cruise ship illness statistics

These are the cruise ships with the best — and worst — sanitation scores so far this year

• The CDC randomly inspects cruise ships to help prevent the spread of stomach viruses. 
• The agency has reported 13 norovirus outbreaks on cruise ships this year.
• These are the cruise ships with the best and worst sanitation report cards in 2023 so far.

There's nothing like a stomach virus to ruin your vacation, as hundreds of cruise ship passengers have unfortunately learned this year.

The Centers for Disease Control and Prevention has reported 13 norovirus outbreaks on cruise ships so far in 2023. The last time the industry's yearly gastrointestinal illness outbreak total was that high was back in 2016 — and it's only July.

For the agency to report a cruise-ship outbreak, 3% or more of passengers or crew members must report symptoms of gastrointestinal illness, such as vomiting and diarrhea, to the ship's medical staff. During the most recent outbreak, a 14-day cruise aboard the Viking Neptune in June, slightly over 13% of passengers (110 of 838) reported being ill with predominant symptoms of abdominal cramps, vomiting, and diarrhea, according to the CDC.

The nasty stomach bug isn't just a cruise-ship problem, though. Norovirus cases have spiked across the United States this year, which some experts say is the result of ending COVID-19 restrictions .

"People often associate cruise ships with acute gastrointestinal illnesses such as norovirus, but acute gastrointestinal illness is relatively infrequent on cruise ships," the CDC says on its website. "Health officials track illness on cruise ships. So outbreaks are found and reported more quickly on a cruise ship than on land."

To try to help prevent the spread of stomach viruses at sea, the CDC randomly inspects cruise ships and scores them on a scale of 0 to 100 through the Vessel Sanitation Program . Inspection scores of 85 and lower are considered "not satisfactory" by the agency.

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Most vessels have received scores in the high 90s — only one cruise ship, the MSC Seaside, has failed the CDC's sanitation inspection so far this year. The vessel received an unusually low score of 67 , nearly 20 points below the agency's passing grade.

An MSC Cruises representative told Insider at the time that the cruise line had launched an internal investigation based on the inspector's concerns and taken immediate corrective actions.

"MSC Cruises rigorously adheres to health protocols, and the results of this inspection do not reflect the brand's high standards," the person added.

In the past 10 years, only three other cruise ships have received sanitation scores below 70, CDC records show. Violations can include something as small as not posting a raw-eggs advisory on the omelet station or a single fly hovering in a food area. But before going on your next cruise adventure, it doesn't hurt to check out the ship's most recent sanitation rating.

These are the cruise ships with the highest and lowest sanitation scores so far this year:

The 15 cruise ships with perfect scores of 100

The 15 cruise ships with scores below a 95.

Correction: July 17, 2023 — An earlier version of this story included a photo caption that misstated how many passengers and crew members aboard the Nieuw Amsterdam reported being ill during a May voyage. It was 284 people, not 539.

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Nearly 70 Celebrity Cruises guests sick in norovirus outbreak

• Nearly 70 passengers and five crew members got sick in a norovirus outbreak on a Celebrity Cruises ship.
• The ship is currently sailing week-long Alaska voyages between Vancouver and Seward.
• The illness is frequently associated with cruise ships, but those outbreaks account for just 1% of all outbreaks reported, according to the CDC.

Nearly 70 Celebrity Cruises passengers got sick in a norovirus outbreak during a recent cruise.

The Centers for Disease Control and Prevention said 68 of Celebrity Summit’s 2,264 guests reported being ill during a cruise that ended on Friday, along with five crew members. Their main symptoms were diarrhea and vomiting.

The ship is currently sailing week-long Alaska voyages between Vancouver and Seward, according to CruiseMapper . In response to the outbreak, the cruise line isolated sick guests and crew and collected samples for testing, among other steps, the health agency said. 

There were an isolated number of cases on board and the impacted guests are no longer on the ship, according to Nathaniel Derrenbacher, a spokesperson for Celebrity’s parent company Royal Caribbean Group. Summit was also sanitized.

