Post on 31-Jul-2022
Special Commission of Inquiry into the Ruby Princess
EXHIB
IT 53 Statement of Dr Vicky Sheppeard dated 9 June 2020
1
SPECIAL COMMISSION OF INQUIRY INTO THE RUBY PRINCESS
Statement of Vicky Sheppeard, 9 June 2020
A Introduction
1 My full name is Vicky Sheppeard.
2 I hold the following qualifications: MBBS MPH (Hons), FAFPHM.
3 I am currently Deputy Director of the Public Health Unit in the South Eastern
Sydney Local Health District. I have been in this role since January 2020. I am
the deputy to Professor Mark Ferson.
4 Prior to my current role, I was the Director of Communicable Diseases in the
Ministry of Health for six years.
5 At the time of making this statement, I have been shown a bundle of documents
called “Annexures to NSW Health Witness Statements”. While I have not
reviewed every document in that bundle, throughout this statement I refer to the
documents in the bundle by referring to the tabs behind which they appear.
6 I also annexe additional documents not contained in the Annexures to NSW
Health Witness Statements bundle.
B Terminology and key concepts
7 I use the term “acute respiratory illness” (ARI) as a broad category of respiratory
illness that is “acute” in the sense of being short-term, as opposed to “chronic
respiratory illness” which refers to long-term respiratory illness. ARI may be
severe or may be as mild as a common cold.
8 An influenza like illness (ILI) in my view is an ARI with the addition of a fever,
or other features such as muscle aches and headache.
2
9 There is no practical difference between the terms “ARI” and “acute respiratory
disease” (ARD) in the context of monitoring symptoms on cruise ships.
C Involvement in policy development
10 Throughout February and March 2020, I was involved in the development of
certain new procedures for surveying incoming cruise ships in the context of
the COVID-19 pandemic. I set out the extent of my involvement in the following
paragraphs.
11 On 13 February at 1.18pm, I circulated a document titled “CoVID-19 Response
– Screening of Cruise Ships” to a number of NSW Health public health
colleagues, for the purpose of discussion on a teleconference arranged at
around that time. This draft was based on the procedure in place at Sydney
Airport at the time. My email and the draft appear at Annexure VS-1.
12 I note the following about my 13 February draft:
(1) This draft was intended to get something down on paper, to start a
discussion amongst my colleagues as to the best approach to cruise ship
screening in the context of the COVID-19 pandemic. I did not pay overly
close attention to the language used. My focus was instead upon
identifying key issues and concepts for us to consider.
(2) At paragraph 1.3, the draft states: “Collect a second viral swab from
anyone presenting with ILI and store at 4o C”. The aim was that when a
ship’s doctor tested for influenza, he or she would collect and retain an
additional swab which NSW Health could test for COVID-19 if we
wished. This appeared to us to be an efficient process, however it took
some time for ship doctors to adopt this. I think this was partially because
the initial correspondence from the Chief Health Officer to cruise
companies on 22 February 2020 (which I discuss in more detail below)
may not have reached them, but also because ships had trouble
procuring sufficient supplies of swabs, which were generally in short
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supply at that time. As at 13 February, when I circulated my draft
procedure, I was not aware that cruise ships were having significant
difficulties in procuring swabs for COVID-19 testing.
(3) At paragraph 1.6, the draft states: “Ensure any persons with respiratory
symptoms and fever are isolated…” While it was established as at 13
February that people with COVID-19 could present with either
respiratory symptoms or fever, these symptoms in isolation are non-
specific. Accordingly, I considered it appropriate for cruise ships to
isolate passengers with both respiratory symptoms and a fever (rather
than one or the other), indicating more severe infection, and for cruise
ship doctors to use their clinical judgment as to whether or not
passengers with respiratory symptoms alone should be isolated. I
considered that isolating people with respiratory symptoms alone would
not necessarily be warranted, as it was to be expected that a significant
number of people on board a cruise ship would have a runny nose, a
chronic cough, or other minor respiratory symptoms that, at that time,
was unlikely to indicate the presence of COVID-19. Therefore, the ship’s
doctor should exercise clinical judgment as to whether passengers with
respiratory symptoms alone should be isolated, as a ship’s doctor was
in the best position to assess whether or not a person’s symptoms were
explained by a condition other than COVID-19 (for example, allergies or
chronic bronchitis).
(4) At paragraph 2.2, the draft states: “Cruise Ship Program to monitor
MARS reports and follow up with any ships on ILI greater than ?%” I
included a placeholder for the percentage of “ILI” that required follow-up,
as I recall that I wanted to check the appropriate percentage to include
with Ms Kelly-Anne Ressler, a Senior Epidemiologist in my Public Health
Unit, who had expertise based on her experience in monitoring cruise
ships for over a decade. I note that I included a reference to “ILI” (that is,
“influenza like illness”) rather than “ARI” (that is, “acute respiratory
illness”) because I understood that cruise ships had not collected and
provided my Public Health Unit with data on rates of ARI on board ships
4
in the past, and so we did not have any data on which to assess what
amounted to an elevated rate of ARI on board a ship that would warrant
further investigation. It therefore was my intention that our procedures
focus upon the rate of ILI (rather than ARI) as a basis for detecting
greater than expected levels of respiratory viral illness when following up
with ships.
(5) At paragraph 2.8, the draft states “Cruise doctor to arrange for all people
who meet the criteria in 2.7 to be cohorted in a location for health
screening prior to disembarkation”, and at paragraph 2.10, the draft
states “PHU to arrange for at least two officers to meet each ship –
suggest an environmental health officer and a registered nurse”. It was
intended at that stage that any people who met any of the criteria of
exposure risk or illness set out in paragraph 2.7 would be screened by
the public health team. Ultimately, we decided that we could achieve
better public health outcomes using our resources by conducting a more
detailed risk assessment prior to the arrival of each ship, and then having
a larger team board ships to conduct health screening where indicated
by the risk assessment.
(6) At paragraph 3, the draft sets out a procedure for screening passengers
and crew on arrival based on the Sydney Airport screening procedure.
The screening focused on arranging testing for people who had been in
a country with local transmission of COVID-19 prior to boarding and who
had subsequently developed fever or respiratory symptoms, as was the
process in place at the Airport at the time.
13 At 2.49pm on 13 February I circulated a further version of the draft procedure.
My email and the attachments appear at Annexure VS-2. The main differences
in this version were that on the advice of Ms Ressler the information requested
from the ship at paragraph 2.2 was changed to the ARD Log, and the percent
positive ILI rate of concern was fixed at greater than 1%.
5
14 Later on 13 February, at 4.24pm, I circulated what I would describe as an
algorithm, which summarises diagrammatically the process of responding to
passengers and crew with fever or respiratory symptoms on cruise ships. My
intention was for the algorithm to reflect the contents of the draft procedure I
circulated earlier that afternoon. In that algorithm, I distinguish a “low risk” and
a “high risk” scenario, based on criteria consisting of “features of concern”. I
once again refer to a rate of presentation of ILI over 1% as a “feature of
concern”, rather than ARI, because, as I explain above, our focus was on the
rate of ILI rather than ARI, given our understanding of background rates of ILI
on cruise ships, and that ILI represents a more severe form of infection. While
the diagram may be read as indicating that passengers and crew with “fever or
respiratory symptoms” should be isolated, it was my intention that only patients
with fever and respiratory symptoms be required to be isolated on board,
consistent with the draft procedure I prepared earlier on the same day, and that
whether or not patients with respiratory symptoms alone be isolated therefore
be left to the ship doctor’s clinical judgment. My email, and the attached
algorithm appear at Annexure VS-3.
15 On 14 February at 12.53pm, I circulated a further draft of the cruise ship
procedure, together with the draft algorithm for comment. I also circulated a
draft “NSW Health Screening Process” and a “Kit” list, which were both practical
documents directed to the approach to be adopted when boarding a ship for
health screening. The main changes to this version were to clarify the
arrangements for people requiring transport for health assessment, to provide
advice about logistics for health screening if required (2.10 and 2.11), and to
set out arrangements for granting pratique (by which I meant, in this context,
the right to disembark) (3.7). These changes followed a debrief of an on-board
assessment conducted that day. The procedure retains a query for the panel
regarding how to define a country of concern, as at that stage the national case
definition only nominated mainland China as a risk exposure, whereas it was
known that local transmission was also occurring in Hong Kong and Singapore.
My email and its attachments appears at Annexure VS-4.
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16 On 15 February, at 8.15am, Dr McAnulty circulated a further draft of the cruise
ship procedure, as well as the algorithm, to me and Professor Ferson, copying
in others. As far as I can recall the draft is based on the earlier drafts I had
circulated and appears to include comments from both me and Professor
Ferson, though I cannot now remember the order in which we made those
comments, or why Dr McAnulty sent the draft containing my comments back to
me (and Professor Ferson). Dr McAnulty’s email and its attachments appear at
Annexure VS-5. I note the following in respect of this draft, which differs from
my earlier draft:
(1) The draft refers to action to be taken where a “respiratory outbreak is
reported on board” (on page 1) and also action to be taken where there
is “no respiratory outbreak or a mild respiratory outbreak”. Where the
draft refers to “>1% of passengers affected” under the heading “Where
a respiratory outbreak is reported…” I understood this to refer to (and
believe the phrase was intended to refer to) a scenario where >1% of
passengers had presented with an ILI, rather than merely an ARI.
(2) The draft includes two headings; the first, on page one, “Where a
respiratory outbreak is reported on board…”, and the second, on page
two, “Where there is no respiratory outbreak or a mild respiratory
outbreak that is explained by positive influenza test results…” The first
heading later evolved into what we characterised as a “high risk”
scenario, and the second heading evolved into what we characterised
as a “medium risk” and “low risk” scenario (following further stratification
of risk in our procedure). I deal with these distinctions in greater detail
below.
17 A short time later on 15 February, at 9.47am, I sent Dr McAnulty and Professor
Ferson (copying others) an updated draft of the procedure, including additional
comments. My email, and its attachments, appear at Annexure VS-6. Beyond
the matters I explain in relation to the draft circulated at 8.15am, I note the
following in relation to this draft:
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(1) Under the heading “Pre-arrival requirements” I made clear in my
amendments that persons with both a fever and respiratory symptoms
should be isolated while on board; this is consistent with earlier drafts
and our thinking at the time, as I explain above.
(2) I added in a requirement that the ARD log provided by ships include
details of countries persons on the ARD log “have visited in the 14 days
prior to embarkation”. I added this because this would aid our risk
assessment of people who had respiratory illness on board, as travel in
countries where there was local transmission of COVID-19 within 14-
days prior to boarding would prompt higher scrutiny.
(3) My reference to the “Yokohama vessel” in comment “VS1” was a
reference to the Diamond Princess. My understanding at the time was
that the person who was the source of the outbreak on the Diamond
Princess was from Hong Kong, rather than mainland China, so it was
important to have our screening criteria broad enough to identify people
at risk of COVID-19.
18 Later on 15 February, at 1.14pm, Dr Leena Gupta emailed comments and
queries in relation to the developing cruise ship procedure. Her email included
a suggestion that “we need high level hub with an expert panel…” I believe that
around this time was the first time we considered using an expert panel to
assess the risks of incoming cruise ships, rather than having a public health
team meet each cruise ship arriving in Sydney. I agreed with Dr Gupta’s
observation that a procedure or protocol would “not cover every situation”, and
that using an expert panel to assess risk would allow us to adopt a more
nuanced approach to assessing risk, and to better use our resources to respond
to such risks. Dr Gupta’s email appears at Tab 7.
19 On 17 February at 2.03pm, I circulated a further updated draft of the procedure for comments. My email, and attachment, appear at Tab 12. I note the following
in respect of that draft, which had changed from earlier drafts:
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(1) By this stage we required ships, ahead of arrival, to “actively ask
passengers or crew if they have respiratory symptoms or fever and ask
them to present to the ship’s doctor for assessment free of charge”. This
was because we were aware that the cost of medical assessment on
some ships may discourage some passengers from attending the clinic.
