09.04.2021
COVID-19. GVA Review and Maritime Recommendations

Coronavirus COVID-19 GVA maritime recommendations
The whole world is suffering from COVID19 – coronavirus that was completely unknown till December 2019.

18 months passed after the first case in Wuhan, the capital of Hubei Province in China, and the total number of confirmed cases as of April 09, 2021 exceeded 130,000,000, affecting all continents and countries.

With so much information circulating around, we believe that the crews of the vessels more than ever need guidance by medical professionals based on what the world’s medical community gained about COVID19 over the last year. It is particularly important to be aware of key practices for safety and protection of crew as well as the guidelines for the crew officers when facing a suspected case on board or onshore.

Geography of COVID-19

The best known resource for the geographical overview for the confirmed cases worldwide is the John Hopkins University Center for Systems Science and Engineering (CSSE) COVID-19 Interactive Map:

John Hopkins CSSE COVID-19 Interactive Map

The more detailed information on the geography of the virus is available at the World Health Organization in its daily COVID-2019 Situation Reports:

WHO COVID-2019 Situation Reports

With the rapidly changing situations at the regional level, for the deeper overview of the cases certain countries, visiting the national healthcare authorities COVID-19 informational resources is the best way to receive the updated information on the epidemic geography at the country level. As an example, here is the dedicated page by the Ministry of Health of Italy: COVID-19 Ministry of Health of Italy.

So what is the coronavirus (COVID-19)?

Coronavirus is not something new to healthcare professionals. It is one of the numerous groups of viruses causing respiratory problems in humans.

COVID-19 is just a new strain of coronavirus that has not previously been detected in human population. It is closely related to SARS - Severe Acute Respiratory Syndrome identified in 2013.

What are the symptoms of COVID-19?

From what healthcare professionals currently know now about COVID-19, the symptoms can occur between 2 and 14 days from exposure to the virus. Some medical sources state up to 21 days of incubation period. The symptoms range from more minor ailments like fever, sore throat, fatigue, dry cough and running nose to more serious symptoms like difficulty in breathing, high fever, painful coughing, loss of smell and taste. Many people with the virus look and feel like having a common flu.

The proven fact is that elderly people (from 60 years old), or those with pre-existing health conditions like chronic pulmonary problems, diabetes, oncological or severe autoimmune diseases are more likely to experience severe symptoms that may finally lead to fatal outcomes.

Can COVID-19 be transmitted from person to person?

Yes. Coronavirus is spread most often by what are known as "respiratory droplets" from an infected person — the little secretions we generate when we sneeze or cough. That is why the spread of the virus between people generally occurs through close contact. Close contacts are those people who have been face to face with a person infected with the virus for at least 15 minutes, or were in the same closed space with an infected person for at least 2 hours at the distance less than 1 meter.

How is COVID-19 diagnosed?

The current testing available for COVID-19 includes obtaining nose and throat swabs and sending them for laboratory testing. Testing can be done by real-time polymerase chain reaction (RT-PCR) – the research method being the standard for infectious diseases diagnostic. This method allows to determine the presence of the pathogen, even if its amount in the sample is low.

There is a variety of testing systems for presence of antibodies produced by the immune system in response to the COVID19 sickness or vaccination. The methods vary from qualitative (indicating just a presence of the antibodies) to quantitative (indicating the level of antibodies). There is still no unification of the measurement units in the results of the tests from laboratory to laboratory.

What is the treatment for COVID-19?

No specific antiviral treatment for COVID19 is currently available. The clinical management includes provision of symptomatic care for those with mild illness, and the certain treatment protocols for more severe forms of the disease in the in-patient environment. Since the offset of the pandemics, the treatment protocols have been significantly corrected based on the world’s medical professional’s experience and clinical studies.

Is COVID-19 vaccination available?

A variety of vaccines is currently available. They are based on several technological platforms. The access to vaccination differs from country to country. The distribution of the vaccines and the schedule of vaccination is strictly regulated by the National Governments.

