible
to hospital where they’ll be kept in isolation and given
treatment (antivirals, antibiotics, steroids, a ventilator) for
their symptoms.
How to protect Wash your hands thoroughly and regularly.
yourself and others When coughing or sneezing, cover your mouth and nose.
from it
Don’t share food, drink or cups/plates/cutlery.

Wear masks that cover the nose and mouth when you’re
close to an infected person.

Swine flu

Mode of transmission Airborne

Description Swine flu is the popular name for a relatively new strain of
influenza virus which was responsible for the flu
pandemic in 2009-10.

Flu viruses change their form regularly and this is why new
strains with new characteristics to which people have no
immunity regularly spread around the world.
Symptoms • Fever (temperature >38ºC)

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 • Headache
• Runny or blocked nose
• Aches and pains
• Loss of appetite
Outcome The outcome is generally good with recovery in a few days.
How it’s treated Rest, drink plenty of fluids and take painkillers.

How to protect Flu immunisation with currently active strains is effective.

yourself and others Wash your hands thoroughly and regularly.
from it When coughing or sneezing, cover your mouth and nose.
Don’t share food, drink or cups/plates/cutlery.

Bird (avian) flu

Mode of transmission Airborne

Description Bird flu is an infectious viral illness that spreads among
birds, but in rare cases can affect humans. Two types have
caused serious concern over the years – the H5N1 (since
1997) and H7N9 (since 2013) viruses.

Although these viruses don't infect people easily and are

usually not transmitted from human to human, several
people have been infected around the world, causing a
number of deaths.
Symptoms • Fever
• Headache
• Cough
• Runny nose
• Aches and pains
• Diarrhoea and vomiting
• Chest pain
• Bleeding nose and/or gums

Unless you’ve been recently handling birds in a high risk

area, the presence of these symptoms is very unlikely to
mean you have bird flu.
Outcome Some people with bird flu quickly develop severe
respiratory problems which may be fatal but a future
epidemic might not have the same outcome.
How it’s treated Immediate admission to hospital is vital, and the patient
may have to be kept in isolation for some days.
How to protect Avoid going to animal markets and poultry farms.
yourself and others
from it Don’t touch birds, even when they’re dead.

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 Don’t touch surfaces on which there are bird droppings.

Wash your hands thoroughly and regularly.

Ebola

Modes of
Blood and body fluids
transmission

Description Ebola is a virus which belongs to the group of viruses that

cause viral haemorrhagic fever. It’s one of the world’s most
dangerous diseases and in 2014-2015 West Africa was at
the centre of the largest Ebola outbreak in history.

The major risk of contracting the virus is through direct

physical contact with an infected person, in particular with
any of their body fluids:
o blood
o vomit
o faeces
o saliva
o sweat
o mucus
o semen
o tears
o urine
Ebola is spread through:
• direct physical contact with an infected person,
whether alive or dead
• sexual activity with an infected person
• unsafe medical procedures that use contaminated
needles and syringes, including tattoo equipment
• eating meat from an infected wild animal which
hasn’t been adequately cooked

Even though the risk of contracting Ebola during a visit to

affected countries is very low, and infected people usually
feel so unwell that they cannot travel, the fact that the
illness has a long incubation period and is difficult to
diagnose in the early stages means that people who have
contracted the virus could carry it to other countries.
Symptoms Someone who has been infected may not display
symptoms for up to three weeks. When symptoms do
develop, they’re often similar to flu:
• fever
• headache

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 • aching limbs
• a sore throat

The World Health Organization reports other symptoms

associated with Ebola, including rash, red eyes, lethargy,
stomach pain, difficulty swallowing, breathing difficulties
and hiccups.

After eight or ten days, the person may have:

• severe diarrhoea and vomiting
• bleeding from their internal organs
Outcome In up to 90% of cases the fluid loss is followed by multiple
organ failure, shock and finally death within two weeks.
However, the disease may be survivable if diagnosed and
treated early enough.
How it’s treated Vaccines are now being trialled for medical staff in high risk
areas but there is no proven cure. Infusions of fluid and
antibiotics to help prevent secondary infections are the
more standard treatments available.
How to protect If a ship has to visit a port in an affected area, there are
yourself and others certain steps that everyone on board must take:
from it • Where at all possible, stay on board the ship
• Avoid shaking hands with anyone who comes on
board, e.g. local authorities, agents and stevedores

If you must go ashore:

• Avoid close physical contact with the bodily fluids

(semen, blood, saliva), vomit and faeces of anyone
who has, or may have, the disease. Using a condom
is not going to prevent infection with the Ebola virus.
• Avoid contact with wild animals, whether alive or
dead. Some can carry the disease, and the virus
doesn’t die with the animal.
• Don’t handle or eat bush meat (meat from non-
farmed wildlife – animals, reptiles, birds)
• Wash your hands frequently and thoroughly,
wherever you are
• Protect areas of your body that have cuts or
damaged skin
What to do if you start If you develop a fever, sore throat, aching limbs, diarrhoea,
to feel ill vomiting or stomach pain and have recently had close physical
contact with someone in a port in an Ebola-affected area, you
must report it immediately to the Master or officer
responsible for medical care. It’s for your own protection,
and the protection of everyone else on board.

