exhib it 53 - rubyprincessinquiry.nsw.gov.au

Special Commission of Inquiry into the Ruby Princess

EXHIB

IT 53 Statement of Dr Vicky Sheppeard dated 9 June 2020

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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.

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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

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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%.

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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

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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

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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.

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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

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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

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


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:[email protected]

Annexure VS-2 25

mailto:[email protected]



















https://qam.health.nsw.gov.au/API/v1/attachments/6b2d00de-a6ba-e040-69c1-8ecb8151d683?fileName=Cruise%20ship%20procedure%20v1.1.docx

https://qam.health.nsw.gov.au/API/v1/attachments/604a4483-08bd-b212-512f-070bf1cffcbe?fileName=Cruise%20ship%20procedure%20-%20App%20A%20-%20patient%20assessment%20form.docx

https://qam.health.nsw.gov.au/API/v1/attachments/151107c5-5097-d550-43c1-68499f049ccf?fileName=image001.jpg

https://qam.health.nsw.gov.au/API/v1/attachments/4f9ba8cf-2a93-5295-0132-96466dabe76e?fileName=image002.jpg

https://qam.health.nsw.gov.au/API/v1/attachments/c2dd2b97-99c8-d600-ea52-bb495513b699?fileName=image003.png

https://www.seslhd.health.nsw.gov.au/public-health

1



Patient details


GIVEN NAMES:


Email:

Mobile:



Date Location

Contact in Australia (if not Australian resident): Symptoms of illness:

Measured Temp: Other clinical notes (if applicable): PLAN (if applicable)

26

1



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



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




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


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)


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


3.1. 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



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:


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


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:[email protected]

Annexure VS-4 32

















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https://qam.health.nsw.gov.au/API/v1/attachments/642ded20-7bba-bfb4-0f7e-a49c568f1a9d?fileName=Debrief%2014022020.docx

https://qam.health.nsw.gov.au/API/v1/attachments/151107c5-5097-d550-43c1-68499f049ccf?fileName=image001.jpg

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https://www.seslhd.health.nsw.gov.au/public-health

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


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


1


FAMILY NAME: Date of birth: Sex: F/M

GIVEN NAMES:


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



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



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




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



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)


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


3.1. 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



3.7. 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


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


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


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


Appendix 1:



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


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:


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


Appendix 2:TRAVELLER RECORD FORM

Arrival date:

Vessel name:

Assessors name:

Patient details


GIVEN NAMES:

Patient/parent contact details:Email:Mobile:



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


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


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


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


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):


PLAN (if applicable):


Notes:

MIN.102.001.2146

52


Fact sheet

Hand gel/masks

SwabTransfer

Other:


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:


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


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:


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


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:


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

56

SES.101.001.0877

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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