What about port restrictions?

The local port agents and correspondents normally possess with the most updated and true information about the restrictions implicated by the local Healthcare Authorities in the rapidly changing situation. The early and continuous checks with the situation at port of calls is highly recommended.

What are the general preventive measures?

Among COVID-19 risk groups are people with comorbidity and compromised immunity. First of all one has to follow the simple general recommendations, which allow the human immune system to work correctly:

1. Avoid sleep deficit.

2. Perform simple-support exercises to be in good physical shape.

3. Eat healthy food avoiding any new or suspicious dishes.

4. Get the COVID19 vaccine as well as all other essential vaccines depending of vessel routes to avoid contraction of a disease that would deteriorate COVID19 state if it occurs.

Pre-boarding precautions

1. Careful inspection of crewmembers in order to detect symptoms:

- general weakness

- general chills

- fever over 37.5 C

- cough

- running nose

- sore throat

- headache

- muscle ache

2. Collecting information on contacts with mentioned above symptoms the crewmember had for the last 14 days.

3. Collecting information on the country the crewmember came from as well as countries he/she crossed for the last 14 days.

On board precautions

COVID-19 has a relatively low resistance in the external environment: the virus can survive for several hours on smooth surfaces as well as for several days at suitable humidity and temperature. For example, in an environment with the humidity of 40% and the temperature of 20 C, the virus can remain virulent for up to five days.

The main risks of viral shedding on board are related to the sanitary condition of the commonly used areas and the duration of the route.

Self-protection is the key measure of COVID-19 prevention. The measures do not generally differ from what one should take to avoid contraction of flu:

1. Frequent hand washing using soap and hot water or alcohol-based (96%) hand sanitizer for 20 seconds.

2. Avoidance of touching the face including mouth, nose and eyes with unwashed hands.

3. Crewmembers should be encouraged to cover their mouth and nose with a disposable tissue when sneezing, coughing, wiping and blowing the nose, then dispose of the used tissue immediately and wash the hands.

4. If a tissue is not available, crewmembers should cover their nose and mouth with flexed elbow when sneezing or coughing. Note: sneezing or coughing into hands may contaminate objects, surfaces or people that are touched.

5. Crewmembers should aim to keep at least 1 meter distance from people having fever, cough or other common cold/flu symptoms.

6. Clean and disinfect frequently touched surfaces especially when someone is ill. Refer to recommendations for disinfection in suspected COVID19 case below.

7. Daily pre-duty self-body temperature measurement is strongly recommended.

8. Report immediately to the Master if any of the flu symptoms appear.

What about face masks?

Although face masks may provide some protection – especially if there is a risk of exposure when interacting with persons from outside the vessel – the routine use of face masks is not generally recommended as a measure of protection of a healthy individual against COVID-19.

Face masks are for the sick people, not for healthy ones.

Wearing of face mask by a person is absolutely essential when any of the flu symptoms persist with the person. The maximum length of use of mask is 1 hour. After use, the mask shall be disposed to a container with any antiseptic solution.

If a crewmember is healthy, it is only necessary to wear a mask if the person is taking care of another person with suspected COVID-19 infection.

For the face masks types, the respirator face mask №95 is highly recommended. This mask refrain particles from the air breathed through it. These respirators filter out at least 95% of very small (0.3 micron) particles.

Remember that thorough hand and respiratory hygiene are the most important measures of prevention.

Vessel precaution measures:

Masters of vessels should secure the following items to the stock.

Personal protection equipment (PPE) and decontaminants:

1. Disposable gowns/suits. Boiler suit disposable polypropylene, IMPA code 190568. Rough estimate: 1 gown for 3 crew members a day – 130 pcs of gowns for 20 crew members for 20 days.

