Steps to Prevent Gastrointestinal Illness Aboard Ships

As the fall/winter travel season begins, the following is intended to provide more information about cruise industry efforts to prevent the introduction and/or spread of Gastrointestinal Illness (such as Norovirus) aboard cruise ships:

Historic incidence rates of Gastrointestinal Illness aboard cruise ships are low and according to the U.S. Centers for Disease Control and Prevention (CDC) the vast majority of outbreaks occur in land based settings such as schools, hospitals, and nursing homes. Nevertheless, Cruise Lines International Association (CLIA) member lines regularly communicate with one another, local and state health departments, the U.S. CDC and other international public health authorities to gather epidemiological information, identify sources of infection and share best practices.

If necessary, the cruise line industry can employ a variety of enhanced sanitation practices, including implementing specific, well established Outbreak Prevention and Response Plans, designed to keep passengers healthy during their cruise vacations. One of the cruise industries’ top priorities is preventing Gastrointestinal Illness from being brought on board a ship. Though should it occur, CLIA lines employ numerous practices to mitigate its spread and treat ill passengers and crew. Enhanced passenger health screening implemented by CLIA lines, especially during the flu season assists in identifying ill passengers prior to boarding. CLIA lines also educate their crew and passengers on proper hand hygiene practices in an effort to maintain a clean and healthy environment throughout the cruise vacation.

Additional practices cruise lines employ to maintain a healthy environment on all ships are as follows:

• Regularly sanitizing frequently contacted hand touch surfaces such as door handles, railings and elevator buttons
• Providing hand sanitizers to passengers during their cruise
• Sending public health specialists as well as additional medical personnel to ships as required
• Amending food service practices as required, to include providing staff service in traditionally self-service areas like buffets
• Communicating well established educational hand hygiene practices and additional methods of decreasing the transmission of illness to all passengers and crew
• Asking ill passengers to recuperate in their cabins until symptoms subside in an effort to reduce the spread of any illness of public health concern

Lastly, CLIA lines report cases of Gastrointestinal Illness and share information collected from symptomatic passengers with local and federal health officials. This practice enables these agencies to better identify the original source of infection and allows the cruise lines to more effectively implement mitigating strategies. Among other details, this information includes flight and hotel information prior to embarkation.

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What is norovirus?
Norovirus is a common type of gastrointestinal virus that can affect the stomach and intestines. It is the second most prevalent illness in the general population behind the common cold. Symptoms include diarrhea, vomiting and/or stomach cramping. Most norovirus infections are not serious and most people will recover from their symptoms within one or two days. Norovirus can be transmitted from person to person, by eating or drinking foods and liquids infected with norovirus, or indirectly from touching surfaces or objects infected with norovirus and then touching his/her mouth, nose or eyes. The number of cases can be amplified in areas of close living quarters such as dormitories, hospitals, nursing homes, schools and cruise ships.

Why does norovirus seem to affect cruise ships often?
While norovirus is very common, it is not generally considered a reportable illness in the U.S. health system. However, health officials track gastrointestinal illnesses on cruise ships and thereby are able to track and report gastrointestinal illnesses such as norovirus more quickly on a cruise ship than on land. Norovirus is not confirmed until specimens are analyzed. In most confirmed cases of norovirus reported on cruise ships, the CDC has determined that the increased incidents of norovirus were sourced from passengers bringing the illness on board and transmitting it through direct or indirect contact – not from food or water sources. (CDC’s Facts About Noroviruses on Cruise Ships)

Through thorough and regular inspections, the CDC ensures that cruise ships operating from U.S. ports have exceptional food handling and sanitary practices. The chief of the CDC Vessel Sanitation program has said that the standard by which cruise ships are held for sanitation is the highest in the world.

What do cruise lines do to prevent illness from spreading?
Cruise lines wish to provide an enjoyable vacation and recognize that one ill passenger is one too many. In addition to screening passengers for illness before boarding, each CLIA member cruise line has an outbreak prevention and response plan to address gastrointestinal illness. The most effective means of preventing the spread of the virus, based on the cruise lines’ experience, include:

• An aggressive communications effort on board ships encourages passengers to thoroughly wash their hands frequently. Washing one’s hands regularly (every hour or two) is a very good way to help prevent getting and spreading any contact virus such as norovirus.
• Aboard ship, staterooms and public areas are cleaned and disinfected as continuously as possible.
• Cleaning procedures include the use of disinfectants on areas including, but not limited to: counters, bathroom surfaces, door handles, railings and grab bars, exercise equipment, video arcade equipment and vanities.
• Cleaning measures go as far as disinfecting the Scrabble game tiles, poker chips and anything that a passenger might touch.
• Other measures include disposing of playing cards after each evening in the casino; not shaking hands at cocktail parties to reduce the risk of spreading the virus; and altering all self-serve buffets so that instead of serving themselves, passengers point to the food they would like and staff will serve them.
• Areas where people are or have been sick are immediately and thoroughly cleaned, sanitized/disinfected.
• On turnaround days, extra crew may spend additional time cleaning and disinfecting the ship with the CDC-recommended disinfectants from top to bottom before additional passengers board.
• Passengers with obvious symptoms of illness are asked to contact health personnel.
• To avoid the risk of spreading the virus, passengers and crew who experience symptoms are asked to remain in their cabins. This procedure is endorsed by the CDC.

What can passengers do to protect themselves from norovirus and to stay healthy in general while on board?
The CDC and cruise lines cannot emphasize hand washing enough. The CDC provides the following information in their Cruising Tips.

1. Wash your hands for 20 seconds or longer.
   Before and after eating or smoking.
   After touching your face or going to the bathroom.
   When your hands are dirty.
2. Leave the area if you see someone get sick (vomiting or diarrhea).
   Report to cruise staff, if not already notified. You could become ill from contaminated particles that travel through the air.
3. Take care of yourself.
   Get plenty of rest and drink lots of water. Resting helps rebuild your immune system. Drinking water helps prevent dehydration.
4. Be considerate of other people’s health.
   If you’re ill before taking a cruise, call the cruise line to determine if there are alternative cruising options.