Miguel Dávila Cornejo

In this article, we review the implications for Spain of the identification of a haemorrhagic fever outbreak in an endemic region, focusing on the recent outbreak of Marburg virus disease that occurred in Rwanda during the autumn of this year. In response to this event, we describe the rapid risk assessment process carried out in Spain and the public health measures implemented to evaluate and manage the potential risk of importation and transmission.

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Following the announcement of the retreat of troops from Afghanistan, the Spanish Government organised the so-called “Antigone Operation” for the evacuation of Afghan collaborators. The most relevant ministries were involved in the response. The Ministry of Health, through the Foreign Health Department, performed the health control on arrival. The whole operation was conducted at an air base. It included the health control of refugees composed of temperature measurement, a basic visual control and a coronavirus disease (COVID-19) rapid antigen test for those over 12 years of age; the assessment of their basic needs (food and hygiene); identification and security procedures; and the initial administrative processing. The refugees were accommodated in a temporary facility at the base, where they waited to be transferred to their final destinations. Between 19 and 27 August 2021, 2168 refugees arrived on 17 flights; 680 of them were children under 12 years of age. One thousand four hundred and ninety-nine rapid antigen tests were performed, with one positive result. “Antigone Operation” is unprecedented in Spain and is one of the most complex operations carried out in recent years. The COVID-19 pandemic required the establishment of a health control system on arrival, performed by Foreign Health, which contributed significantly to the overall success of the operation.

The aim of the study is to describe the routine inspections conducted by competent Public Health Authorities (PHAs) on board passenger ships (cruise ships, inland vessels or ferries) sailing in European countries during the EU HEALTHY GATEWAYS joint action and according to the hygiene standards set out in the European Manual for Hygiene Standards and Communicable Disease Surveillance on Passenger Ships (Edition 2nd, April 2016). From 2018 to the end of April 2022, 138 inspection reports were submitted by PHAs in 38 ports in SIS by 76 inspectors, three SHIPSAN experts, 16 inspectors in training and 31 observers, along with 130 Corrective Action Statements by shipping companies or officers of ships.

In response to the COVID-19 pandemic, the European Union Joint Action HEALTHY GATEWAYS developed guidelines for cruise operators and authorities to restart operations and provide common COVID-19 public health preparedness and response standards. In February 2022 under the Joint Action framework, a COVID-19 outbreak onboard a cruise ship was analysed, applying the Intra-Action Review (IAR) methodology at a European level. Participants included national public health authorities and local port health authorities involved in the event response, as well as cruise line representatives. Good practices and challenges observed during the COVID-19 event are presented. Moreover, we documented the lessons learned which provided the basis for proposed revisions to future versions of HEALTHY GATEWAYS guidelines.

The coordination of public health events related to ships presents a challenge to the port health authorities, and communication means and routes are not well established. The EU Common Ship Sanitation Database provides a platform for port-to-port communication of public health events on board ships. The last seven years of operation, 64 public health events were communicated through the system by port health authorities from seven EU countries. Although the usage of the platform has been appreciated, promoted, and legislated in several EU MSs, actions at the national and EU levels are needed to promote the use of the platform by all EU MS are necessary.

Spain is a country with an important flow of cruises in Europe. Since the restarting of cruise activity, 1,106 events with 12,134 confirmed cases of COVID-19 were reported from 21 ports. 72.3% of cases and 73.7% of events were registered in the Balearic Islands, Barcelona, Tenerife and Las Palmas, ports with the highest number of layovers and passengers. The events reported increased from October 2021, with a peak in January and April 2022. The cases raised later, in December 2021 with two peaks in January and April and a substantial increase in June 2022. The peak of January coincides with the peak of COVID-19 cases registered in Spain and Europe. The increases in April and June 2022 coincides with the Easter period and the beginning of summer holidays.

Soft power is a geopolitics concept that implies achieving what one wants through non-coercitive measures. In the context of ship sanitation, port health authorities can provide “hard” and coercitive mandates, and also non-coercitive recommendations. Herein we examine the presence of soft power in ship sanitation literature, the advantages and limitations of hard power, and the importance of the legal framework. Soft power often requires investing time in dialogue and mutual understanding and maintaining a good image; but in any case in the context of ship sanitation awareness and collaboration of all involved parts is necessary for long-term success. To conclude we recommend a careful combination of hard power and soft power.

Transmission of infectious diseases on passenger ships is a well-known fact and efforts have been made to fight against it for years

The purpose of this study was to report the data analysis results from the International Health Regulations (2005) Ship Sanitation Certificates (SSCs), recorded in the European Information System (EIS). International sea trade and population movements by ships can contribute to the global spread of diseases. SSCs are issued to ensure the implementation of control measures if a public health risk exists on board. EIS designed according to the World Health Organization (WHO) “Handbook for Inspection of Ships and Issuance of SSC”. Inspection data were recorded and SSCs issued by inspectors working at European ports were analysed. From July 2011–February 2017, 107 inspectors working at 54 ports in 11 countries inspected 5579 ships. Of these, there were 29 types under 85 flags (including 19 EU Member States flags). As per IHR (2005) 10,281 Ship Sanitation Control Exception Certificates (SSCECs) and 296 Ship Sanitation Control Certificates (SSCCs) were issued, 74 extensions to existing SSCs were given, 7565 inspection findings were recorded, and 47 inspections were recorded without issuing an SSC. The most frequent inspection findings were the lack of potable water quality monitoring reports (23%). Ships aged ≥12 years (odds ratio, OR = 1.77, 95% confidence intervals, CI = 1.37–2.29) with an absence of cargo at time of inspection (OR = 3.36, 95% CI = 2.51–4.50) had a higher probability of receiving an SSCC, while ships under the EU MS flag had a lower probability of having inspection findings (OR = 0.72, 95% CI = 0.66–0.79). Risk factors to prioritise the inspections according to IHR were identified by using the EIS. A global information system, or connection of national or regional information systems and data exchange, could help to better implement SSCs using common standards and procedures.