2. Disposable medical masks, Face Mask Disposable, IMPA code 391283 or analogue, 100 pieces per set. Rough estimate: 8 masks for one person a day – 32 sets for 20 crew members for 20 days.

3. Disposable gloves, Gloves Disposable Vinyl, IMPA code 190135 or analogue, 100 pieces per set. Rough estimate: 6 sets for 20 crew members for 20 days.

4. Antiseptic Gel Bottles, Hand Liquid Disinfectant Antiseptic for hand washing - IMPA code 550263 or analogue, 500 ml per bottle. Rough estimate: 10 bottles for 20 crew members for 20 days.

5. Alcohol- or chlorine-containing solutions for surface treatment, 10 liters per canister. Rough estimate: 20 canisters for 20 days.

Medical pack on board:

1. Thermometers, IMPA codes 391846/392037/391422, 2 pcs.

2. Pulseoxymeter, any model of portable finger device for home use. Rough estimate: 5 pcs per vessel + stock of AA or AAA batteries depending of the model of the device. Note: Pulseoxymeter measures the oxygen saturation.

3. Paracetamol tab 1000 mg, Ibuprofen 400 mg. Rough estimate: Paracetamol - 1000 mg every 6 hours – 1,600 tabs for 20 crew for 20 days. Ibuprofen – 400 mg every 12 hours, 800 tab for 20 crew for 20 days. Note: Paracetamol and Ibuprofen used as antipyretics and analgesic drugs only for treatment, not for prevention purposes.

4. Azithromycin tab 500 mg, Ciprofloxacin tab 500 mg, Ceftriaxone amp 1000 mg/amp. Rough estimate: Azithromycin – 400 tabs for 20 crew members for 20 days, Ciprofloxacin - 400 tabs for 20 crew members for 20 days, Ceftriaxone – 40 ampules. Note: these antibiotics used for respiratory tract infections treatment, which are the most common complications of COVID-19.

5. Dexamethasone tab 0.5 mg. Rough estimate: 1600 tabs for 20 crew members for 20 days. Note: Dexamethasone is a steroid medication and must be used only by prescription of the attending doctor or the doctor of telemedicine.

6. Apixaban tab 5 mg. Rough estimate: 1600 tabs for 20 crew members for 20 days. Note: Apixaban is an anticoagulant and must be used only by prescription of the attending doctor or the doctor of telemedicine.

7. Ringer's lactate, injection solution, w/o IV set and needle, 1000ml. Rough estimate: 3 liters per a day for 25% of all crewmembers – 300 liters for 20 crew members for 20 days.
Note: this is a fluid maintenance solution used for complicated cases.

8. There are medications with the scientifically unproven clinical effect for treatment or prevention of COVID19. These medications did not go through multiple double-blind placebo-controlled clinical trials and are not in the list of the officially WHO-approved medications for the treatment of COVID19. They have been approved by healthcare authorities of several countries as part of the complex therapy of the confirmed cases of COVID19:

    a. Hydroxychloroquine tab 200 mg

    b. Zinc Sulfate tab 50 mg

Managing a suspected case on board

A suspected case is:

- A patient with severe acute respiratory infection that is fever and cough AND with no other etiology that fully explains the clinical presentation AND a history of travel to or residence in the countries with established community transmission of COVID-19 during the 14 days prior to symptom onset

- A patient with any acute respiratory illness AND at least one of the following during the 14 days prior to symptom onset: contact with a confirmed or probable case of COVID-19 disease OR visiting a healthcare facility where patients with confirmed or probable COVID-19 disease were treated.

If a suspected case is identified the ship should start an outbreak management plan on board, even before lab results confirm an infection.

1. Isolation

Crewmember should be isolated immediately in either isolation ward, cabin, room or quarters with the door closed. The body temperature and oxygen saturation should be regularly monitored and recorded. To relieve the symptoms Paracetamol or Ibuprofen are used.

Any person entering the isolation room should wear disposable gowns, gloves and medical masks. The patient should strictly wear the medical mask as well.

