Cruise Ship Travel

Background

In 2003, over 8 million passengers embarked from North American ports for cruise travel. Popular destinations for cruises from the United States include the Caribbean, Mexico, Central and South America, Canada, Alaska, and Florida. Worldwide, 10 million passengers travel on cruise ships annually, and more than 70 million cruise ship bed-days are available. The Caribbean and the Mediterranean rank as the most popular destinations for cruises, but cruise itineraries include all continents and areas not easily accessible by other means of travel. Given the broad appeal and relative high value of cruise ship travel, the cruise industry has had overall passenger occupancies at full capacity in recent years. While the industry average for the duration of a cruise is about 7 days, cruise voyages can last from several hours (e.g., gambling cruises) to several months (e.g., around-the-world and semester-at-sea cruises).

Cruise ships and all ocean-sailing vessels engaged in international commerce show flags of registry, which are required for operation in international waters. Ships are most often registered in the United Kingdom, Liberia, Panama, Norway, the Netherlands, the Bahamas, and the United States. Flag registry states provide comprehensive maritime expertise and administrative services; require annual safety inspections before issuance of a passenger vessel certificate; and monitor vessel compliance with international and flag state standards. International Health Regulations stipulate health and sanitation requirements for international conveyances. In the United States, the U.S. Coast Guard enforces maritime safety requirements and CDC has regulatory responsibilities for sanitation and public health on cruise ships.

Today's typical large cruise ship can be considered a gathering place for the global community, where opportunities for interpersonal interactions and sharing common activities and food and beverages are plentiful. The diversity of passengers and crew members on a typical large cruise ship also means diverse background in health and immunisation status, medical and public health tendencies and behaviour, and potential for disease exposure. Moreover, the cruise ships' rapid movement from one port city to another, where there may be differences in sanitation standards and infectious disease exposure risks, can result in frequent and recurrent introduction of communicable diseases by embarking passengers and crew members. This movement may result in disease spread to other passengers and crew members in a ship's relatively closed and crowded environment, as well as dissemination of those diseases to the home communities of disembarking passengers and crew members.

CDC Vessel Sanitation Programme (VSP)

In 1975, in response to several large gastrointestinal disease outbreaks on cruise ships, CDC established VSP, a joint cooperative programme with the cruise industry to establish and maintain a high level of sanitation and hygiene on cruise ships. VSP encourages the cruise industry to establish and maintain a comprehensive sanitation programme and conducts biannual unannounced sanitation inspections on each cruise ship arriving in the United States with an international itinerary and 13 or more passengers. VSP is also actively engaged in the design and construction of new ships as well as retrofitting older ones to enhance facilities and provisions that promote shipboard sanitation and environmental control.

Official shipboard sanitation inspections are conducted in ports in the United States and its territories and cover environmental health and control measures, including 1) water supply, storage, distribution, disinfection, and protection; 2) food-handling practices, including storage, preparation, and service; 3) product temperature control; 4) potential contamination of food, water, and ice; 5) personal hygiene and sanitation practices followed by crew members; 6) general cleanliness, facility repair, and vector control; and 7) training programs in environmental and public health practices. A score of 86 or higher out of 100 at the time of inspection indicates an acceptable level of sanitation. In general, the higher the score, the higher the level of sanitation. VSP could recommend or require that a cruise ship not sail if sanitation deficiencies could pose a public health threat. VSP sanitation scores and reports for specific ships are available at http://www.cdc.gov/nceh/vsp.

Cruise Ship Medical Facilities

In 2000, the American College of Emergency Physicians (ACEP) Cruise Ship and Maritime Medicine Section published ACEP Health Care Guidelines on Cruise Ship Medical Facilities, a consensus report on facilities and staffing needs that are considered appropriate aboard cruise ships within the recognised limitations of the sea environment. These recommendations, found at http://www.acep.org/1,593,0.html, include communicable disease control measures such as isolation rooms, medications for infectious diseases, and emergency and mass casualty preparedness. Large cruise lines that operate in the United States are generally well equipped and staffed. However, cruise travellers should note that these guidelines for large cruise lines may not be followed by smaller ships or those run by independent operators where there may be no medical provisions on board. Cruise ship travellers who have chronic diseases, who require more comprehensive facilities or who may require medical treatment should consult with their health-care providers.