(2) This draft now incorporates what became the expert panel procedure,
noting that, “Where a respiratory outbreak is reported on board a cruise
ship…” “a team of senior public health officers will assess the risk that
novel coronavirus is on board the ship and report the risk assessment to
the Chief Human Biosecurity Officer”.
(3) This version also includes my suggestions on the risk assessment form,
which I believe had been drafted by the Public Health Emergency
Operations Centre and includes a risk rating of low, medium and high.
My comments clarified that foreign ports related to the current cruise and
queried whether transit in China needed to be identified.
20 The last version I saw was the ’Draft 5pm 16 Feb 20’. The attached pre-arrival
risk assessment form sets out the consequences of an assessment of low,
medium or high.
21 If the assessment is low, additional assessment of the ship is generally not
required, swabs would usually not be required to be urgently removed from the
ship and passengers and crew can disembark because contact details are
readily available and symptomatic people can on travel home with a mask, fact
sheet and hand rub.
22 If a medium risk assessment, further discussion was required by the expert
panel whether boarding by a Health Team is required, whether or not swabs
need to be urgently removed, and whether passengers and crew can disembark
before results are known.
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23 If the risk assessment is high, the procedures contemplates that swabs would
usually need to be urgently required and passengers and crew would usually
not disembark until the results of the testing are known.
24 As I noted above, in my initial 13 February draft procedure, I had proposed that
all passengers and crew be required to remain on board a ship while available
swabs were tested for COVID-19. My public health colleagues and I gave this
matter detailed consideration between 13 February and 16 February, and
ultimately concluded that this was not a proportionate response to risk, in
circumstances where a ship was considered to be low or medium risk in our
opinion.
25 Ships have a 12-hour turnaround at ports and delaying disembarkation would
substantially delay the turnaround time of ships in ports. While that was
considered to be an appropriate impact in a high risk scenario, we did not
consider we should delay every ship that docked in Sydney. If a ship was low
or medium risk, a proper public health response did not demand holding
everyone on board a ship. In a medium risk scenario, a variety of actions could
be considered to achieve public health outcomes, such as allowing
disembarkation of ships and requiring all symptomatic passengers (and crew,
if any disembarked) to go into self-isolation pending results of swab testing, if
the Human Biosecurity Officer carrying out on-board health screening approved
such a course. In a Low Risk scenario, we did not consider there to be any
basis for delaying disembarkation from a public health perspective, given that
we had assessed the risk of COVID-19 being present on board to be low.
26 I understood the risk being assessed in carrying out expert panel risk
assessments under the 16 February (and subsequent versions) Risk
Assessment Form to be the risk that COVID-19 may be circulating on an
incoming ship.
27 I understood the factors constituting each of the “High”, “Medium” and “Low”
risk categories to be based on the CDNA Guidelines, as well as SESLHD Public
10
Health Unit’s expertise in assessing the risk of disease circulating on cruise
ships. In particular:
(a) High: In the context of the time, when almost all cases of COVID-
19 were related to China, a respiratory outbreak (that on the basis
of testing did not appear to be due to influenza) affecting
passengers or crew who had been in mainland China or in contact
with a confirmed COVID-19 case in the 14 days prior to
embarkation was considered likely to be due to COVID-19. In this
case no-one was to leave the ship until COVID-19 test results
were available.
(b) Medium: This was the situation where there was a respiratory
outbreak on board the ship, however there was a lower likelihood
of it being due to COVID-19 as there was no exposure to China
or confirmed cases, but nevertheless some risk due to exposure
to countries with low level circulation of COVID-19. This risk level
may also be met should the outbreak seem severe, or not due to
influenza. As the risk of COVID-19 causing the outbreak was
lower, it may not be necessary to keep everyone on board
provided all those who disembarked could be readily contacted
and quarantined if required.
(c) Low: This was the situation where there was either low rates of
respiratory disease, or if there was an outbreak tests showed it
was likely due to influenza and the passengers and crew had a
low level risk of exposure to COVID-19 prior to boarding. In this
case no on-board health assessment was required and
passengers could disembark as normal.
28 I did not consider the criteria for each of the risk assessment to be prescriptive.
That is, I understood that the expert panel would use its expertise to assess the
risk of an incoming ship based on all available information. In my mind, the
“medium” risk category was to be used when a precautionary approach was
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warranted. That is, a ship was not “high” risk, but there was one or more factors
present that warranted a precautionary approach to be adopted, so that the risk
posed by a ship may not be “low”, even if not all of the criteria for a “medium”
risk assessment were present.
29 On 22 February, a document titled “Enhanced COVID-19 Procedures for the
Cruise Line Industry” (the 22 February Procedure) was sent to cruise ship
industry representatives, behind a letter from Dr Kerry Chant. Dr Chant’s letter
and the 22 February Procedure appears at Tab 23. I do not recall commenting
on a draft of the 22 February Procedure, which was directed at cruise ships,
rather than NSW Health. However, I note that the 22 February Procedure tells
Cruise Ship representatives that “[c]ruise ship vessel staff should ensure that:
… Passengers who may be infectious are appropriately isolated”. This reflected
our view that it was necessary for cruise ships to ensure that passengers who
the ship’s doctor deemed to be infectious, based on their clinical judgment,
were isolated. This would almost certainly include all patients with a fever but
might also include patients who had respiratory symptoms absent a fever if the
ship’s doctor considered them to be infectious based on their symptoms
considered as a whole. To my knowledge, the various iterations of the NSW
Cruise Ship Policy or Procedure were never provided to the cruise line industry
– they were internal documents – and so the statement in the 22 February
Procedure represented NSW Health’s advice to cruise ships at that time.
30 On 28 February, at 3.17pm, I circulated a draft I described, in my cover email,
as a “SOP” for review (the Draft SOP). “SOP” stands for “Standard Operating
Procedure”. The purpose of the document is set out under the heading
“Context”, namely, to provide guidance and to delineate “responsibilities for
public health units and the Public Health Emergency Operations Centre” (which
sits within the Ministry) “in the risk assessment and screening process for cruise
ships docking in Sydney”. The draft SOP I circulated included a number of draft
attachments, including a draft email to be sent to ships 48 hours prior to arrival
(Attachment 1), an updated version of the 16 February Risk Assessment Form
(Attachment 2), and a number of further draft emails to be sent to ships in
12
differing scenarios. My email and its attachment appear at Tab 28. I note in
particular:
(1) The SOP states that NSW Health should email cruise ship companies
requesting that ships “[e]nsure all passengers with respiratory symptoms
and/or fever are appropriately isolated while on board…” (emphasis
added). I used the word “appropriately” in this context to give discretion
to the ship’s doctor about which ill people need to be isolated, consistent
with my observations above that isolation may not be appropriate for
someone with a runny nose or mild cough, particularly if due to another
known cause, and so the isolation of passengers with respiratory
symptoms absent a fever was a matter appropriately left to the ship’s
doctor’s discretion. I also ask my colleagues if they think that isolating
any passengers or crew with current respiratory symptoms is too broad
for the same reason.
(2) This version of the SOP only requires the doctor to collect and retain a
second swab for people with a negative influenza test or a risk of
exposure to COVID as most ships had a shortage of swabs, and hence
had been reluctant to collect two swabs on every patient. In my view it
was pragmatic just to collect a COVID-19 swab where there was a higher
chance of the person having COVID-19.
(3) The SOP states “[t]he panel will consider factors such as the rate of ILI
reported, the rate of influenza confirmation amongst ILI cases, the travel
history of people with acute respiratory illness, and the travel history of
the entire ship’s passengers and crew (where available) to assess the
likelihood (low, medium or high) of COVID-19 on board.” Thus, while we
had a threshold for an ILI outbreak of concern, the pattern of ARI (or
respiratory symptoms without fever) was also taken into consideration,
particularly if there was relevant travel history.
31 On 3 March, at 4.28pm, Dr Sean Tobin circulated a draft document tiled
“Enhanced COVID-19 Procedures for the Cruise Line Industry” for comments.
13
I understood this to be an update of the procedure circulated to cruise line
industry representatives on 22 February. Dr Tobin’s email and attachment
appear at Tab 30.
32 On 4 March at 4.39pm, Dr Gupta circulated comments on the Draft SOP from
Sydney Local Health District (SLHD) Public Health Unit. Dr Gupta’s email, and
attachments, appear at Tab 33. As far as I am aware, there were no further
comments on the Draft SOP after Dr Gupta’s email, and the Draft SOP was
never finalised. As I understood it, the expert panel applied the Draft SOP in
the form I circulated on 28 February throughout the period March 2020, as the
Draft SOP was never amended to respond to SLHD’s comments.
33 Later on 4 March at 5.20pm, Professor Ferson responded to Dr Tobin’s email
of 3 March, attaching an updated draft of the Enhanced COVID-19 Procedures
document, incorporating his comments and those of Ms Kelly-Anne Ressler and
me. Professor Ferson’s email and its attachment appear at Tab 34. My
understanding of this document was that it was intended to make the
requirements placed on cruise ships clearer and easier for cruise ships to
understand. The draft states on page 2 that cruise ship staff should ensure that
“Passengers with ARI/ILI who may be infectious are appropriately isolated…”
(emphasis added). This was consistent with the 22 February Procedure, which
required cruise ship doctors to isolate passengers they considered to be
infectious, based on their clinical judgment. As was the case in the 22 February
Procedure, and is made explicit in this draft, this could include passengers with
either an ILI or an ARI.
34 I was aware at around this time in early March 2020 that a National Protocol
was being developed for managing COVID-19 risk from cruise ships, but I do
not believe I had the opportunity to comment on the National Protocol.
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D Involvement in risk assessment process
8 March Arrival
35 By 7 March, I had reviewed most of the 35 risk assessment forms that had been
prepared for incoming cruise ships. In my Public Health Unit, either Professor
Ferson or I would then participate in the expert panel to undertake the risk
assessment; we would determine which of the two of us would participate
based on other urgent demands or who was on-call at the relevant time.
36 I was a member of the expert panel that performed the risk assessment of the
Ruby Princess cruise arriving into Sydney on 8 March 2020.
37 On 7 March at 10.58am I received an email from Ms Laura-Jayne Quinn, an
environmental health officer in my public health unit, attaching a risk
assessment form in respect of the Ruby Princess scheduled to arrive on 8
March. I requested a copy of the ARD Log which I received at 12.21pm. A copy
of the email I received at 12.21 pm and its attachment appear at Tab 38.
38 I reviewed the completed Risk Assessment Form, together with the ARD Log
provided by the ship. I amended certain details on the Risk Assessment Form,
based on my review of the ARD Log, and applying my clinical judgment and
expertise. For example, the form Ms Quinn sent me referred to the fact that
passengers on-board the cruise ship had travelled to Sydney on a flight from
Darwin, which included passengers who had been quarantined in Darwin,
having travelled there from Wuhan. I considered that information to be irrelevant
to our risk assessment, because the people on the Darwin flight had completed
their self-isolation period, and so did not pose a risk of transmitting COVID-19.
39 At 12.52pm on 7 March, I sent the updated Risk Assessment Form to the expert
panel for consideration. I noted in my email that, while the “ILI rate is low I am
concerned that two pax who spent several days in Singapore prior to boarding
had onset of ARI on 29/2 and 4/3, and both were assessed on 6/3. Both were
swabbed for flu (despite no fever) and were negative.” I raised this concern
15
because I knew, at that time, that Singapore had a high rate of community
transmission, and the two passengers who had spent time in Singapore had
respiratory symptoms that were unexplained. I took the view that this warranted
seeking further information and suggested this course to the panel. My email
and the attached Risk Assessment Form appear at Tab 39.
40 I note that, in the context of preparing this statement, I have reviewed the Risk
Assessment Form I circulated on 7 March and can see that there is a “0” noted
in the field “Number of passengers and crew who have been in another country
of concern within 14 days of embarking”. This field should have had a “2” written
in it, consistent with the field noted further down on the Form stating, “Number
of ill passengers and crew who have been in countries included in the Australian
CoVID-19 testing criteria in the 14 days before embarkation”.
41 I emailed the ship’s doctor to obtain further information about the two ill
passengers who had been in Singapore and to request that new swabs be
obtained and stored. The ship’s doctor described the two passengers as having
had upper respiratory tract infections without fever and were generally well. She
confirmed that swabs would be collected and they would remain in isolation.