The news follows another norovirus outbreak on Celebrity Constellation in January that left nearly 100 guests sick. The CDC has logged seven outbreaks of gastrointestinal illness on cruises that met its threshold for public notification so far this year. Norovirus was listed as the causative agent in all but one.

Cruise ship medical facilities: What happens if you get sick or injured (or bitten by a monkey)

The illness is frequently associated with cruise ships, but those outbreaks account for just 1% of all outbreaks reported, according to the CDC. Dr. Sarah E. Hochman, a hospital epidemiologist and the section chief of infectious diseases at NYU Langone Health’s Tisch Hospital, told USA TODAY in April that those happen in communities on land, too.

“There's not something special or unique about cruise ships,” she said at the time. “It's really any type of congregate setting, but it's also happening out in the community on a much smaller scale among households and household contacts. It just doesn't come to the attention of public health as much as it does for larger congregate settings.”

Nathan Diller is a consumer travel reporter USA TODAY based in Nashville. You can reach him at [email protected].

The Key Points at the top of this article were created with the assistance of Artificial Intelligence (AI) and reviewed by a journalist before publication. No other parts of the article were generated using AI. Learn more .

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Norovirus outbreaks on cruise ships surge to decade-high levels: How to avoid the stomach bug

In 2023, a decade-high number of cruise ships have reported an unwelcome passenger on board: norovirus.

Outbreaks of the stomach bug have surged on cruise ships this year, reaching the highest levels seen in 10 years. Since January 2023, there have been 13 confirmed norovirus outbreaks on cruise ships under U.S. jurisdiction — that's more outbreaks in six months than there have been during any full year since 2012, according to data from the U.S. Centers for Disease Control and Prevention .

After a lull during the COVID-19 pandemic, cases of the highly contagious virus that causes diarrhea and vomiting, aka stomach flu, spiked this winter and spring on land. As post-pandemic travel surges and millions of Americans return to cruise ships, an increasing number of cruise lines are reporting outbreaks at sea.

Norovirus outbreaks on cruise ships

Most recently, a norovirus outbreak in June on the Viking Neptune sickened 110 passengers (over 13% of the ship's guests) and nine crew members with vomiting, diarrhea and abdominal cramps, according to the CDC . The CDC has tracked outbreaks of gastrointestinal illness on cruise ships through its Vessel Sanitation Program (VSP) since 1994.

Several weeks prior, a Celebrity Summit cruise ship reported an outbreak of norovirus that sickened more than 150 passengers and 25 crew members, per the CDC . It was the third norovirus outbreak on a Celebrity Cruises vessel this year. Another popular cruise line, Royal Caribbean International, has reported four outbreaks since January.

Cruise ships are required to report cases of gastrointestinal illness to the CDC before arriving at any U.S. port, and the CDC will notify the public about outbreaks if they meet certain criteria, including: the ship is carrying 100 or more passengers, the voyage is three to 21 days long, and 3% or more of passengers or crew report symptoms, per the CDC .

The number of outbreaks in the first six months of 2023 is higher than the yearly total during every year since 2012, when there were 16 outbreaks on cruise ships reported to the CDC.

Norovirus can spread year-round, but it tends to have a wintertime seasonality and peak during the colder months. Outbreaks are most common between November and April, TODAY.com previously reported.

"It's a virus we typically see all throughout spring, so it’s not unusual to be see cases in April and May, (and) we are continuing to see many cases now," Dr. Luis Ostrosky, an infectious disease specialist at UTHealth Houston and Memorial Hermann in Houston, tells TODAY.com.

However, as travel surges this summer, travel-related illnesses are expected to surge, as well. “I think our travel frenzy after COVID is partially fueling this continued spread (of norovirus),” says Ostrosky.

What should people know about norovirus and how to avoid getting sick on cruise ships this summer?