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 Your symptoms may not necessarily be evidence of Ebola
infection and might be due to another fever related illness
so don’t immediately assume the worst, but you must seek
immediate assistance.
What to do if someone Act immediately
shows symptoms If anyone on board develops symptoms which resemble
Ebola, it should be reported immediately to the ship
operator or manager, and expert advice should be sought
from a shore-based medical facility.

The port health authority should be notified immediately.

Under ‘free pratique’ regulations (quarantine clearance
from the port health authority), it may be possible to
transport the person to a shore-based facility for treatment,
or to airlift someone out to the ship to provide medical
assistance.

Wherever the patient is, if Ebola is recognised and treated

early enough, it can be survived. The giving of intravenous
fluids, at an early stage, to combat the severe fluid loss that
sufferers often experience is vital.

Isolate the infected person on board

The person receiving treatment must be kept totally
isolated from the moment the symptoms are recognised.
This might mean keeping their cabin door closed, or
placing them in an isolation room.

A log should be kept of all people who enter the cabin or

isolation room, and anyone who is to care for the person or
to go into the cabin or isolation room should first be fully
briefed about the risks of Ebola and about the precautions
they must take.

Zika virus

Note: Knowledge of this disease is still developing. Refer to the latest World Health
Organization (WHO) guidance if your ship is entering affected areas.

Mode of transmission Mosquito

Description As with dengue and yellow fever, the Zika virus is
transmitted by the Aedes aegypti mosquito which is
present in Africa, America, Asia and the Pacific. It might
also be spread through sexual contact.

Unlike Ebola which is a risk to life, the Zika virus in its

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 current form causes no lasting harm to the patient, but it
has been linked to an increased risk of birth defects in
children where the mother has been exposed to infection
during pregnancy.
Symptoms There are either no symptoms, or they’re generally minor
and last 2-7 days. They may include:
• a slight fever
• headache
• painful, swollen joints
• itching
• rash
• eye pain
• conjunctivitis (red eyes)

Outcome Women who contract the virus at any stage of pregnancy

(or even before becoming pregnant) may have an
increased risk of giving birth to a baby with an abnormally
small head and brain damage.
How it’s treated There’s currently no specific treatment for the Zika virus.
Get plenty of rest, drink enough fluids, and take
paracetamol to relieve symptoms.
How to protect So far, there’s no vaccination against the Zika virus so you
yourself and others should follow the advice for dengue and yellow fever
from it protection. Cover up and use an insect repellent.

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2.3 Individual responsibilities
As seafarers, you should be aware of the risks and the part you can play in helping to
reduce them. Always follow the recommended guidance, and in high risk areas don’t go
ashore unless it’s absolutely necessary.

For individual emerging epidemics, contact your ship’s agents to obtain the latest local
information.

If you feel ill, don’t make a guess at what might be the cause – seek medical advice and,
if you’re advised to do so, go for testing in the next port.

2.4 Master and ship responsibilities

All ships when entering high risk areas must have in place a comprehensive plan to
protect the crew and avoid any contact with the source of infection.

The ship’s Master should have up to date information on the risks in each port and the
precautions that need to be taken. You should be briefed on these before entering a
potentially infected port. The precautions required will depend on the infection present its
level of risk, the severity of the disease, the scope for prevention and treatment and the
route of transmission.

The Master should also harden ship security in line with the International Ship and Port
Facility Security (ISPS) Code to control and minimise the number of people coming on
board, their level of access to the ship, and the amount of physical contact they have
with crew members.

Cargo operations in the affected ports is dependent on stevedore labour, so before they
come on board a ship, the Master should agree with the stevedore company or their
foreman what the arrangements for comfort breaks and meals will be. Where possible,
these should be taken off the ship.

However, when it’s necessary for the ship to provide stevedores with latrine facilities on
board, the Master must make sure that these areas are thoroughly cleaned afterwards
with disinfectant or bleach by personnel wearing appropriate PPE.

Similarly any gangway railings, and cargo handling gear such as the ship’s winch and
hatch controls must also be cleaned after operations are completed.

Crew changes should not be made in affected ports unless it’s absolutely unavoidable.

Supplies of fuel, water, food and other critical supplies should be sufficient to cope with
any delays or diversions and avoid the need to divert to an affected port.

Every ship must also have adequate stocks of appropriate sanitation material and
medical personal protective equipment (PPE).

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2.5 Points to remember
• Most infectious diseases are dangerous, some more than others.
• Everyone involved with a ship must play a part in containing any outbreak.
• Guidance is available on all known risks and following the recommended
measures will keep everyone safe and will be rapidly developed by national and
international health organisations whenever a new infection emerges.
• Report any symptoms to the Master or officer responsible for medical care.

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3 WHERE TO FIND OUT MORE
Useful websites and publications
Centers for Disease Control and Prevention (United States) www.cdc.gov
European Centre of Disease Prevention and Control http://ecdc.europa.eu
International Seafarers’ Welfare and Assistance
Network (ISWAN) www.seafarerswelfare.org
World Health Organization (WHO) www.who.int

The World Health Organization regularly updates its factsheets on all emerging
epidemics, listing the areas where the disease can be found, its symptoms, protective
measures, etc.

Your national public health service should also have up to date information and guidance.

The booklet Safe Travel is available from ISWAN’s website.

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