42 At 4.12pm on 7 March, I emailed the expert panel confirming that extra
information had been received, and that a teleconference could be held to
discuss the risk assessment. My email to this effect appears at Tab 40.
43 I don’t have a specific recollection of the teleconference on 7 March, as I was
participating in almost at least one such teleconference per day around that
period. However, I do recall that we concluded the ship should be assessed as
“medium” risk, and I do recall my reasons for that conclusion.
44 The main factor that led me to this conclusion was that two of the passengers
who were symptomatic and had a negative flu test had been in Singapore within
14 days of embarking on the cruise which, as at 7 March, was a significant red
light.
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45 Another important factor was what I considered to be the very large number of
people who presented to the clinic with acute respiratory illness symptoms
(170), even though the rate of ILI on board was relatively low. Another
consideration was that a relatively small proportion of people swabbed tested
positive for influenza (6 out of 30), suggesting to me that some other virus may
have been causing symptoms on the ship.
46 As I explained above, while there was (and is) no good data as to the
background rate of ARI that might be expected on cruise ships, and so the rate
of ARI on a ship that might indicate an outbreak of some kind was not clear,
based on my experience in assessing incoming cruise ships throughout
February and March, during which period we did assess the rate of ARI
presentations on board, I considered presentations of 4% to be high.
47 I noted at the time that no swabs were collected for testing for COVID-19 on the
Ruby Princess cruise arriving in Sydney on 8 March. When the ship
commenced its journey on 24 February, NSW Health had only recently
requested that cruise ships keep swabs for COVID-19 testing (namely, on 22
February), and I did not consider it surprising that no swabs had been retained
for COVID testing, as I thought it likely the cruise ship simply did not have swabs
on board to comply with this request. This was confirmed by the doctor asking
me in her email at 2.29pm if I knew where she could procure swabs as she only
had six left on board. A copy of the email I received at 2.29pm is Annexure VS-7.
48 I note that the Ruby Princess Risk Assessment shows that there was not an ILI
outbreak affecting the ship, however, once again, as I explain above, I
understood that, as with many aspects of public health, risk assessment should
be applied using public health expertise and judgement as not all factors can
be specified in an algorithm or protocol, particularly in a rapidly evolving
situation such as a pandemic. The symptomatic passengers who had travelled
to Singapore prior to embarkation whose symptoms were not explained by flu
were of concern to me, and so I considered a precautionary approach,
represented by a “medium risk” classification, was appropriate.
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Boarding
49 As a result of our assessment of the Ruby Princess as “medium” risk, in
accordance with the Draft SOP, an assessment team boarded the Ruby
Princess after it docked on 8 March to carry out a health assessment. I was the
doctor for that boarding.
50 I have reviewed the statement of Ms Kelly-Anne Ressler dated 1 May 2020 at
paragraphs 46-58, where Ms Ressler sets out her recollection of boarding the
Ruby Princess on 8 March. Based on my recollection, Ms Ressler’s account is
factually accurate. Ms Ressler is correct in her account that my decision to swab
passengers and crew who presented for health screening was based on the
presence of a constellation of factors, namely respiratory symptoms, the
presence of a fever and a negative result from a rapid influenza test, which
meant that their symptoms were unexplained.
51 What is understandably missing from Ms Ressler’s account is the clinical and
public health decision-making behind my decision, as the Human Biosecurity
Officer carrying out the on-board health assessment, to allow the ship to
disembark all passengers who were not swabbed for COVID-19, following my
carrying out the on-board health assessment, in accordance with the SOP.
52 My overall assessment, having spoken to almost all of the 366 passengers who
presented for health screening on 8 March was that COVID-19 was unlikely to
be on board the ship. This was because there was no evidence of severe
disease or high respiratory infection rates amongst travellers who had come
from high risk countries. Further, most of the travellers who had had a
respiratory infection were improving. Overall, I was concerned about six
passengers due to factors such as unexplained fever, being systemically
unwell, or having a severe cough. I suspected two of those six passengers had
influenza, and the ship’s doctor performed rapid tests and that diagnosis was
confirmed. For the other four passengers, and an additional three crew with a
fever, we requested COVID-19 swabs as a precaution. I describe this approach
as “precautionary”, because not all of the passengers and crew that I swabbed
18
fit the then current CDNA definition of a “suspect case”, as they did not fit the
epidemiological criteria. However, I considered testing such passengers and
crew to be appropriate, because if COVID-19 had been introduced to the ship
from passengers that fit the epidemiological criteria (namely the passengers
travelling from Singapore) even passengers who had not travelled to countries
of concern may have been exposed.
53 I also reviewed the two passengers who had been in Singapore, and they were
both recovered. My overall assessment was that it was unlikely that COVID-19
had been transmitted on the ship, as if it had I would have expected more sick
passengers rather than the mainly recovered passengers I found. However, as
I had tested some for COVID-19 I considered it prudent to keep those nine
passengers and crew in isolation until the test results were available.
54 It is relevant in this context to note that I am a Human Biosecurity Officer under
the Biosecurity Act (which Ms Ressler is not) and was previously a Chief Human
Biosecurity Officer (a role that Dr Tobin presently holds). The role of Human
Biosecurity Officer requires one to be able to make rapid decisions as to
whether or not to disembark planes when a listed human disease is suspected
to be present. I am therefore experienced in making rapid public health risk
assessments as to the appropriate public health response in circumstances
where a disease may be present in a particular scenario and was able to apply
that expertise on 8 March when deciding to disembark the Ruby Princess.
19 March arrival
55 While I was copied into emails relating to the risk assessment of the Ruby
Princess on 18 March 2020, on that occasion Mark, rather than me, was the
expert panellist who participated in the risk assessment on behalf of our public
health unit. As such, I did not review emails relating to the Ruby Princess cruise
arriving on 18 March and was not involved in the risk assessment process in
respect of that cruise.
19
E Further observations
CDNA
56 I was a member of the Communicable Diseases Network Australia (CDNA)
from 2013 to 2019. I was not a member in 2020 and was not involved in the
development of the definition of a “suspect case” of COVID-19.
The MARS Report
57 I understood that Ms Ressler and other staff would take information from the
Commonwealth Maritime Arrival Reporting System (MARS) as part of
completing the Risk Assessment Form for incoming cruise ships. I did not have
access to the MARS.
Signed:
Name: Vicky Sheppeard
Date: 9 June 2020
1
From: Vicky Sheppeard (South Eastern Sydney LHD)
< >
Sent: Thursday, 13 February 2020 1:18 PM
To: Darrin Eade; Peta Pippos (Ministry of Health); Christine Selvey; William Rawlinson
(NSW Health Pathology); Anna Condylios (NSW Health Pathology); Jeremy
McAnulty; Mark Ferson (South Eastern Sydney LHD); David Durrheim (Hunter New
England LHD); Craig Dalton (Hunter New England LHD); MOH-PHEOPlanning;
MOH-PHEOOperations; Tracey Oakman; Leena Gupta (Sydney LHD); Tony Merritt
(Hunter New England LHD)
Subject: RE: URGENT TELECOFERENCE - Cruise ships
Attachments: Cruise ship procedure - App A - patient assessment form.docx; Cruise ship
procedure.docx
Follow Up Flag: Follow up
Flag Status: Flagged
Draft procedure for discussion -----Original Appointment----- From: Darrin Eade Sent: Thursday, 13 February 2020 12:56 PM To: Darrin Eade; Peta Pippos (Ministry of Health); Christine Selvey; William Rawlinson (NSW Health Pathology); Anna Condylios (NSW Health Pathology); Vicky Sheppeard (South Eastern Sydney LHD); Jeremy McAnulty; Mark Ferson (South Eastern Sydney LHD); David Durrheim (Hunter New England LHD); Craig Dalton (Hunter New England LHD); MOH-PHEOPlanning; MOH-PHEOOperations; Tracey Oakman; Leena Gupta (Sydney LHD); Tony Merritt (Hunter New England LHD) Subject: URGENT TELECOFERENCE - Cruise ships When: Thursday, 13 February 2020 1:15 PM-2:15 PM (UTC+10:00) Canberra, Melbourne, Sydney. Where: Teleconference Dial: 1800 108 839 Code: Importance: High Dear Directors Apologies for the late notice, this teleconference is to discuss the consistent approach to the management of cruise ship arrivals. Dial in – 1800 108 839 Code: Kind regards Darrin Eade Logistics Team
Tel | | www.health.nsw.gov.au << OLE Object: Picture (Device Independent Bitmap) >>
Annexure VS-1 20
2
21
1
TRAVELLER RECORD FORM
Arrival date: Vessel name: Assessors name:
Patient details
FAMILY NAME: D.O.B.: Sex: F/M
GIVEN NAMES:
Patient/parent contact details:
Email:
Mobile:
HAS THE PERSON BEEN IN CHINA (including HK and Macau) SINCE 1 FEBRUARY Y/N
Travel details prior to joining the cruise/flight:
Date Location
Contact in Australia (if not Australian resident): Symptoms of illness:
Measured Temp: Other clinical notes (if applicable): PLAN (if applicable)
22
1
CoVID-19 Response - Screening of Cruise Ships –
1. SESLHD Cruise Ship Program to Notify All Cruise Companies of New
Requirements: Cruise Ship Program to email all cruise ship companies on 13/2/20 requesting all ships arriving into NSW ports are to: 1.1. Confirm arrangements on accepting passengers who have been in China
(including Hong Kong & Macau) or in contact with a confirmed case of CoVID-19 in the 14 days prior to embarking
1.2. Ensure they have stocks of viral swabs and transport medium 1.3. Collect a second viral swab from anyone presenting with ILI and store at 4°C 1.4. Notify the Cruise Ship Program of any ILI in passengers or crew (including
date of onset, travel history, symptoms, and result of rapid test) who have been in a country with local transmission1 or in contact with a confirmed case of CoVID-19 at least 48 hours out from port
1.5. Provide a report at least 48 hours before arrival on the number of: people who have been in contact with a confirmed case within 14
days of embarking people who have been in a country with local transmission of CoVID-
19 within 14 days of embarking people who have presented with respiratory illness or fever people who have been tested for influenza, and the number of
positive results swabs collected for CoVID-19 testing
1.6. Ensure any persons with respiratory symptoms and fever are isolated and provided with alcohol based hand gel and surgical masks to wear when disembarking
1.7. Provide a list of people meeting the criteria in 2.7 24 hours prior to arrival 1.8. Retain a list of all passengers and contact details
2. Pre-arrival Procedure
2.1. Cruise Ship Program to maintain and disseminate to relevant PHUs list of
arriving ships, including travel history and passenger numbers 2.2. Cruise Ship Program to monitor MARS reports and follow up with any ships
on ILI greater than ?% 2.3. Cruise Ship Program to forward to relevant PHU pre-arrival reports received
from ships 2.4. Should any ship’s report indicate ILI in passengers who had been in countries
with local transmission1 in 14 days before onset, Cruise Ship Program to also advise PHEOC to facilitate helicopter retrieval of specimens before arrival
2.5. Local PHU to liaise with Health Pathology to arrange pick up and transport to SaVID-SEALS or ICPMR of viral swabs collected from other passengers
2.6. Local PHU to liaise with Patient Transport to be available to transport any persons requiring CoVID-19 testing to a suitable location (RPA Clinic for Sydney ports, local ED for regional ports)
1 Currently China (including Hong Kong) and Singapore
23
2
2.7. Cruise Ship Program to ask the ship doctor to provide a list of all passengers who have:
been in a country with local transmission of CoVID-19 within 14 days of disembarking
current symptoms of fever or respiratory illness (sore throat, cough, shortness of breath, rhinorrhoea)
been diagnosed with pneumonia on the cruise 2.8. Cruise doctor to arrange for all people who meet the criteria in 2.7 to be
cohorted in a location for health screening prior to disembarkation 2.9. PHU to liaise with port biosecurity officers for arrival time and ….. 2.10. PHU to arrange for at least two officers to meet each ship – suggest an
environmental health officer and a registered nurse 2.11. PHU to confirm that any swabs from any person in 2.4 above are
negative for CoVID-19 – if results are not through, or positive, notify CHBO immediately
3. Screening Passenger and Crew on Arrival
3.1. Screening team to arrive at port per instructions from local biosecurity 3.2. Screening team to have supplies of PPE including contact and droplet
precautions, patient assessment forms, no touch thermometers, fact sheets and waste bags
3.3. Screening team to apply the patient assessment form and measure the temperature of each person in 2.7 (see detailed procedure Appendix 2)
3.4. Any person who has been in a country with local transmission in the previous 14 days who has a fever or respiratory symptoms to be transported to local clinic for testing
3.5. Any other person screened who has a fever or respiratory symptoms to be asked to self-isolate, provided with a mask, and advised to contact their GP or HealthDirect should they need medical attention
3.6. Well persons screened who have been in mainland China in the past 14 days should be advised to home quarantine until 14 days since leaving China passes, and provided a home quarantine fact sheet.