Norovirus symptoms and treatment

The most common symptoms of norovirus are vomiting, nausea, diarrhea and abdominal pain, Dr. Albert Ko, infectious disease physician and professor of public health, epidemiology and medicine at Yale School of Public Health, tells TODAY.com.

Less commonly, norovirus may cause a headache, muscle aches, or a low-grade fever — symptoms usually develop within one to two days after exposure to the virus,  per the CDC .

In the vast majority of people, norovirus symptoms will last several days and resolve on their own.

There’s no specific treatment or antiviral for norovirus, according to Ostrosky, but most cases can be managed at home with supportive care like hydration and rest. Sick people should also isolate until their symptoms resolve, the experts emphasize.

Some people are at higher risk of developing severe norovirus symptoms — these include infants, the elderly, and people with compromised immune systems, Ostrosky noted.

How does norovirus spread?

Norovirus is highly contagious and can spread directly through sick people and contaminated surfaces, food, or drinks.

Transmission often occurs when tiny virus particles in feces or vomit from an infected person end up in another person's mouth through direct contact or by touching contaminated surfaces and putting unwashed hands in the mouth or nose, TODAY .com previously reported .

Norovirus can also get into food before, during or after preparation, and it's the top germ causing foodborne illness in the U.S., per the CDC . Virus particles can contaminate drinking water that isn't treated properly or pools when people poop in the water.

It only takes a small number of virus particles for norovirus to spread, which is why norovirus causes so many explosive outbreaks, Ko previously told TODAY.com.

Exposure to less than 100 norovirus particles can make someone sick, and infected people typically shed billions of particles, according to the CDC.

Most people are infectious from symptom onset until about two or three days after recovering, but some people can remain contagious for weeks, Ko notes. People can get infected with norovirus multiple times in their lifetime.

Is norovirus common on cruise ships?

Certain environments are more conducive to the virus spreading. According to the CDC , the most common settings for norovirus outbreaks are health care facilities, restaurants or catered events, schools, day cares and, of course, cruise ships.

Cruise ships are often associated with norovirus because of the enclosed spaces, close living quarters, communal dining and high turnover of passengers, experts note. That said, outbreaks of acute gastrointestinal illnesses are relatively infrequent on cruise ships compared to settings on land, the CDC notes .

How to avoid norovirus on a cruise

Hand hygiene is key to prevent the spread of the highly contagious virus — but the way you clean your hands matters, experts note. It has to be with soap and water, because alcohol-based hand sanitizers are not effective against norovirus.

“Norovirus is one of the few viruses that doesn’t get deactivated by alcohol. You actually need to use soap and water to physically destroy it and remove it from your hands,” Ostrosky previously told TODAY.com.

It's important to wash your hands with soap and clean water frequently, but especially after using the bathroom or changing diapers, before eating and before touching your face.

Surfaces or objects that are contaminated with norovirus can be cleaned with a high-level disinfectant like bleach, per Ostrosky.

On cruise ships, avoid sick people if you can. Passengers who experience norovirus symptoms like vomiting and diarrhea should notify staff and follow recommended precautions, per the CDC .

Caroline Kee is a health reporter at TODAY based in New York City.

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More cruise ships are under CDC investigation following COVID-19 outbreaks on board

The Associated Press

Carnival Cruise Line's Carnival Horizon cruise ship is shown docked at PortMiami in April. The Centers for Disease Control and Prevention is investigating more cruise ships due to new COVID-19 cases aboard. Wilfredo Lee/AP hide caption

Carnival Cruise Line's Carnival Horizon cruise ship is shown docked at PortMiami in April. The Centers for Disease Control and Prevention is investigating more cruise ships due to new COVID-19 cases aboard.

MIAMI — The U.S. Centers for Disease Control and Prevention is investigating more cruise ships due to new cases of COVID-19 as the omicron variant drives extremely high infection levels in the industry hub of Florida.

The CDC said 88 vessels are now either under investigation or observation, but it did not specify how many COVID-19 cases have been reported. Four other vessels are also being monitored by the CDC as well.