2. Reporting to the next port of call

The Master is required to inform the health authorities at the next port of call to determine if the necessary capacity to transport, isolation and care for the individual is available. The ship may need to proceed to another nearby port if the local capabilities are insufficient.

The Master should check the latest port entry requirements for the next port of call and be ready to provide:

- Health declaration

- Body temperature list

- Information list on crewmembers with symptoms

- Information list on previous port calls

- Information list on crewmembers’ travel history (concerning the regions with unfavourable epidemiologic situation)

3. Ships ventilation system should be turned off to avoid air exchange with the rest of the accommodations.

4. The area outside the isolation room should be allocated, where individual protective gear can be removed and disinfected after visiting the patient.

5. Disposable cups, plates and other cutlery should be used, disposing them as contaminated items.

6. Maintaining high level cleaning and disinfection measures during ongoing on-board case management.

7. If a COVID19 returns positive, any crewmembers who were in close contact with the patient should go under onshore quarantine.

How laboratory tests are provided?

If testing for COVID-19 is recommended, the vessel will be directed to berth at a port and the ill person can either be tested at the port or transferred to a medical facility. Laboratory examination of clinical specimens for suspect cases should be undertaken by the competent authorities who will then inform the vessel’s officers about the test results.

Key tips for cleaning and disinfecting when COVID-19 is suspected on board

In case of coronavirus symptoms presented it is advisable to clean all areas with application of the disinfectant only on surfaces/items having direct contact with the COVID-19 suspect, especially the areas, which may have been occupied by the person.

Clean the hard, non-porous surface first with detergent and water, and then apply disinfectants according to the product instructions. Ensure correct concentrations and sufficient exposure time for effective disinfection. Carefully remove porous materials, where possible, such as upholstery, rugs, and carpeting that have been in contact with the suspect case. Launder in accordance with the product instructions or dispose of the materials as described below.

All used PPE and all soiled items (used tissues, disposable masks, pillows, blankets, mattresses not covered with an impermeable plastic covering, etc.) in the contaminated areas, should be treated as Bio hazardous waste and stored in an impermeable plastic bag labelled biohazard. The bag should be tied up, not reopened and disposed according to the ship protocol for clinical waste. If incinerator is available on board, then waste must be incinerated. If waste must be delivered ashore, then special precautions are needed and the port authority should be informed before waste delivery.

How Telemedicine can be of help for you?

Telehealth should increasingly be viewed as a key way to help fight the COVID19 outbreak, especially among the maritime community.

With a suspected case of COVID19, the telemedical session with a qualified physician will assist the Master and his crew with better understanding of the medical problem by professional assessment of the range of medical services required for avoiding immediate deviations. The 24/7 Telemedicine services include performing an initial remote assessment, determining if a crewmember needs any diagnostic tests, offering treatment recommendations based on the medical inventory on board and giving recommendations regarding hospitalization ashore or medical evacuation.

How medical transport of the diagnosed COVID-19 crewmember is possible?

Currently there are many restrictions for cross-border transport of confirmed COVID-19 patients. Moving a COVID19 patient by commercial air carrier is completely prohibited. The restrictions for air ambulance transport are caused by both sanitary concerns for cabins of the air ambulance aircrafts and the cross border transfer of such patients implicated by the healthcare authorities of various countries. We are monitoring the travel restrictions through our own network of partners around the Globe on literally hourly basis, the restrictions are only increasing for some of the areas.

However, there is no complete impossibility of transferring a SARS COVID19 patient by a very limited number of aircrafts, crews and medical teams today. Along with the use of medical aircrafts equipped by special modules available (like for Ebola cases), there will be additional costs involved on top of regular life-support medical transfer budget due to the use of unique equipment and additional safety measures for the medical team, the crews and the cabin.

The possibility for air medical transport of a certain patient from A to B in each and every case will be subject to scrutiny in assessed details.