24
6/1/2020 Archive Manager
https://qam.health.nsw.gov.au/print.html#/print-single?includeIds=284626850%7C0 1/1
Updated draft procedure - cruise ship screening
Sent: February 13, 2020 2:49 PM
From: Vicky Sheppeard (South Eastern Sydney LHD)
To: Leena Gupta (Sydney LHD); David Durrheim (Hunter New England LHD); Craig Dalton (Hunter New
England LHD); Tracey Oakman; Anthony Cook (South Eastern Sydney LHD); Sven Nilsson (Sydney LHD);William Rawlinson; Jeremy MCANULTY; Christine SELVEY; Sean TOBIN; Peta Pippos (Ministry of Health);Darrin EADE;CC: MOH-PHEOPlanning; MOH-PHEOOperations; MOH-PHEOLogistics; Mark Ferson (South Eastern Sydney
LHD); Kelly-Anne Ressler (South Eastern Sydney LHD); Hanna Hildenbrand (South Eastern Sydney LHD);
5 Attachments
Cruise ship procedure v1.1.docx (44 KB); Cruise ship procedure - App A - patient assessmentform.docx (40 KB); image001.jpg (22 KB); image002.jpg (5 KB); image003.png (5 KB);
Please find a�ached – A�achment 2 s�ll in prepara�onVicky Dr Vicky SheppeardDeputy Director | South Eastern Sydney Public Health Unit
l , Locked Bag 88, Randwick NSW 2031Tel | Fax | Mob 8 | |https://www.seslhd.health.nsw.gov.au/public-health
http://internal.health.nsw.gov.au/communications/e-signatures/images/NSW-Health-South-Eastern-Sydney-LHD.jpg
Descrip�on: Descrip�on: NSW Health_Ending HIV_prevent_equa�on cid:image003.png@01D47B78.2F0D9BE0
Annexure VS-2 25
1
TRAVELLER RECORD FORM
Arrival date: Vessel name: Assessors name:
Patient details
FAMILY NAME: D.O.B.: Sex: F/M
GIVEN NAMES:
Patient/parent contact details:
Email:
Mobile:
HAS THE PERSON BEEN IN CHINA (including HK and Macau) SINCE 1 FEBRUARY Y/N
Travel details prior to joining the cruise/flight:
Date Location
Contact in Australia (if not Australian resident): Symptoms of illness:
Measured Temp: Other clinical notes (if applicable): PLAN (if applicable)
26
1
CoVID-19 Response - Screening of Cruise Ships –
1. SESLHD Cruise Ship Program to Notify All Cruise Companies of New
Requirements: Cruise Ship Program to email all cruise ship companies on 13/2/20 requesting all ships arriving into NSW ports that have visited any overseas destination are to: 1.1. Confirm arrangements on accepting passengers who have been in China
(including Hong Kong & Macau) or in contact with a confirmed case of CoVID-19 in the 14 days prior to embarking
1.2. Ensure they have stocks of viral swabs and transport medium 1.3. Collect a second viral swab from anyone presenting with ILI and store at 4°C 1.4. Notify the Cruise Ship Program of any ILI in passengers or crew (including
date of onset, travel history, symptoms, and result of rapid test) who have been in a country with local transmission1 [VS1]or in contact with a confirmed case of CoVID-19 at least 48 hours out from port
1.5. Provide a report at least 48 hours before arrival on the number of: A. people who have been in contact with a confirmed case within 14
days of embarking OR people who have been in a country with local transmission of CoVID-19 within 14 days of embarking
B. people who have presented with respiratory illness or fever, according to those in group A and not in group A
C. people who have been tested for influenza, and the number of positive results, according to those in group A and not in group A
D. swabs collected for CoVID-19 testing 1.6. Ensure any persons with respiratory symptoms and fever are isolated and
provided with alcohol based hand gel and surgical masks to wear when disembarking
1.7. Provide a list of people meeting the criteria in 2.7 24 hours prior to arrival 1.8. Retain a list of all passengers and contact details
2. Pre-arrival Procedure
2.1. Cruise Ship Program to maintain and disseminate to relevant PHUs list of
arriving ships, including travel history and passenger numbers 2.2. Cruise Ship Program to ask every ship for their ARI report and follow up with
any ships with fever or ILI greater than 1% 2.3. Cruise Ship Program to forward to relevant PHU pre-arrival reports received
from ships 2.4. Should any ships with passengers who had been in countries with local
transmission1 in 14 days before onset report cases of fever or ILI, Cruise Ship Program to also advise PHEOC to facilitate helicopter retrieval of specimens before arrival
2.5. Local PHU to liaise with Health Pathology to arrange pick up and transport to SaVID-SEALS or ICPMR of viral swabs collected from other passengers
1 Currently China (including Hong Kong and Macau) and Singapore
27
2
2.6. Local PHU to liaise with Patient Transport [VS2]to be available to transport any persons requiring CoVID-19 testing to a suitable location (RPA Clinic for Sydney ports, local ED for regional ports)
2.7. Cruise Ship Program to ask the ship doctor to provide a list of all passengers who have:
A. been in a country with local transmission1 of CoVID-19 within 14 days of disembarking
current symptoms of fever or respiratory illness (sore throat, cough, shortness of breath, rhinorrhoea) if not already reviewed by ship’s doctor
been diagnosed with pneumonia on the cruise 2.8. Cruise doctor to arrange for all people who meet the criteria in 2.7 to be
cohorted in a location for health screening prior to disembarkation; for patients with pneumonia who require hospitalisation notify the Cruise Ship Program and ensure transport is arranged to hospital advised by local PHU
2.9. PHU to liaise with port biosecurity officers for arrival time and port access arrangements
2.10. PHU to arrange for at least two officers to meet each ship – suggest an environmental health officer and a registered nurse
2.11. PHU to confirm that any swabs from any person in 2.4 above are negative for CoVID-19 – if results are not through, or positive, notify CHBO immediately
3. Screening Passenger and Crew on Arrival
3.1. Screening team to arrive at port per instructions from local biosecurity officer 3.2. Screening team to have supplies of PPE including contact and droplet
precautions, patient assessment forms, no touch thermometers, fact sheets and waste bags
3.3. Screening team to apply the patient assessment form and measure the temperature of each person in 2.7 (see detailed procedure Appendix 2)
3.4. Any person who has been in a country with local transmission1 in the previous 14 days who has a fever or respiratory symptoms to be transported to local clinic for testing
3.5. Any other person screened who has a fever or respiratory symptoms to be asked to self-isolate, provided with a mask, and advised to contact their GP or HealthDirect should they need medical attention
3.6. Well persons screened who have been in mainland China in the past 14 days should be advised to home quarantine until 14 days since leaving China passes, and provided a home quarantine fact sheet.
28
From: Jeremy McAnultySent: Thu, 13 Feb 2020 17:11:19 +1100To: MOH-PHEOPlanningSubject: FW: Updated draft procedure - cruise ship screeningAttachments: Ship Port Algorithm.docx
From: Vicky Sheppeard (South Eastern Sydney LHD) Sent: Thursday, 13 February 2020 4:24 PMTo: Craig Dalton (Hunter New England LHD) ; Leena Gupta (Sydney LHD) ; David Durrheim (Hunter New England LHD) ; Tracey Oakman ; Anthony Cook (South Eastern Sydney LHD) ; Sven Nilsson (Sydney LHD) ; William Rawlinson ; Jeremy McAnulty ; Christine Selvey ; Sean Tobin ; Peta Pippos (Ministry of Health) ; Darrin Eade Cc: MOH-PHEOPlanning ; MOH-PHEOOperations ; MOH-PHEOLogistics ; Mark Ferson (South Eastern Sydney LHD) ; Kelly-Anne Ressler (South Eastern Sydney LHD) ; Hanna Hildenbrand (South Eastern Sydney LHD) ; HNELHD-PHController Subject: RE: Updated draft procedure - cruise ship screeningThanks Craig and Zeina for comments so far.Can I check if the attached algorithm makes things a bit clearer?Vicky
From: Craig Dalton (Hunter New England LHD) Sent: Thursday, 13 February 2020 4:01 PMTo: Vicky Sheppeard (South Eastern Sydney LHD) < ; Leena Gupta (Sydney LHD) < ; David Durrheim (Hunter New England LHD)
; Tracey Oakman ; Anthony Cook (South Eastern Sydney LHD) >; Sven Nilsson (Sydney LHD) ; William Rawlinson Jeremy McAnulty ; Christine Selvey
; Sean Tobin ; Peta Pippos (Ministry of Health) ; Darrin Eade
Cc: MOH-PHEOPlanning >; MOH-PHEOOperations>; MOH-PHEOLogistics <Mark Ferson (South Eastern Sydney LHD)
Kelly-Anne Ressler (South Eastern Sydney LHD) Hanna Hildenbrand (South Eastern Sydney LHD) >; HNELHD-PHController
Subject: RE: Updated draft procedure - cruise ship screeningThanks Vicky, Very comprehensive. A few comments in the attached document. Think it could be good to capture severe resp outbreaks where multiple POC influenza tests re negative, particularly if clinical pneumonias, in the absence of travel/epi link. Regards, Craig.
From: Vicky Sheppeard (South Eastern Sydney LHD) Sent: Thursday, 13 February 2020 2:50 PMTo: Leena Gupta (Sydney LHD) David Durrheim (Hunter New England LHD) Craig Dalton (Hunter New England LHD)
Tracey Oakman Anthony Cook (South Eastern Sydney LHD) ; Sven Nilsson (Sydney LHD)
MIN.102.001.2116
Annexure VS-329
William Rawlinson ; Jeremy McAnulty ; Christine Selvey
; Sean Tobin ; Peta Pippos (Ministry of Health) ; Darrin Eade
Cc: MOH-PHEOPlanning >; MOH-PHEOOperations>; MOH-PHEOLogisticsMark Ferson (South Eastern Sydney LHD)
Kelly-Anne Ressler (South Eastern Sydney LHD) Hanna Hildenbrand (South Eastern Sydney LHD)
Subject: Updated draft procedure - cruise ship screeningPlease find attached – Attachment 2 still in preparationVickyDr Vicky SheppeardDeputy Director | South Eastern Sydney Public Health Unit
Locked Bag 88, Randwick NSW 2031Tel | Fax | Mob | https://www.seslhd.health.nsw.gov.au/public-health
MIN.102.001.2117
[MM]+[lliu]+['“«"]=(|PHealth9 9
South Eastern SydneyLocal Health DistrictNSW
HEP CEASY
30
*currently China (including Hong Kong and Macau) and Singapore
Passenger or crew with fever or respiratory symptoms
Positive exposure history within 14 days of onset:
In country with localised transmission*
Contact of a confirmed case of CoVID-19
No relevant exposure history
Ship’s doctor to:
Collect 2 swabs – perform rapid flu and store second sample
Isolate patient Notify NSW Cruise Program
immediately with full history and rapid flu results
Cruise Program to discuss with CHBO and SaVID, and if indicated:
PHEO-Logistics to arrange helicopter collection of second sample 48 hours prior to port arrival, or as soon as feasible if < 48 hours notice
CHBO to advise ship that pratique will not be granted until specimen result is clear
Ship’s doctor to:
Collect 2 swabs – perform rapid flu and store second sample
Isolate patient Include details on ARD list to
Cruise Program 48 hours prior to arrival, updated as needed
High risk:
Withdraw pratique
Swabs to be transported urgently to SaVID and passengers to stay on board pending test results.