Florida hit a new record for daily cases on Tuesday with 46,900 new cases in a day. Since Christmas, the state's 7-day average of daily cases has surpassed previous records set during last summer's surge, rising to 29,400 infections.

Coronavirus hospitalizations in the state have also risen from about 1,200 patients two weeks ago to about 3,400 on Wednesday. But that is still less than one-fifth the number of hospitalizations reported in late August due to the delta wave.

Democratic Sen. Richard Blumenthal is calling for the CDC and cruise lines to again halt cruise travel, six months after the industry mounted its comeback.

"Our warnings have proved sadly prescient and continuously compelling. Time for CDC and cruise lines to protect consumers, again pause — docking their ships," the Connecticut senator posted on Twitter.

Cruise lines have not announced any plans to halt cruising. And the CDC did not say it would adopt any changes, adding it still had plans to allow for the expiration of a set of rules that cruises must follow to sail during the pandemic. The regulation, called a conditional sailing order, is scheduled to expire on Jan. 15 to become a voluntary program.

Coronavirus Updates

Covid-19 outbreaks hit 3 cruise ships as florida breaks record for new cases.

"CDC acknowledges that it is not possible for cruising to be a zero-risk activity," CDC spokesperson Jasmine Reed said in an emailed statement.

Most lines require adult passengers to show proof of vaccination against COVID-19. Cruise ships are allowed to relax measures such as mask use if at least 95% of passengers and 95% of crew are fully vaccinated.

The federal agency recommends that people avoid cruise travel if they are at increased risk of severe illness, regardless of vaccination status.

None of the ships so far appear to have so many cases that they would overwhelm medical resources on board and require a return to port. But some have been denied entry at some foreign ports.

Several Florida-based ships have reported outbreaks. The Carnival Freedom was denied entry to Aruba and Bonaire after an undisclosed number of passengers and crew aboard caught the virus.

Some cruise ships have not been allowed to disembark in Mexican ports due to cases reported, bringing to memory the early days of the pandemic when cruise lines negotiated docking plans as ships were being turned away by officials worried about the virus's spread.

The Mexican government said Tuesday it would allow cruise ships with reported coronavirus cases to dock. The country's Health Department said passengers or crew who show no symptoms will be allowed to come ashore normally, while those with symptoms or a positive virus test will be quarantined or given medical care.

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Norovirus on Cruise Ships

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• Incidents of norovirus or other gastrointestinal (GI) disease are quite rare on cruise ships. The Centers for Disease Control and Prevention (CDC) reports that 20 million people on land in the U.S. come down with norovirus every year.
• In the U.S., the risk of getting norovirus each year is about 1 in 15; a cruise passenger has about a 1 in 5,500 risk of getting laboratory-confirmed norovirus during a shipboard outbreak.

What is Norovirus?

Worldwide Industry Facts

• Worldwide, norovirus is the leading cause of acute gastroenteritis. About 1 in 5 cases of acute gastroenteritis, which leads to diarrhea and vomiting, is caused by norovirus.

Incorrectly Called the Cruise Ship Disease

• While global information on norovirus outbreaks is not available, the CDC runs the Vessel Sanitation Program (VSP) , which collects the total number of GI illness cases on cruise ships before the ship arrives at a U.S. port, when sailing from a foreign port.
• “Cases of acute gastroenteritis illness on cruise ships are relatively infrequent.”
• “Collaborative efforts with the cruise industry have allowed VSP to provide more rapid support to cruise lines and ships experiencing higher than expected levels of acute gastroenteritis.”
• “Fewer and less severe outbreaks are likely the result of earlier detection of acute gastroenteritis, along with cruise industry efforts to identify and control outbreaks.”

Preventing Norovirus Onboard

• Cruise lines do their part to ensure a healthy cruise experience and that passengers and crew maintain good hygiene onboard.  
• Cruise ship crew members employ strict cleaning and sanitation practices developed with the CDC and other public health authorities.
• The best way to prevent norovirus is thorough, frequent hand washing, taking care of yourself by getting plenty of rest and drinking lots of water, and being aware and considerate of other people’s health.
• All of the efforts made by cruise ship crews cannot replace the responsibility that rests with each and every individual. Passengers and crew alike must also be committed to keeping themselves, their family and their fellow travelers healthy.

