Cruise Ship Travel

Preventive Measures

Cruise ship travelers often are uncertain what prevention behaviors and immunizations are appropriate for their particular cruise itineraries, partly because their trip usually involves disembarking at more than one international port to sightsee and experience local culture. Among cruise ship passengers and crew, risk of exposure to geographic-specific infectious diseases is difficult to quantify because of limited data. Therefore, CDC advises first ensuring that all routinely recommended age- and medical condition-specific childhood and adult immunizations are up to date. Then, CDC advises following the prevention and vaccine recommendations that apply to each country visited (as detailed in this text and at CDC's Travelers' Health website, http://www.cdc.gov/travel). Travelers also should consider consulting a travel health specialist, who may tailor prevention behaviors and immunizations depending on the duration of cruise ship travel and length of visits on shore.

In recent years and in collaboration with the cruise industry, CDC has investigated outbreaks of influenza-like illness on cruise ships. In response to these investigations, CDC published preliminary guidelines for the prevention and control of influenza-like illness among passengers and crew members (http://www.cdc.gov/travel/CDCguideflufnl.pdf, in Adobe Acrobat Reader format). If travelers are at high risk for influenza-related complications, either because of age or a medical condition, and they were not vaccinated with influenza vaccine during the preceding fall or winter, they should consider receiving influenza vaccine, barring any contraindications, at least 2 weeks before traveling on a cruise ship.

In the event of an identified disease outbreak on board, such as the Norovirus infections that occurred during the autumn of 2002, the cruise line should inform passengers and crew of the outbreak and what control and prevention actions are being taken. Passengers and crew also should be informed of their potential risk of exposure to disease and of its symptoms and signs. Because the extent of medical facilities varies on each ship (depending on the ship size, the expected number of patient visits, and the itinerary), travelers who would like more information about the medical facilities on board a particular ship are advised to contact the cruise line for additional information.

Sanitation

In 1975, because of several large disease outbreaks on cruise ships, CDC established the Vessel Sanitation Program (VSP) as a cooperative activity with the cruise ship industry. This joint program strives to achieve and maintain a level of sanitation on passenger vessels that will lower the risk of gastrointestinal disease outbreaks and provide a healthful environment for passengers and crew members. CDC addresses the program goals by encouraging the industry to establish and maintain a comprehensive sanitation program and by overseeing its success through an inspection process. Every vessel having a foreign itinerary and carrying >13 passengers is subject to biannual unannounced inspections and, when necessary, reinspections. Inspections are conducted only at ports under U.S. control and cover such environmental aspects as the following:

• Water supply, storage, distribution, backflow protection, and disinfection
• Food handling during storage, preparation, and service
• Product temperature control
• Potential contamination of food, water, and ice
• Employee practices and personal hygiene
• General cleanliness, facility repair, and vector control
• Training programs in general environmental and public health practices

A score of >86 (of a possible 100) at the time of the inspection indicates that the ship is providing an acceptable standard of sanitation. In general, the lower the score, the lower the level of sanitation; however, a low score does not necessarily imply an imminent risk of an outbreak of gastrointestinal disease or other illness related to sanitation. After each inspection, each ship is required to document a plan for corrective action. Although a rare event, inspectors will recommend that a ship not sail if they detect an imminent health hazard aboard ship (e.g., inadequate facilities for maintaining safe food temperatures or a contaminated drinking water system). Full information on inspection criteria can be obtained by writing to the VSP office at the address listed at the end of this section. At any time, CDC may determine that failure to implement corrective actions presents a threat of communicable disease being introduced into the United States and may take additional action, including detaining the ship in port.

The scores and inspection reports for each ship are available on the Internet on the Vessel Sanitation Program site at http://www.cdc.gov/nceh/vsp. Scores are also published biweekly in the Summary of Sanitation Inspections of International Cruise Ships, commonly known as the “Green Sheet.” This sheet is distributed to travel-related services worldwide and is a way to communicate a ship's compliance with VSP recommendations, both to the cruise ship industry and to the consumer. The Green Sheet is also available on the Internet site, as well as through the CDC fax information service (1-888-232-6789; request information on “Cruise Ship Sanitation Inspection Updates”). Information can also be requested by sending an e-mail to vsp@cdc.gov or by writing to the Vessel Sanitation Program, National Center for Environmental Health, CDC, 4770 Buford Highway, NE, Mailstop F-16, Atlanta, Georgia 30341-3724.

— Ulana Bodnar, David Forney