If pratique granted:
Cruise Program to review ARD list – if features of concern (e.g. >1% ILI rate, high acuity, flu negative) discuss with CHBO.
Low risk:
Swabs to be transported from port to SaVID by Health Pathology on arrival
PHU team to review passengers with current respiratory symptoms or a positive exposure history in the past 14 days and arrange clinic/ED review per protocol
MIN.102.001.2118
31
Archive Manager
https://qam.health.nsw.gov.au/print.html#/print-single?includeIds=284894664%7C0 1/1
Feedback from Norwegian Jewel; updated cruise ship procedures
Sent: February 14, 2020 12:53 PM
From: Vicky Sheppeard (South Eastern Sydney LHD)
To: MOH-PHEOOperations; MOH-PHEOLogistics; Leena Gupta (Sydney LHD); Sven Nilsson (Sydney LHD);
Zeina Najjar (Sydney LHD); David Durrheim (Hunter New England LHD); Tony Merritt (Hunter New EnglandLHD); Anthony Cook (South Eastern Sydney LHD); Tracey Oakman;CC: Mark Ferson (South Eastern Sydney LHD); Kelly-Anne Ressler (South Eastern Sydney LHD); Reannon
Johnson (South Eastern Sydney LHD); Tracey Papa (South Eastern Sydney LHD); Toni Cains (South EasternSydney LHD); Hanna Hildenbrand (South Eastern Sydney LHD);
9 Attachments
Cruise ship procedure - Att 1 - traveller record form.docx (53 KB); Ship Port Algorithm.docx (44 KB); Cruise ship procedure v2.0.docx (44 KB); Att 2 Seaport Assessment Guide Nursing and EHO.docx (23
KB); Kit.docx (12 KB); Debrief 14022020.docx (12 KB); image001.jpg (22 KB); image002.jpg (5KB); image003.png (5 KB);
Please find our debrief from this morning’s screening and updated procedures, including suggested kit list.Opera�ons – can you please arrange a teleconference early a�ernoon for a discussion?ThanksVicky Dr Vicky SheppeardDeputy Director | South Eastern Sydney Public Health Unit
l , Locked Bag 88, Randwick NSW 2031Tel | Fax | Mob | |https://www.seslhd.health.nsw.gov.au/public-health
http://internal.health.nsw.gov.au/communications/e-signatures/images/NSW-Health-South-Eastern-Sydney-LHD.jpg
Descrip�on: Descrip�on: NSW Health_Ending HIV_prevent_equa�on cid:image003.png@01D47B78.2F0D9BE0
Annexure VS-4 32
NSW Health Screening Process for nCoV @ Sea Ports
V1.1 SES 1 1 June 2020
Use of PPE
Clinical staff to wear droplet and contact PPE (surgical mask, gloves, gown plus eye goggles
or visor); don and doff in correct sequence
EHOs to wear mask and gloves
PPE to be donned in dedicated traveler assessment zone
Remove all PPE except mask in other areas.
Responsibility of ship’s crew
Ensure all passengers/crew requiring assessment are wearing a mask
Request all people requiring assessment to complete traveler record form
Provide bilingual crew (wearing a mask) to support passengers whose language is not English
Ensure sufficient space for people waiting to be assessed, preferably sitting; need separate
assessment areas for record form, initial clinical assessment, those waiting for second temp,
and for discharge.
Supply water for passengers
Hand hygiene dispenser at entry to assessment area
Passengers needing to use the bathroom
Patients requiring to use a toilet are to be escorted by Biosecurity officer to the bathroom
and then are returned to the assessment area
Temperature and symptom review– Nurse (wearing droplet and contact PPE - surgical mask,
gloves, gown plus eye goggles or visor)
Passengers will be called to Nurse who will take temperature and review form
If temperature < 37.4 patient and no symptoms reported passenger to move onto EHO
If temperature 37.4 and above sit passenger in chair for 5 minutes. Ask passenger to remove
excess jackets
Repeat temperature at 5 minutes, if remains 37.4 and above OR if respiratory symptoms
o If history of travel to country with local transmission1 OR contact with confirmed
case of CoVID-19 in the 14 days before onset transfer to clinic/ED for assessment or
swab on ship (if mild symptoms)
o If no history of travel to country with local transmission OR contact with confirmed
case of CoVID-19 in the 14 days before onset send to EHO for discharge information
If repeat temperature <37.4 and no respiratory symptoms refer to EHO for discharge
Transfer for testing – Clinic Supervisor (wearing droplet and contact PPE (surgical mask, gloves,
gown plus eye goggles or visor)
Review symptoms and travel history with patient.
If nil concerns/doesn’t meet criteria for testing then refer to EHO for discharge
If meets testing criteria arrange swab or transfer:
o If well swab and
o Explain to patient the process; ensure sitting in a comfortable location, at least 2
meters away from others; ask ship to provide water/food as needed
o Call Ambulance Control Centre to arrange transport 8395 5029
1 Currently China (including Hong Kong and Macau) and Singapore
33
NSW Health Screening Process for nCoV @ Sea Ports
V1.1 SES 2 1 June 2020
o Fill in transfer form
o If after 10am patient likely to go to RPA – if earlier Ambulance will advise which
ED for assessment
o Call receiving ED or RPAH clinic (see list of numbers over page) to handover
patient
o Let biosecurity know who will arrange delivery of luggage. The patient has not
yet passed customs so cannot collect their luggage
o Keep patient updated if any delays
When Ambulance advise pick up time & location, request Biosecurity Officer to take patient
& any accompanying family to meet Ambulance
Contact details review and discharge– EHO
EHO to confirm local contact details and onward travel plans provided on assessment form
Provide travelers with symptoms and those who have been in China in the past 14 days with
extra masks
Advise travelers with symptoms to remain in home isolation while symptomatic, and provide
isolation factsheet
Advise travelers who have been in China in the past 14 days to stay in home quarantine until
14 days have passed, and provide home quarantine factsheet.
Provide other asymptomatic people who have not been in China with general info
sheet/letter.
Welfare check if home quarantine or isolation: ensure traveler has ability to buy food and
has accommodation i.e. advise to do online shopping. If the passenger expresses concern
that they cannot do online shopping and want to stay separate from family but have no
access to accommodation or money for hotel etc. advise them to ring 1800 020 080
Coronavirus Health Information line and they can connect them to welfare assistance)
Note: passengers who need to travel to reach home may do so, however ensure they have a
supply of masks and hand gel to use during travel
Cleaning
All zones to be wiped down with Clinell Universal wipes
Useful numbers:
Vicky
Mark
CHBO
Virology
Franz (BO)
RPA Clinic
RPA ED
POW ED
St Vincent’s ED
St George ED
SCH ED
Sydney Hospital ED
Ambulance Chief Superintendent
Ambulance Sydney Control Centre
34
TRAVELLER RECORD FORM
1
Arrival date: Vessel name: Assessors name:
FAMILY NAME: Date of birth: Sex: F/M
GIVEN NAMES:
Patient/parent contact details:
Email:
Mobile:
Contact in Australia (if not Australian resident): Phone: Address:
Travel details in the 14 days prior to joining the cruise:
Date Location
Onward travel arrangements (dates, transport, accommodation, contact details) Other accompanying travellers: Symptoms of illness (tick if present, cross if not present):
Cough Fever Runny nose Shortness of breath Other: _____________________________________________ Nil Onset of first symptom: ____/_______/______
NSW HEALTH USE ONLY:
Measured temp: First: Second (if needed): Other clinical notes (if applicable): PLAN (if applicable):
Fact sheet Handgel/masks Swab Transfer Other:
35
1
CoVID-19 Response - Screening of Cruise Ships –
1. SESLHD Cruise Ship Program to Notify All Cruise Companies of New
Requirements: Cruise Ship Program to email all cruise ship companies on 13/2/20 requesting all ships arriving into NSW ports that have visited any overseas destination are to: 1.1. Confirm arrangements on accepting passengers who have been in China
(including Hong Kong & Macau) or in contact with a confirmed case of CoVID-19 in the 14 days prior to embarking
1.2. Ensure they have stocks of viral swabs and transport medium 1.3. Collect a second viral swab from anyone presenting with ILI and store at 4°C 1.4. Notify the Cruise Ship Program of any ILI in passengers or crew (including
date of onset, travel history, symptoms, and result of rapid test) who have been in a country with local transmission1 [VS1]or in contact with a confirmed case of CoVID-19 at least 48 hours out from port
1.5. Cruise Ship Program to send email (Att 3) requiring ship to provide a report at least 48 hours before arrival on the number of:
A. people who have been in contact with a confirmed case within 14 days of embarking OR people who have been in a country with local transmission of CoVID-19 within 14 days of embarking
B. people who have presented with respiratory illness or fever, according to those in group A and not in group A
C. people who have been tested for influenza, and the number of positive results, according to those in group A and not in group A
D. swabs collected for CoVID-19 testing 1.6. Ensure any persons with respiratory symptoms and fever are isolated and
provided with alcohol based hand gel and surgical masks to wear when disembarking
1.7. Provide a list of people meeting the criteria in 2.7 24 hours prior to arrival 1.8. Retain a list of all passengers and contact details
2. Pre-arrival Procedure
2.1. Cruise Ship Program to maintain and disseminate to relevant PHUs list of
arriving ships, including travel history and passenger numbers 2.2. Cruise Ship Program to ask every ship for their ARI report and follow up with
any ships with fever or ILI greater than 1% 2.3. Cruise Ship Program to forward to relevant PHU pre-arrival reports received
from ships 2.4. Should any ships with passengers who had been in countries with local
transmission1 in 14 days before onset report cases of fever or ILI, Cruise Ship Program to also advise PHEOC to facilitate helicopter retrieval of specimens before arrival
2.5. Local PHU to liaise with Health Pathology to arrange pick up and transport to SaVID-SEALS or ICPMR of viral swabs collected from other passengers
1 Currently China (including Hong Kong and Macau) and Singapore
36
2
2.6. Local PHU to liaise with Ambulance Control to be available to transport any persons requiring CoVID-19 testing to a suitable location (RPA Clinic for Sydney ports, local ED for regional ports)
2.7. Cruise Ship Program to ask the ship doctor to provide a list of all passengers who have:
A. been in a country with local transmission1 of CoVID-19 within 14 days of disembarking
B. current symptoms of fever or respiratory illness (sore throat, cough, shortness of breath, rhinorrhoea) if not already reviewed by ship’s doctor
C. been diagnosed with pneumonia on the cruise 2.8. Cruise doctor to arrange for all people who meet the criteria in 2.7 to be
cohorted in a location for health screening prior to disembarkation; for patients with pneumonia who require hospitalisation notify the Cruise Ship Program and ensure transport is arranged to hospital advised by local PHU
2.9. Ship to provide Traveller Record Form and PHU letter to all passengers requiring screening the evening before for completion
2.10. Ship to plan adequate space for assessment – should have space to seat at least 50 passengers, and three separate assessment areas, and hand gel station on entry
2.11. PHU to liaise with port biosecurity officers for arrival time and port access arrangements
2.12. PHU to arrange for a team to meet each ship – suggest an environmental health officer, two registered nurses, one medical officer, a logistics officer and field commander
2.13. PHU to confirm that any swabs from any person in 2.4 above are negative for CoVID-19 – if results are not through, or positive, notify CHBO immediately
3. Screening Passenger and Crew on Arrival
3.1. Screening team to arrive at port per instructions from local biosecurity officer 3.2. Screening team to have supplies of PPE including contact and droplet
precautions, patient assessment forms, no touch thermometers, fact sheets and waste bags (see kit list)
3.3. Screening team to review the patient assessment form and measure the temperature of each person in 2.7 (see detailed procedure Appendix 2)
3.4. Any person who has been in a country with local transmission1 in the previous 14 days who has a fever or respiratory symptoms to be transported to local clinic for testing
3.5. Any other person screened who has a fever or respiratory symptoms to be asked to self-isolate, provided with a mask, and advised to contact their GP or HealthDirect should they need medical attention
3.6. Well persons screened who have been in mainland China in the past 14 days should be advised to home quarantine until 14 days since leaving China passes, and provided a home quarantine fact sheet.