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5 Illnesses You Can Get on a Cruise Ship (Besides COVID)

Plus, tips on how to avoid getting sick while at sea and ports of call.

Rachel Nania and Nicole Gill Council,

Concerns over the spread of COVID-19 have loomed over the travel industry for the last three years, but with the public health emergency coming to an end and a robust menu of preventive tools and treatments available, many of those fears are fading.

A new  AARP survey  shows 81 percent of adults 50-plus who plan to travel in 2023 believe it’s safe to do so now, up from 77 percent in 2021. And while interest in cruising is down slightly among the 50-plus population this year compared to last, a recent AAA survey finds that, overall, the share of travelers considering a cruise vacation in 2023 is up.

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However, the return to the skies and seas does not mean COVID-19 is no longer a threat.

“Indoor densely populated places where we’re exchanging exhaled breath with one another is still going to be a concern for me,” says Wilbur Chen, M.D., adult infectious disease physician and director of the University of Maryland, Baltimore Travel Medicine Practice.

That concern isn’t limited to COVID, either. Flu spreads in a similar way, Chen points out.

It’s important to note, though, that since the start of the pandemic, many cruise lines have invested in better air circulation systems with medical-grade HEPA filters , says travel expert Pamela Kwiatkowski, cofounder and chief insurance officer at Goose Insurance Services in Vancouver, British Columbia. “I think that’s the first step they’ve taken in terms of improving the air filtration system, which removes almost all of the airborne pathogens,” she says.

Still, plenty of bugs can lurk on busy boats. Read on to discover some common illnesses you can pick up on a cruise — and what you can do to help keep yourself healthy on your next getaway. 

1. Flu and other respiratory illnesses

Flu season spiked early this year in the U.S., along with another  respiratory illness  that can be particularly dangerous for older adults, respiratory syncytial virus, which is known as RSV . Cases of flu and RSV have declined from fall’s peak, data from the Centers for Disease Control and Prevention (CDC) shows, but the viruses that cause these two illnesses are still circulating in the U.S. and other parts of the globe.

“Influenza is complicated during cruise travel because, of course, people on a cruise ship — both the passengers and the crew — may come from different parts of the world, which means that the rates of influenza for your particular country may not necessarily be the same as in other places,” says Jose Lucar, M.D., an infectious disease physician and associate professor of medicine at the George Washington University School of Medicine and Health Sciences in Washington, D.C.

According to the CDC, flu season in the southern hemisphere, which includes Australia and parts of South America and Africa, typically runs April through September. In the tropics, flu flares up throughout the year.

Staying healthy:  If you haven’t rolled up your sleeve for the flu shot yet, make sure you get it at least two weeks before going on a cruise, Lucar says. The same applies to the latest  COVID booster . When it comes to RSV, there isn’t a vaccine yet, but the FDA could approve one soon.

A few other tips: If you’re at high risk for  flu complications , talk to your doctor about antiviral treatment and prevention before your trip, the CDC recommends. Don’t forget about high-quality face masks, which can help to tamp down the spread of respiratory illnesses. And be sure to make — and pack — a list of all the medications you take, in case you wind up needing medical care on board. “That just makes it easier for everyone, so that if there is an emergency, if you’re not able to talk really well, you can at least hand the sheet over and it’s done,” Chen says.

2. Norovirus

This is one of the most well-known bugs that can foil fun on a ship. Norovirus — marked by diarrhea , vomiting, nausea and stomach pain — is to blame for more than 90 percent of diarrheal disease outbreaks on cruises, according to the CDC. That said, norovirus outbreaks on ships account for only 1 percent of all such reported cases.

