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Carnival Cruise Line Water Safety Program

1ST INTERNATIONAL LEGIONELLA FAST DETECTION CONGRESS

Legionella Prevention and Detection Onboard Cruise Ships

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CCL Water Safety Program

• At the moment, Carnival Cruise Line provides cruises through United States (US) and Australia based vessels

• Total number of 24 vessels are operated by CCL

• Coming 2016: • A new vessel class will be launched – VISTA Class • The maiden vessel will be named Carnival Vista • CCL will also provide cruises in the Asian market with two vessels being stationed

in home ports of China

Ship Class FANTASY SPIRIT CONQUEST DESTINY DREAM FANTASY SPIRIT CONQUEST SUNSHINE DREAM ECSTASY PRIDE GLORY TRIUMPH MAGIC

SENSATION LEGEND VALOR VICTORY BREEZE FASCINATION MIRACLE LIBERTY

IMAGINATION

FREEDOM INSPIRATION SPLENDOR

ELATION

PARADISE

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Waterborne disease remains one of the major health concerns in the world, regardless if dealing with the drinking water system or artificially created recreational water facilities

• CCL Vessel Sanitation Program is further expanding already implemented water safety measures thru the sub-division - Water Safety Program ( WSP)

• Large section of the WSP is dedicated to Legionella prevention and control

• Current procedures and practices are in compliance with the CDC Vessel Sanitation Program requirements and they are continuously evaluated thru their unannounced inspections.

Water Safety Program Flow Diagram

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• Risk-based approach to drinking water safety

• Similar to HACCP and multiple barrier approach

• Recommended by WHO • Includes all steps from source to

consumer • WSP can be applied in any water

system: old or new, small or big, simple or complex

• Standardization of the water systems and components by ship class would assist with the implementation and routine use of the WSP


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CCL WSP set the goals to:

• Establish a comprehensive and practical Water Safety Plan for specific vessel • Determine, categorize and prioritize risks involved in potable water systems

and recreational water facilities (RWF) • Implement strict control measures and define operational critical limits • Establish monitoring by assessing control measures • Implement a system to validate the control measures • Organize effective record keeping system • Follow, evaluate and implement new technologies available in regards to

water safety and quality • Verify the effectiveness of the WSP (does the system meet the set goal)

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WHO - Examples of water-related pathogens and their transmission pathways

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• Starting point of Water Safety Plan also required by CDC Vessel Sanitation

Program and use of rapid testing technology

CDC VSP Regulation 5.1.1.2.2 - Onboard Test: • Water samples collected and analyzed by the vessel

for the presence of E. coli may be substituted for the microbiologic report from each port water system. The samples must be analyzed using a method accepted in Standard Methods for the Examination of Water and Wastewater. Test kits, incubators, and associated EQUIPMENT must be operated and maintained in accordance with the manufacturers’ specifications. If a vessel bunkers POTABLE WATER from the same port more than once per month, only one test per month is required.

Monitoring for E. Coli and total coliforms

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• This monitoring has been done for years and is an integrated part of the Water Safety Program in regards to potable water quality

• Testing of water done following every potable water bunkering in every port of call (even home ports)

Monitoring for E. Coli and total coliforms

Simple and fast test for detecting presence (absence) of E. Coli and total coliforms • At the moment, 24-hourst test kit in use • in future, possibility to implement 18-hours test kit considered • Strategic planning and time is crucial

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• Implementation of rapid test kit for Pseudomonas aeruginosa and bioload is in progress

Monitoring for Pseudomonas aeruginosa

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Control of organic material build up in PW/RWF systems

• As early as 1973, researchers studied microbial slimes in industrial water systems and showed that they were not only very tenacious but also highly resistant to disinfectants such as chlorine (Emerging Infectious Diseases • Vol. 8, No. 9, September 2002)

• Among other pathogens, organic material buildup provides a suitable breeding substrate for Legionella bacteria.

• Legionnaire's disease can be a result of aspiration of clumps of Legionella formation detached in water heating/cooling and distribution systems.

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Monitoring for Legionella spp.

• Legionella monitoring and control have been established on Carnival Cruise Line for many years.

• Increased number of water/swab samples being collected and processed is a direct result of further development of the Water Safety Program

• At the moment, CCL conducts 2 rounds of Legionella sampling per year (bi-annual sampling in place) by vessel.

Laboratory Testing by ELITE certified Laboratory using the cultural method: • Officially recognized and accepted method that is currently utilized by CCL. • Laboratory processing of filtered water (250ml or 1000 ml ) and swab samples • 14 days from sampling to laboratory results it is long time waiting to evaluate

the control measures that were used during the sampling time. ( patient health vs diagnostic time )

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Legionella Culture Method – CDC’s ELITE PROGRAM

• The CDC’s ELITE Program was created as a way for laboratories to test their Legionella isolation techniques against standardized samples.

• Participating labs receive a panel of lyophilized test samples biannually. The test samples are divided between Legionella positive or negative and may be mixed with other organisms commonly found in water.

• Labs that correctly identify Legionella from the test samples in two consecutive panels receive a certificate of proficiency and are listed among CDC’s ELITE Members

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Monitoring and prevention - Legionella spp.

For the period from 2011-2015, total number of collected samples was 7070

• 2011 total number of collected samples was 1091



• 2015 total number of collected samples thus far is

2618 Estimated number of samples end of 2015 season is 2800

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• Routine sampling includes areas such as: 1. PW storage (tanks) and different distribution system components

PW Tank PW Distribution Pumps PW Heaters

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2. Hotel Accommodation

Water Samples - Staterooms

Swab Samples - Staterooms

Swab Samples – Spa Equipment

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Monitoring for Legionella spp. 3. Recreational Water Facilities

Water and Swab Samples

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Monitoring for Legionella spp. 4. Technical Water Connections

Window Washing System and deck washing connections - Water Samples collected

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Legionella Urine Antigen Test

• Only Legionella rapid test kit currently utilized in the CCL fleet on regular basis

• Used in case of any reportable lower respiratory illness in guest or crew

• Limited to detection of Legionella Serogroup 1

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Advantage of Legionella Rapid Detection

• No need for offloading and shipping of the samples • Able to conduct onboard sampling and processing by trained personnel. • Able to receive reliable result in a considerably shorter time • Provides a strong learning tool in further developing the Water Safety Program . • Easy to repeat the test as many time is necessary • Mobile, easy to use portable “laboratories” • No comprehensive training or microbiological background needed

• In case of detectable levels of Legionella in the system after regular water sampling,

by using the rapid test kit, able to: • set up numerous “investigative” sample points in the system with a goal of

identifying the source of contamination • much shorter time to be spent on evaluation and eliminate parts of the PW

system if they are potential source of contamination. • Big advantage in covering a large and comprehensive plumbing system

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Legionella Rapid Detection

• Simple Legionella rapid test kits utilized on several occasions on vessels • Although highly useful in regards to providing fast

results (within 30 minutes), the kit used is limited to detection and screening of Legionella pneumophila serogroup 1 (SG1)

• Large number of similar rapid test kits available on the market, but with same flaw of being limited to SG1

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Legionella Rapid Detection

• New rapid test kits available and technology evolving

• Allows fast, on-sight data collection and processing

• Sensitivity and specificity of the test is high

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