3.7. Team leader to report back to PHUD number screened, number tested, number transferred, and any concerns; PHUD to confirm if pratique granted.
37
Debrief 14/2/20 – Norwegian Jewel
2118 pax, 1058 crew.
Ship asked to identify passengers with respiratory symptoms, pneumonia, or who had been in China
or Singapore in the previous 14 days. A number of announcements were made; passengers to be at
medical centre at 7am; crew assembled separately.
ARI log provided – only two patients.
Arrived 6am: 80 passengers waiting: 50 with no symptoms who were in Singapore from 1-4 Feb.
Passengers due for hospital transfer assessed first.
6 crew who had transited Singapore – all well.
Space too small and hot.
No symptomatic patients had risk exposure history.
Those with symptoms mostly mildly unwell; one had a high fever and a bit glazed.
Issues:
Media – reports of coronavirus on ship
Pneumonia transfer to RPA – Ambulance told RPA there was a confirmed case on board causing
great concern.
Hand gel – need small packs for symptomatic patients.
Fact sheets – not appropriate for well people with risk history; need more copies
High viz vests
Insufficient staff for number screened; need MO and logistics
Need medium and large gloves
Viral TM
Seating for waiting passengers
People with high fever – can ship do rapid flu? Or send to GP?
Review content of fact sheets
Agents need to leave time for screening for transits.
Disposable pens?
People need assistance completing form; DoB not understood.
Ran out of surgical masks (gave 4 per symptomatic person)
Needed to ask ship for water.
Need instructions for ship on requirements.
38
Kit:
Gowns – 10
Gloves – med & large – 1 box each
Masks – 200
Goggles – 4
Tympanic thermometers (4) and covers (100)
Clinell wipes – 4
Waste bags - 4
Hand gel – 6 large pump; 50 small
Box of pens
Fact sheets – symptomatic – 100
Risk exposure (not China) – 100
Risk exposure (China) - 20
Letter - 200
Traveller record form – 20
Patient transfer form 20
Laboratory request form 20
Green swabs – 1 box
6 copies of procedure.
39
*currently China (including Hong Kong and Macau) and Singapore
Passenger or crew with fever or
respiratory symptoms
Positive exposure history within 14
days of onset:
In country with localised
transmission*
Contact of a confirmed case of
CoVID-19
No relevant exposure
history
Ship’s doctor to:
Collect 2 swabs – perform rapid
flu and store second sample
Isolate patient
Notify NSW Cruise Program
immediately with full history
and rapid flu results
Cruise Program to discuss with
CHBO and SaVID, and if indicated:
PHEO-Logistics to arrange
helicopter collection of second
sample 48 hours prior to port
arrival, or as soon as feasible if <
48 hours notice
CHBO to advise ship that
pratique will not be granted
until specimen result is clear
If negative:
Ship’s doctor to:
Collect 2 swabs – perform rapid
flu and store second sample
Isolate patient
Include details on ARD list to
Cruise Program 48 hours prior
to arrival, updated as needed
Assessed as high risk:
Swabs to be transported
urgently to SaVID and
passengers to stay on board
pending test results.
If negative:
Cruise Program to review ARD list –
if features of concern (e.g. >1% ILI
rate, high acuity, flu negative)
discuss with CHBO.
Assessed as low risk:
Swabs to be transported
from port to SaVID by
Health Pathology on
arrival
PHU team to review passengers
with current respiratory symptoms
or a positive exposure history in the
past 14 days and arrange clinic/ED
review per protocol
40
From: Jeremy McAnultySent: Sat, 15 Feb 2020 08:15:51 +1100To: Vicky Sheppeard (South Eastern Sydney LHD);Mark Ferson (South Eastern Sydney LHD);Christine Selvey;MOH-PHEOPlanningSubject: Cruise ship protocolAttachments: Cruise Ship Screening Policy 15022020.docx, ATT00001.htm, image001.jpg, ATT00002.htm
Thanks Vicky and MarkI think its getting there …. I have a couple of comments in yellow - see what you think.
BTW, Kerry is happy to use the Cruise vessel program uniforms rather than Hi-Viz gear.
Jeremy
MIN.102.001.2019
Annexure VS-541
DRAFT CRUISE SHIP SCREENING PROCEDURE FOR PORTS OF FIRST ENTRY INTO AUSTRALIA
Public Health Team health team mmeets all cruise ships that have arrived from international waters at first port of arrival.
Pre-arrival requirements 48 hours before arrival The Public Health Team will ask the cruise ship is required tto provide a report to the PHU with:
o Copy of full ARD log (including details of patients presenting with fever or ARI, and results of rapid influenza testing)
o List of passengers and crew on the vessel who have been in contact with a confirmed case of novel coronavirus infection within 14 days of embarking
o List of passengers and crew who have been in country with possible local transmission (currently mainland ChinaChina, including Hong Kong and Macau) and Singapore ofmainland China1 [will need to make it visited a country included in Australian CoVID-19 testing criteria to match the process below] COVID-19 within 14 days of embarking
o Number of swabs collected for COVID-19 testing. The ship is required to obtain accurate passenger contact information (mobile phone and email
addresses) for all passengers to enable rapid communication if needed following disembarkation.
The ship must ensure all passengers with respiratory symptoms and fever are isolated while on board and provide them with hand rub and masks for onward travel.
The ship must provide any updates of the ARD loglist to the Public Health Team PHU of passengers or crew meeting the following criteria:been in a country with local transmission of COVID-19 within 14 days of embarking ANDEITHER current symptoms of fever or respiratory illness (sore throat, cough, shortness of breath, rhinorrhoea) ORbeen diagnosed with pneumonia on the cruise.For passengers who present to the ship’s doctor with respiratory illness For these people, Tthe ship’s doctor must:
o collect 2 swabs – perform rapid influenza test and store second sampleo isolate patiento update details on Acute Respiratory Disease logist and email to the Public Health Team
<who>o
Where a respiratory outbreak is reported on board a cruise ship and passengers or crew, regardless of symptoms, have either:
o visited a country with local transmissionincluded in Australian CoVID-19 testing criteria2 in the 14 days before embarkation OR
o had contact with a confirmed case in the 14 days before embarkation, OR
o other features of concern (>1% of passengers affected, or more than one patientspassenger who has severe illness, or majority of ARI cases have tested negative for influenza)
The ship will not be allowed to disembark passengers or crew until given clearance by the Human Biosecurity Officer
1 May be expanded if suspect case definition changes2 As of February 14 2020 includes China (including Hong Kong), Thailand, Japan, Indonesia, Singapore
Commented [VS1]: If this definition was applied to the Yokahama vessel then the index case would have been missed.
Commented [MF2]: Is this what we mean?
Commented [MF3]: ditto
Commented [VS4]: I’m not sure we need this anymore. The ARD log identifies pneumonia cases; the ship won't know about current URTI unless they have presented, and they don't have good information on where passengers have been.
Commented [VS5]: This doesn’t fit well here – this is an ongoing activity, not just 24 hours before arrival
MIN.102.001.2020
42
DRAFT CRUISE SHIP SCREENING PROCEDURE FOR PORTS OF FIRST ENTRY INTO AUSTRALIA
The ship must urgently provide swabs from any person suspected with fever or respiratory infection for testing prior to disembarkation. Public Health Emergency Operations Centre will facilitate urgently retrieval of specimens for urgent testing.
If the swabs test positive then:o All passengers and crew must be assessed for respiratory symptoms or fever (>=37.48
degs) by the Public Health Public Health Team team (with additional support)an emergency medical team before disembarkation
o Passengers and crew who are well must be placed in home quarantine for 14 days and be medically assessed if fever or respiratory symptoms develop
o Passengers and crew who have fever or respiratory symptoms must be assessed for CoVID-19 ; if infection excluded they move to home quarantine for 14 days and placed in isolation for 14 days
If the swabs test negative then the Public Health Team to assess passengers and crew as outlined below.:
o All passengers who have been in country with local transmission in the previous 14 days OR who have current symptoms or fever of respiratory illness must be assessed for respiratory symptoms or fever (>=37.8 degs) by the Public Health team before disembarkation
o Passengers and crew who have fever or respiratory symptoms AND who have been in country with local transmission in the previous 14 days must be assessed and tested for CoVID-19 and may disembark if appropriate, but must place themselves in self- isolation until contacted with the results
o Passengers and crew who are well may disembark. Should the results of any patients who are tested for CoVID-19 be positive, they will be contacted and instructed to go into self-isolation.
Where there is :is no respiratory outbreak or a mild respiratory outbreak that is explained by positive influenza test results
OR are passengers on board who visited a country with local transmission in the 14 days before embarkation who were in contact with a confirmed case in the 14 days
and o No passengers who have been in a country with local transmission in the 14 days
before embarkation or contact with a confirmed case in the last 14 days
Any samples taken on board for flu testing must be forwarded to the lab for coronavirus testing at disembarkationon arrival into the port.
Prior to the ship disembarking, Ppassengers and crew who have had fever or respiratory symptoms on the voyage must be instructed to present to the Public Health team Team for assessment if they have had fever and respiratory symptoms on the voyage and:
Be assessed for respiratory symptoms or fever (>=37.8 degs) by the Public Health team before disembarkationThe Public Health Team will measure temperature, review symptoms and exposure history. Passengers meeting the suspect case definitionAustralian testing criteria3 should be swabbed for CoVID-19 and discharged embarked to isolation.
3 As of February 14 2020 is a person with fever or respiratory symptoms who in the 14 days before onset has been in China (including Hong Kong), Thailand, Singapore, Japan or Indonesia, or in contact with a confirmed case of CoVID-19
Commented [MF6]: I have added the word RESPIRATORY before symptoms everywhere
Commented [VS7]: What if there is no respiratory outbreak but some passengers have been in a country with local transmission in the past 14 days?
MIN.102.001.2021
43
DRAFT CRUISE SHIP SCREENING PROCEDURE FOR PORTS OF FIRST ENTRY INTO AUSTRALIA
Passengers and crew who have fever or symptoms must be assessed for CoVID-19, and may disembark if appropriate, but must place themselves in self- isolation until contacted with the results
Following the Public Health Team assessment, Ppassengers and crew who are well may disembark. Should the results of any patients who are tested for CoVID-19 be positive, they will be contacted and instructed to go into self-isolation.
Should any sample test positive for novel coronavirus, a specific response will be mounted to manage the potential outbreak, including rapidly contacting all passengers to ensure that they self-isolate and to be tested and managed if symptomatic.
MIN.102.001.2022
44
DRAFT CRUISE SHIP SCREENING PROCEDURE FOR PORTS OF FIRST ENTRY INTO AUSTRALIA
Appendix 1:
*currently China (including Hong Kong and Macau) and Singapore
Passenger or crew with fever or respiratory symptoms
Positive exposure history within 14 days of onset: In country with localised
transmission* Contact of a confirmed case of
CoVID-19
No relevant exposure history
Ship’s doctor to: Collect 2 swabs –
perform rapid flu and store second sample
Isolate patient Notify NSW Cruise
Program immediately with full history and rapid flu results
Cruise Program to discuss with CHBO and SaVID, and if indicated: PHEO-Logistics to arrange
urgent collection of second sample 48 hours prior to port arrival, or as soon as feasible if < 48 hours notice
CHBO to advise ship that pratique will not be granted until specimen result is clear
Ship’s doctor to: Collect 2 swabs – perform
rapid flu and store second sample
Isolate patient Include details on ARD list
to Cruise Program 48 hours prior to arrival, updated as needed
High risk:Withdraw pratiqueSwabs to be transported urgently to SaVID and passengers to stay on board pending test results.If pratique granted:
Cruise Program to review ARD list – if features of concern (e.g. >1% ILI rate, high acuity, flu negative) discuss with CHBO.