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“This infection is very contagious,” Lucar says. The virus is also a “hearty” one, Chen points out. It can survive for long periods of time on surfaces and is resistant to common disinfectants.

Close living quarters, shared bathrooms, populated pools, busy buffet lines and rapid turnover of passengers make it difficult to control the spread of the virus once it hits a ship. “It’s just really the perfect scenario for transmission of highly contagious GI [gastrointestinal] pathogens,” Lucar says.

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According to the Cruise Lines International Association, the risk each year of getting laboratory-confirmed norovirus during a ship outbreak is about 1 in 5,500. The association, which says it is the largest cruise industry trade association in the world, noted on its website that crew members use strict sanitation and cleaning practices created with the CDC’s Vessel Sanitation Program. Cabins are cleaned once a day, and other common areas, such as elevators and pools, are cleaned multiple times a day.

In late February, more than 300 people aboard a Princess Cruises ship fell ill with diarrhea and vomiting, according to the CDC, though the agency didn’t cite the cause of the illness that sickened the 284 passengers and 34 crew. The  Ruby Princess  increased disinfection and cleaning procedures in the wake of the outbreak.

Other bugs that have popped up on boats include salmonella and E. coli. One to keep an eye on is shigella, which the CDC notes has been behind GI outbreaks on cruise ships. This bacterium causes an infection known as shigellosis, which can cause fever, stomach pain and diarrhea that can be bloody or prolonged.

Typically, the infection is treated with antibiotics, Chen says, but the CDC recently  issued a warning  that antibiotic-resistant strains are circulating in the U.S. Chen isn’t aware of any outbreaks of the resistant varieties on cruise ships, but it’s something to monitor.

Staying healthy:  To avoid getting a GI bug, be sure to wash your hands with soap and water before eating and after going to the bathroom and coming into contact with high-touch surfaces, like doorknobs and stair railings. Hand sanitizers don’t work well against norovirus, Lucar notes.

Travel expert Kwiatkowski also recommends  drinking plenty of water  to keep your body running at its best. However, she advises passengers stay away from the water at ports, particularly if a passenger is vulnerable to gastrointestinal illnesses.

“Handwashing, cleaning your stateroom, watching what you eat and how much you eat, and making sure that you stay hydrated will go a long way in preventing these illnesses, from you catching them even if they are there,” she says.

Talk to a doctor or pharmacist about any medications you should pack, such as loperamide (Imodium) to help treat diarrhea or dimenhydrinate (Dramamine, Gravol) for nausea. If your immune system is compromised, your doctor may want to prescribe something ahead of your trip.

Although less common than respiratory and GI illnesses, measles, along with chicken pox and other  vaccine-preventable diseases , can circulate on cruise ships.

Measles, a highly contagious virus that can linger in the air even hours after an infected person leaves the room, was declared eliminated from the U.S. in 2000, thanks to a successful vaccine program. But cases still pop up in the States, and the virus is common in many countries around the world.

If an unvaccinated or under-vaccinated passenger or crew member contracts the virus and brings it on board, other vulnerable people can get sick, Chen explains. (A ship was quarantined off the coast of St. Lucia in 2019 when measles was reported on board.) The same goes for chicken pox (varicella), which is similarly caused by a highly contagious virus that can circulate among unvaccinated people.

Staying healthy:  To avoid these and other vaccine-preventable diseases, make sure you’re up to date on your routine vaccines before traveling. Two doses of the chicken pox vaccine are more than 90 percent effective at preventing the disease, and two doses of MMR (measles, mumps, rubella) are about 97 percent effective at preventing measles.

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4. Seasickness

Is the motion of the ocean getting to you? Seasickness, while not contagious or related to an infection, can make you feel downright miserable. The good news: Most people recover quickly from seasickness, formally known as motion sickness, and there are medications that can help.

Motion sickness — which can cause dizziness, nausea and vomiting whether you’re on a boat, in a car or on a roller coaster — occurs when the movement you see is different from what your inner ear senses. Interestingly, adults 50 and older are less susceptible than younger adults and children, the CDC notes.