Transmission of Illness on Cruise Ships

Communicable disease occurrences on board cruise ships reflect similar events on shore and may be magnified by increased interpersonal interaction. However, heightened disease surveillance efforts by cruise lines and awareness among cruise ship travellers have yielded the detection of illnesses of potential public health significance that might have otherwise gone unnoticed. Clusters of various communicable diseases—including measles, rubella, varicella, meningococcal meningitis, hepatitis A, Legionnaire's disease, and respiratory and gastrointestinal illnesses—among cruise ship travellers have been reported and investigated. In recent years, influenza and norovirus outbreaks have posed particularly difficult public health challenges for the cruise industry. Information on these and other diseases can be found at http://www.cdc.gov/travel.

The extent of communicable disease control programs and expertise within the cruise industry is highly variable, ranging from less than optimal to a level of sophistication that exceeds CDC recommendations. Cruise ship travellers who suspect that they have become ill with a communicable disease exposure during their cruise travel should contact VSP (for gastrointestinal illness) or one of the CDC Quarantine Stations (other illnesses).

Other Illness or Injury Considerations for Cruise Ship Travel

Because of temperature and weather variations, environmental exposure to pollutants and contaminants, changes in diet and physical activities, and generally increased level of stress being away from the comforts of home, the cruise ship traveller may be subject to exacerbation of existing chronic health conditions. A prospective cruise ship traveller with health conditions that might increase his or her potential for injury or illness should consult his or her health-care provider before embarking on a cruise. Special cruises are now available for travellers who have certain medical conditions, including those on dialysis.

Preventive Health for Cruise Ship Travellers

Because of multiple ports visited and the resultant exposures, cruise ship travellers often are uncertain what prevention behaviours and immunisations are appropriate for their itineraries. Among cruise ship passengers and crew members, risk of exposure to infectious diseases is difficult to quantify because of the broad spectrum of cruise ship experiences and limited data. In general, prospective cruise ship travellers should 1) ensure that their routinely recommended age- and medical condition-specific immunisations are up to date, particularly influenza vaccine if indicated; 2) follow the prevention and immunisation recommendations that apply to each country on the itinerary; 3) pay particular attention to hand hygiene, either with soap and water or by using an alcohol-based hand sanitizer; and 4) consult a travel health specialist who may tailor prevention guidelines and immunisations according to the health status of the cruise ship traveller, duration of travel, countries to be visited, and shore-side activities.

Useful Link

  • Cruise Line International Association. Cited in http://www.cruising.org. Accessed on October 26, 2004.
Bibliography
  • American College of Emergency Physicians. Health care guidelines for cruise ship medical facilities. Ann Emerg Med. 1998;31:535.
  • CDC. Vessel Sanitation Programme Operations Manual. [monograph on the Internet]. Atlanta, GA: CDC;2000 [cited 2004 Oct 26]. Available from: http://www.cdc.gov/nceh/vsp/manual/VSP%20Operations%20Manual%202000.pdf.
  • Koo D, Maloney K, Tauxe R. Epidemiology of diarrhoeal disease outbreaks on cruise ships, 1986 through 1993. JAMA 1996;275:545-7.
  • Minooee A, Rickman LS. Infectious diseases on cruise ships. Clin Infect Dis 1999;29:737-44.
  • Peake DE, Gray CL, Ludwig, Hill CD. Descriptive epidemiology of injury and illness among cruise ship passengers. Ann Emerg Med 1999;33:67-72.

- David Kim

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