Low risk:Swabs to be transported from port to SaVID by Health Pathology on arrival
Public Health Team PHU team to review passengers with current respiratory symptoms or a positive exposure history in the past 14 days and arrange clinic/ED review per protocol
MIN.102.001.2023
45
DRAFT CRUISE SHIP SCREENING PROCEDURE FOR PORTS OF FIRST ENTRY INTO AUSTRALIA
Appendix 2:TRAVELLER RECORD FORM
Arrival date:
Vessel name:
Assessors name:
Patient details
FAMILY NAME: D.O.B.: Sex: F/M
GIVEN NAMES:
Patient/parent contact details:Email:Mobile:
HAS THE PERSON BEEN IN CHINA (including HK and Macau) SINCE 1 FEBRUARY Y/N
Travel details prior to joining the cruise/flight:
Date Location
Contact in Australia (if not Australian resident):
Symptoms of illness:
Measured Temp:
Other clinical notes (if applicable):
PLAN (if applicable)
Notes:
MIN.102.001.2024
46
From: Jeremy McAnultySent: Sat, 15 Feb 2020 11:47:36 +1100To: Kerry Chant (Ministry of Health)Subject: Fwd: Cruise ship protocolAttachments: image001.jpg, ATT00001.htm, Cruise Screening Policy 15022020 v2.docx, ATT00002.htm
Hi KerryHere is the latest. At this point it will likely work in the short term if we stick with China. I suspect that will be ok for the next couple of days. Then we could revisit early next week. What do you think? Jeremy
Sent from my iPhone
Begin forwarded message:
From: "Vicky Sheppeard (South Eastern Sydney LHD)" Date: 15 February 2020 at 9:47:14 am AEDTTo: "Mark Ferson (South Eastern Sydney LHD)" , Jeremy McAnulty Cc: Christine Selvey , MOH-PHEOPlanning Subject: Re: Cruise ship protocol
Here is my suggestion for the document - I have omitted the algorithm as it needs updating.
Vicky
From: Mark Ferson (South Eastern Sydney LHD)Sent: Saturday, 15 February 2020 09:23To: Jeremy McAnulty; Vicky Sheppeard (South Eastern Sydney LHD)Cc: Christine Selvey; MOH-PHEOPlanningSubject: Re: Cruise ship protocol
Our experience indicates that they currently do not collect this information routinely.
As cruise ships are variably undertaking some sort of pre-boarding screening, then collecting recent travel histories when passengers are boarding could work if its made a mandatory industry-wide requirement by the appropriate Australian Government Department.
Mark
MIN.102.001.2139
Annexure VS-647
From: Jeremy McAnultySent: Saturday, 15 February 2020 08:51To: Vicky Sheppeard (South Eastern Sydney LHD)Cc: Mark Ferson (South Eastern Sydney LHD); Christine Selvey; MOH-PHEOPlanningSubject: Re: Cruise ship protocol Hi Vicky
Its just that the way it reads now is that :
Where a respiratory outbreak is reported on board a cruise ship and passengers or crew, regardless of symptoms, have either:
o visited a country included in Australian CoVID-19 testing criteria[1]1 in the 14 days before embarkation
They have to the the samples of early and test them before disembarkation. So I don’t think that will be possible to know if the information isn’t provided. So we’ll need to amend the protocol to account for that - can you try and adjust the words so it can work?
Thx J
[1] As of February 14 2020 includes China (including Hong Kong), Thailand, Japan, Indonesia, Singapore
Dr Jeremy McAnulty
Executive Director | Health Protection NSW
Tel | Mob | www.health.nsw.gov.au
MIN.102.001.2140
48
DRAFT CRUISE SHIP SCREENING PROCEDURE FOR PORTS OF FIRST ENTRY INTO AUSTRALIA
Public Health Team health team mmeets all cruise ships that have arrived from international waters at first port of arrival.
Pre-arrival requirements The ship is required to obtain accurate contact information (mobile phone and email addresses)
for all passengers to enable rapid communication if needed following disembarkation. The ship must ensure all passengers with respiratory symptoms and fever are isolated while on
board and provide them with hand rub and masks for onward travel.
For passengers who present to the ship’s doctor with respiratory illness The ship’s doctor must:
o collect 2 swabs – perform rapid influenza test and store second sample for CoVID-19 testing
o record a history of all countries visited in the 14 days prior to embarkationo isolate patiento update details on Acute Respiratory Disease log
48 hours before arrival The Public Health Team will ask the cruise ship is required tto provide a report to the PHU with:
o Copy of full ARD log (including details of patients presenting with fever or ARI, countries they have visited in the 14 days prior to embarkation, and results of rapid influenza testing)
o List of passengers and crew on the vessel who have been in contact with a confirmed case of novel coronavirus infection within 14 days of embarking
o List of passengers and crew who have been in country with possible local transmission (currently mainland ChinaChina, including Hong Kong and Macau) and Singapore ofmainland China1 [ COVID-19 within 14 days of embarking
o Number of swabs collected for COVID-19 testing. The ship is required to obtain accurate passenger contact information (mobile phone and email
addresses) to enable rapid communication if needed following disembarkation. The ship must ensure all passengers with respiratory symptoms and fever are isolated while on
board and provide them with hand rub and masks for onward travel.
The ship must provide any updates of the ARD loglist to the Public Health Team PHU of passengers or crew meeting the following criteria:been in a country with local transmission of COVID-19 within 14 days of embarking ANDEITHER current symptoms of fever or respiratory illness (sore throat, cough, shortness of breath, rhinorrhoea) ORbeen diagnosed with pneumonia on the cruise.For these people, Tthe ship’s doctor must:collect 2 swabs – perform rapid influenza test and store second sampleisolate patientupdate details on Acute Respiratory Disease list and email to the Public Health Team <who>
Where a respiratory outbreak is reported on board a cruise ship and affected passengers or crew, , have either:
o visited a country with local transmissionincluded in Australian CoVID-19 testing criteria2 in the 14 days before embarkation OR
1 May be expanded if suspect case definition changes2 As of February 14 2020 includes China (including Hong Kong), Thailand, Japan, Indonesia, Singapore
Commented [VS1]: If this definition was applied to the Yokahama vessel then the index case would have been missed.
Commented [MF2]: Is this what we mean?
Commented [MF3]: ditto
Commented [VS4]: I’m not sure we need this anymore. The ARD log identifies pneumonia cases; the ship won't know about current URTI unless they have presented, and they don't have good information on where passengers have been.
Commented [VS5]: This doesn’t fit well here – this is an ongoing activity, not just 24 hours before arrival
MIN.102.001.2143
49
DRAFT CRUISE SHIP SCREENING PROCEDURE FOR PORTS OF FIRST ENTRY INTO AUSTRALIA
o had contact with a confirmed case in the 14 days before embarkation, OR
o other features of concern (>1% of passengers affected, or more than one patientspassenger who has severe illness, or majority of ARI cases have tested negative for influenza)
The ship will not be allowed to disembark passengers or crew until given clearance by the Human Biosecurity Officer
The ship must urgently provide swabs from any person suspected with fever or respiratory infection for testing prior to disembarkation. Public Health Emergency Operations Centre will facilitate urgently retrieval of specimens for urgent testing.
If the swabs test positive then:o All passengers and crew must be assessed for respiratory symptoms or fever (≥>=37.4°8
degs) by the Public Health Public Health Team team (with additional support)an emergency medical team before disembarkation
o Passengers and crew who are well must be placed in home quarantine for 14 days and be medically assessed if fever or respiratory symptoms develop
o Passengers and crew who have fever or respiratory symptoms must be assessed for CoVID-19 ; if infection excluded they move to home quarantine for 14 days and placed in isolation for 14 days
If the swabs test negative then the Public Health Team to assess passengers and crew as outlined below.:
o All passengers who have been in country with local transmission in the previous 14 days OR who have current symptoms or fever of respiratory illness must be assessed for respiratory symptoms or fever (>=37.8 degs) by the Public Health team before disembarkation
o Passengers and crew who have fever or respiratory symptoms AND who have been in country with local transmission in the previous 14 days must be assessed and tested for CoVID-19 and may disembark if appropriate, but must place themselves in self- isolation until contacted with the results
o Passengers and crew who are well may disembark. Should the results of any patients who are tested for CoVID-19 be positive, they will be contacted and instructed to go into self-isolation.
Where there is :is no respiratory outbreak or a mild respiratory outbreak that is explained by positive influenza test results
OR are passengers on board who visited a country with local transmission in the 14 days before embarkation who were in contact with a confirmed case in the 14 days
and o No passengers who have been in a country with local transmission in the 14 days
before embarkation or contact with a confirmed case in the last 14 days
Any samples taken on board for flu testing must be forwarded to the lab for coronavirus testing at disembarkationon arrival into the port.
Prior to the ship disembarking, Ppassengers and crew who have had fever or respiratory symptoms on the voyage must be instructed to present to the Public Health team Team for assessment if they have had fever and respiratory symptoms on the voyage and:
Be assessed for respiratory symptoms or fever (>=37.8 degs) by the Public Health team before disembarkationThe Public Health Team will measure temperature, review symptoms and
Commented [MF6]: I have added the word RESPIRATORY before symptoms everywhere
Commented [VS7]: What if there is no respiratory outbreak but some passengers have been in a country with local transmission in the past 14 days?
MIN.102.001.2144
50
DRAFT CRUISE SHIP SCREENING PROCEDURE FOR PORTS OF FIRST ENTRY INTO AUSTRALIA
exposure history. Passengers or crew meeting the suspect case definitionAustralian testing criteria3 should be swabbed for CoVID-19 and discharged embarked to isolation.
Passengers and crew who have fever or symptoms must be assessed for CoVID-19, and may disembark if appropriate, but must place themselves in self- isolation until contacted with the results
Following the Public Health Team assessment, Ppassengers and crew who are well may disembark. Should the results of any patients who are tested for CoVID-19 be positive, they will be contacted and instructed to go into self-isolation.
Should any sample test positive for novel coronavirus, a specific response will be mounted to manage the potential outbreak, including rapidly contacting all passengers to ensure that they self-isolate and to be tested and managed if symptomatic.
3 As of February 14 2020 is a person with fever or respiratory symptoms who in the 14 days before onset has been in China (including Hong Kong), Thailand, Singapore, Japan or Indonesia, or in contact with a confirmed case of CoVID-19
MIN.102.001.2145
51
DRAFT CRUISE SHIP SCREENING PROCEDURE FOR PORTS OF FIRST ENTRY INTO AUSTRALIA
Appendix 1: Traveller Record Form Arrival date:
Vessel name:
Assessors name:
FAMILY NAME: Date of birth: Sex: F/M
GIVEN NAMES:
Patient/parent contact details:Email:Mobile:
Contact in Australia (if not Australian resident):Phone: Address:
Travel details in the 14 days prior to joining the cruise:
Date Location
Onward travel arrangements (dates, transport, accommodation, contact details)
Other accompanying travellers:
Symptoms of illness (tick if present):
Cough Fever Runny nose Shortness of breath
Other: _____________________________________________ Nil
Onset of first symptom: ____/_______/______
NSW HEALTH USE ONLY:
Measured temp: First: Second (if needed):
Other clinical notes (if applicable):
PLAN (if applicable):
Passenger or crew with fever or respiratory symptoms
Notes:
MIN.102.001.2146
52
DRAFT CRUISE SHIP SCREENING PROCEDURE FOR PORTS OF FIRST ENTRY INTO AUSTRALIA
Fact sheet
Hand gel/masks
SwabTransfer
Other:
*currently China (including Hong Kong and Macau) and Singapore
Positive exposure history within 14 days of onset: In country with localised
transmission* Contact of a confirmed case of
CoVID-19
No relevant exposure historyShip’s doctor to:
Collect 2 swabs – perform rapid flu and store second sample
Isolate patient Notify NSW Cruise
Program immediately with full history and rapid flu results
Cruise Program to discuss with CHBO and SaVID, and if indicated: PHEO-Logistics to arrange
urgent collection of second sample 48 hours prior to port arrival, or as soon as feasible if < 48 hours notice
CHBO to advise ship that pratique will not be granted until specimen result is clear
Ship’s doctor to: Collect 2 swabs – perform
rapid flu and store second sample
Isolate patient Include details on ARD list
to Cruise Program 48 hours prior to arrival, updated as needed
High risk:Withdraw pratiqueSwabs to be transported urgently to SaVID and passengers to stay on board pending test results.If pratique granted:
Cruise Program to review ARD list – if features of concern (e.g. >1% ILI rate, high acuity, flu negative) discuss with CHBO.