Staying healthy:  If you’re prone to going a little green when you travel, talk to your doctor ahead of your trip about medications that can help with symptoms. Prescription and over-the-counter antihistamines — like dimenhydrinate (Dramamine), for example — are most frequently used to treat motion sickness. 

However, antihistamines can interact with other medications and often cause drowsiness and decreased mental alertness, and the nonsedating ones appear to be less effective, the CDC says. Your doctor may also prescribe or recommend a patch that can help prevent nausea and vomiting caused by motion sickness.

Another tip: Have your physician review your current list of medications, since common pills — including some antidepressants and painkillers — can make seasickness worse, according to the CDC. 

A few other things that can help with seasickness:

• Try lying down on your stomach, shutting your eyes or looking off into the horizon.
• Avoid the upper levels of the boat.
• Stay hydrated and limit alcohol and caffeine consumption.
• Avoid smoking . Even short-term cessation reduces your susceptibility to motion sickness, the CDC says.
• Distract yourself with music, controlled breathing or aromatherapy (try mint or lavender). Sucking on a flavored lozenge (some experts recommend a hard ginger candy) may also help, the CDC says.
• While the CDC says the scientific data on acupressure for seasickness is lacking, it works for some. You can find wrist bands for motion sickness in many drugstores.

5. Burns and bites

A word of advice from Lucar and Chen: Don’t forget the SPF when packing for your cruise. A burn on vacation can ruin your fun in the sun  and  put you at higher risk for  skin cancer .

“Also, if you’re going to places that have a lot of insects and mosquitoes, make sure you wear your insect repellent so that you don’t get a bunch of bites, because we also are worried about malaria, dengue, chikungunya, Zika — those sorts of things — at ports of call,” Chen says.

Staying healthy:  Opt for a sunscreen with an SPF of at least 15, the CDC recommends, and be sure your bottle says “blocks UVA and UVB” or “broad spectrum” on the label.

When it comes to insect repellent, look for a spray that’s registered with the Environmental Protection Agency. Layering it with sunscreen? Put the repellent on second, over the sunscreen, the CDC advises.

To ease any health-related concerns you might have before booking a cruise, Kwiatkowski suggests using a travel agent who is a cruise line expert or contacting the cruise line to ask about their cleaning protocols and track record. “I know it sounds like a lot of work,” she says, “but travel is a big investment, and you really want to travel worry-free.”

Rachel Nania writes about health care and health policy for AARP. Previously she was a reporter and editor for WTOP Radio in Washington, D.C. A recipient of a Gracie Award and a regional Edward R. Murrow Award, she also participated in a dementia fellowship with the National Press Foundation.

Nicole Gill Council is a writer and editor of travel and diversity, equity and inclusion content for aarp.org. Previously, she was a digital planning manager and a news editor at  USA Today  and Gannett News Service, and a copy editor at the  Los Angeles Times  and  Newsday.​

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Cruise ship barred from docking in Mauritius amid outbreak of stomach illness

Officials in the island nation of Mauritius blocked a Norwegian Cruise Line ship from docking there Sunday after more than a dozen passengers were stricken with a stomach illness.

Around 15 passengers aboard the Norwegian Dawn remain in isolation because of an undisclosed "health risk" and are undergoing testing, according to the Mauritius Ports Authority .

"The decision not to allow the cruise ship access to the quay was taken in order to avoid any health risks," the authority said in a statement.

The sick guests “experienced mild symptoms of a stomach-related illness,” Norwegian Cruise Line said in a statement Sunday. The cause of the outbreak has not been released.

“Due to additional testing being required by local authorities before being allowed entry, the government of Mauritius has delayed disembarkation for the current cruise and embarkation for the next cruise by two days,” the Norwegian statement said.

It’s expected that the ship will be allowed to dock Tuesday, the cruise line said, after results of tests conducted Sunday become available.