Low risk:Swabs to be transported from port to SaVID by Health Pathology on arrival
Public Health Team PHU team to review passengers with current respiratory symptoms or a positive exposure history in the past 14 days and arrange clinic/ED review per protocol
MIN.102.001.2147
53
DRAFT CRUISE SHIP SCREENING PROCEDURE FOR PORTS OF FIRST ENTRY INTO AUSTRALIA
Appendix 2:TRAVELLER RECORD FORMArrival date:
Vessel name:
Assessors name:Patient detailsFAMILY NAME: D.O.B.: Sex: F/MGIVEN NAMES:Patient/parent contact details:Email:Mobile:HAS THE PERSON BEEN IN CHINA (including HK and Macau) SINCE 1 FEBRUARY Y/NTravel details prior to joining the cruise/flight:Contact in Australia (if not Australian resident):
Symptoms of illness:Measured Temp:
Other clinical notes (if applicable):
PLAN (if applicable)
MIN.102.001.2148
54
SES.101.001.0875
Ruby Senior DoctorSat, 7 Mar 2020 14:29:46 +1100SESLHD-PublicHealthUnit-
From:Sent:To:CruiseShipSurv;Valerie.Burrows ;sydney.portagent
Ruby Doctor;Ruby Administration Officer;Ruby Crew Manager;RubyCc:Captain;Ruby Hotel General Manager (RU)Subject:March
RE: Ruby Princess COVID-19 health assessment Sydney arrival Sunday 8
Good afternoon Vicky
Both guests were reviewed this morning.BROWN ROBERT
• This guest with an URIT presented 5/7 after symptom onset; reports to never have been febrile;no fever recorded with either visits with us;mild cough reported; examens generally well
CHARLES PAUL
• This guest with URTI presented 2/7 after symptoms onset, denies fever/ malaise; states to befeeling well; known MS and post-traumatic splenectomy;mild cough reported and examensgenerally well (bi-basal atelectasis due to being wheelchair-bound)
Both remain in isolation, and if required we would go ahead and do viral swabs on them. Pleaseadvise how collection would happen.Please also be advised we have limited swabs available onboard (6), and would greatly appreciatesome more - is there anywhere we can procure some?
Warm Regards
Use
Dr Use von UJatzdorf
Senior PhysicianM/V Ruby PrincessOffice: | Pager:
RUBYPRINCESS
The information contained in this email and any attachment may he confidential and/or legally privileged and has been sentfor the sole use of the intended recipient. If you are not an intended recipient, you are not authorized to review, use, discloseor copy any of its contents. If you have received this email in error please reply to the sender and destroy all copies of themessage.
Annexure VS-7
55
SES.101.001.0876
From: Vicky Sheppeard (South Eastern Sydney LHD) [mailto: ]On Behalf Of SESLHD-PublicHealthUnit-CruiseShipSurvSent: Saturday,March 07, 2020 2:44 PMTo: Ruby Senior Doctor < ; Valerie.Burrowssydney.portagentCc: Ruby Doctor Ruby Administration Officer
Ruby Crew Manager ; RubyCaptain ; Ruby Hotel General Manager (RU)
Subject: Re: Ruby Princess COVID-19 health assessment Sydney arrival Sunday 8 MarchImportance: High
Dear Use and Ruby Princess colleagues
thank you for this information.
The NSW Health expert panel has had an initial review of the information you have providedand there is concern about your two UK passengers who spent several days in Singaporeand developed cough +/- runny nose during the voyage. We note they are flu swab negativeand remain in isolation.
As a priority can you please:- advise us of their current clinical status - current symptoms, temperature?- either retain or re-collect and retain a nose and throat swab from each of those passengersPlease ensure they remain in isolation.
Could you please also obtain and retain any swabs from other passengers and crew whomay present between now and tomorrow morning with ARI or ILL
Once we receive the update on those two passengers and the availability of swabs we willconsult with our panel and advise you of procedures for tomorrow.
kind regardsVicky
Dr Vicky Sheppeard
Deputy Director | Public Health UnitLocked Mail Bag 88 Randwick NSW 2031Tel | Fax | Mob
From: Ruby Senior Doctor < >Sent: 07 March 2020 08:09To: SESLHD-PublicHealthUnit-CruiseShipSurv; Valerie.Burrowssydnev.portagent
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Cc: Ruby Doctor; Ruby Administration Officer; Ruby Crew Manager; Ruby Captain; Ruby HotelGeneral Manager (RU)Subject: RE: Ruby Princess COVID-19 health assessment Sydney arrival Sunday 8 March
Good morning All
As we have several different people working on the same response, I will start adding commentsfrom the medical side.
By lunchtime yesterday, we had a total of 30 individuals on our log. Following the announcementyou requested (made approximately 17:00 time), we consulted/ spoke with a further number ofguests who had symptoms, pushing the total number of ARI on our books to 170.
Please see attached responses:
1. The full ARD log, including travel history in the 14 days before onset, whether a rapid flu test wascollected and the result, and current condition for all passengers and crew assessed Please seeattached document, both sheets
2. A list of passengers and crew who have been in mainland China, or in contact with a confirmedcase of COVID-19, in the 14 days prior to embarkation Admin Officer to provide data
3. A list of passengers and crew who were in Thailand, Indonesia,Hong Kong,Singapore,SouthKorea, Iran, Japan, Italy and Cambodia in the 14 days prior to embarkation (excluding those who onlytransited through these countries i.e. less than 8 hours). Please confirm if any of these people haverespiratory symptoms. Admin Officer to provide data4. A list of any planned medical disembarkations None at this time, and none due to respiratoryillness for the duration of this cruise
5. A list of any deaths during the cruise None
6. The ship's itinerary in the past 14 days and a future itinerary for the next 14 days Admin Officerto provide data
7. Please advise if your medical centre is charging a fee for respiratory consultations. No
Warm Regards
Use
Dr llse von U/atzdorf
Senior PhysicianM/V Ruby PrincessOffice: | Pager:
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RUBYPRINCESS’
The information contained in this email and any attachment may he confidential and/or legally privileged and has been sentfor the sole use of the intended recipient. If you are not an intended recipient, you are not authorized to review, use, discloseor copy any of its contents. If you have received this email in error please reply to the sender and destroy all copies of themessage.
From: SESLHD-PublicHealthUnit-CruiseShipSurv [mailto: -
1Sent: Friday, March 06, 2020 12:58 PMTo: Ruby Senior Doctor < >; Valerie.Burrowssvdney.portaRent Ruby Captain < >Cc: Ruby Doctor < >; Ruby Administration Officer< >; Ruby Crew Manager < >Subject: RE: Ruby Princess COVID-19 health assessment Sydney arrival Sunday 8 March
Dear Dr Watzdorf and Captain Pomata
As you know, NSW Health has instituted a protocol for the novel coronavirus screening of allcruise ships arriving in NSW ports.
As a first step we require your assistance to undertake a risk assessment on the RubyPrincess which will be arriving in Sydney on the morning of 8 March 2020.
Please provide the following information by 9am Saturday 7 March:
1. The full ARD log, including travel history in the 14 days before onset, whether a rapid flutest was collected and the result, and current condition for all passengers and crew assessed
2. A list of passengers and crew who have been in mainland China, or in contact with aconfirmed case of COVID-19, in the 14 days prior to embarkation
3. A list of passengers and crew who were in Thailand, Indonesia, Hong Kong, Singapore,South Korea, Iran, Japan, Italy and Cambodia in the 14 days prior to embarkation(excluding those who only transited through these countries i.e. less than 8 hours). Pleaseconfirm if any of these people have respiratory symptoms.
4. A list of any planned medical disembarkations
5. A list of any deaths during the cruise
6. The ship’s itinerary in the past 14 days and a future itinerary for the next 14 days
7. Please advise if your medical centre is charging a fee for respiratory consultations.
Once we have reviewed this information we will advise if an on board public healthassessment is required.
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In the interim, you should make an announcement to your passengers and crew that anyonewith respiratory symptoms or fever should present to your medical centre for assessment.Please collect respiratory swabs, hold at fridge temperature and we will arrange for CoVID-19 testing in a NSW Health Pathology reference laboratory if appropriate. If you havecollected respiratory swabs throughout this cruise (e.g. for rapid flu testing), we are also ableto test these if not discarded.
Please ensure any passengers or crew with current respiratory symptoms are appropriatelyisolated and provide them with masks and alcohol hand rub for onward travel.
SHOULD AN ON BOARD PASSENGER/CREW ASSESSMENT BY THE NSW PUBLICHEALTH TEAM BE REQUIRED YOU WILL NEED TO DO THE FOLLOWING:
• Make a series of announcements to all passengers that anyone with current respiratorysymptoms and those who were in Thailand, Indonesia, China (including Hong Kong),Singapore, South Korea, Iran, Japan, Italy or Cambodia in the 14 days beforeembarkation (excluding brief transits) will need to be assessed prior to the ship beginningdisembarkation;o Provide a Letter and Traveller Record Form (will be emailed to you if required) to all
passengers and crew asking those who need assessment by the Public Health Team tocomplete as much of the form as they can beforehand and to bring it with them,
o Medical clinic to ensure that patients seen at the clinic with fever and/or ARI are alsorequested to attend for assessment,
o Ensure all passengers and crew with respiratory symptoms/relevant travel history areadvised to be at the designated location (see below) during the period advised by thepublic health team
• Arrange a suitable large, open space (e.g. ballroom, large gym) on the ship for theassessment area capable of holding at least 60 people, set up with 4 stations consisting of adesk and 3 chairs; provide seating and bottled water for those waiting for assessment; handrub dispensers at entry and exit monitored by crew
• Have medical and other staff available to facilitate assessment process, including bilingualstaff if relevant (wearing surgical masks)
• Ensure all passengers/crew requiring assessment are wearing a surgical mask
• Assign sufficient crew to request all people requiring assessment to complete travelerrecord form, for crowd control and to manage flow
PLEASE SHARE THIS REQUEST WITH RELEVANT CREW MEMBERS ANDPROVIDE A COLLATED RESPONSE TO ITEMS 1-7 BY 9am Saturday 7 March.
Also please confirm you have made announcements requesting people with respiratorysymptoms come to your medical centre for assessment.
Kind regardsKelly
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Kelly-Anne Ressler
Epidemiologist | Public Health UnitLocked Mail Bag 88 Randwick NSW 2031Tel | Fax | Mob |Website | Facebook | TwitterIn office Monday Tuesday Thursday Friday
HealthKICW South Eastern Sydney
Local Health DistrictGOVERNMENT
On behalf of
Professor Mark Ferson MBBS MPH MD FRACP FAFPHM FRSPHDirector and Public Health OfficerPublic Health UnitSouth Eastern Sydney Local Health District
This message is intended for the addressee named and may contain confidentialinformation. If you are not the intended recipient, please delete it and notify the sender.Views expressed in this message are those of the individual sender, and are not necessarilythe views of NSW Health or any of its entities.The information contained in this email and any attachment may be confidential and/orlegally privileged and has been sent for the sole use of the intended recipient. If you are notan intended recipient, you are not authorized to review, use, disclose or copy any of itscontents. If you have received this email in error please reply to the sender and destroy allcopies of the message. Thank you.
To the extent that the matters contained in this email relate to services being provided byPrincess Cruises and/or Holland America Line (together "HA Group") to CarnivalAustralia/P&O Cruises Australia, HA Group is providing these services under the terms of aServices Agreement between HA Group and Carnival Australia.
This message is intended for the addressee named and may contain confidentialinformation. If you are not the intended recipient, please delete it and notify the sender.Views expressed in this message are those of the individual sender, and are not necessarilythe views of NSW Health or any of its entities.
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