The Norwegian Dawn has more than 2,100 passengers and 1,000 crew on board. About 2,000 of those travelers were set to complete their journey on Sunday by disembarking in Mauritius, in the Indian Ocean just east of Madagascar, the Ports Authority said. Then more than 2,200 new passengers were scheduled to board.

The authority said that the passengers who were due to start their cruise Sunday would not be able to do so that day and that they would have to be relocated to available hotels.

Norwegian Cruise Line said the ship's "management team met with local authorities to confirm precautions and actions were being taken to ensure the wellbeing of all on board."

Gastrointestinal illnesses are often identified on cruise ships for a few reasons , according to the Centers for Disease Control and Prevention: The ships' close living quarters make it easier for viruses to spread, and the regular addition of new passengers creates opportunities to introduce illness. However, because public health officials track illness cases on cruise ships, such outbreaks may also be reported more often than ones on land.

Last month, an outbreak of norovirus — a common stomach bug that causes vomiting and diarrhea — sickened 92 passengers and eight crew members on a Celebrity Cruises ship.

David K. Li is a senior breaking news reporter for NBC News Digital.

There's COVID-19 on nearly every cruise ship right now: Here's what cruisers need to know

Things are getting iffy again for cruisers -- at least for those with near-term bookings.

The ongoing surge in COVID-19 cases around the world is causing a growing number of disruptions to itineraries and even some last-minute cancellations of entire voyages.

The number of passengers being quarantined on ships (after testing positive for COVID-19) also is on the rise. And passengers who aren't COVID-19 positive are getting caught up in short-term quarantines for being "close contacts" of shipmates who are.

For more cruise guides, tips and news, sign up for TPG's cruise newsletter .

Meanwhile, just getting to ships is becoming increasingly stressful, as getting the pre-cruise COVID-19 test that's often required before cruising is getting more difficult . Plus, a "perfect storm" of soaring COVID-19 cases and rough winter weather has wreaked havoc with airline operations for weeks.

Still, the situation isn't anywhere near as dramatic or disruptive as what we saw at the start of the COVID-19 pandemic two years ago, when whole ships were being quarantined due to outbreaks of the illness and, eventually, the entire industry shut down.

As I saw myself during a cruise to Antarctica in recent weeks, many sailings are operating relatively normally, even when there are COVID-19 cases on board.

Here's a look at everything you need to know if you've got a cruise booked in the coming weeks -- or further out.

COVID-19 cases on ships are up a lot

While cruise ships have recorded relatively few cases of COVID-19 over the past year, in part due to unusually strict health protocols , the number of passengers and crew testing positive on ships has been rising sharply in recent weeks along with the greater surge on land.

At the end of December, the U.S. Centers for Disease Control and Prevention reported that 5,013 COVID-19 cases had been reported on cruise vessels operating in U.S. waters during the last two weeks of the month, up from just 162 cases during the first two weeks of the month.

That's a 3,094% increase.

Anecdotal reports are that the number of cases on ships is up even more in the first 10 days of the new year.

Notably, all 92 cruise vessels currently operating in U.S. waters have recorded at least a handful of COVID-19 cases in recent weeks, according to CDC data.

Still, it's important to note that most of these "cases" of COVID-19 are asymptomatic or mild, only discovered during routine testing. While some ships only are testing passengers who report feeling ill for COVID-19 (and close contacts of those who subsequently test positive), other ships are testing every single passenger at least once per voyage, sometimes more. One line, Viking , is testing every single passenger for COVID-19 every day.

Cruise lines also are testing all crew members regularly.

The result is the detection of many asymptomatic cases that otherwise would have gone undetected. This is a level of surveillance that is much greater than what is the norm for other travel venues such as land-based resorts or theme parks, and it can give the false impression that the positivity rate for COVID-19 on ships is unusually high as compared to other places.

If anything, the positivity rate is far lower on ships than on land, thanks to much stricter health protocols (more on that in a moment).

It's also important to note that the detection of COVID-19-positive passengers or crew on board your ship won't necessarily impact your sailing (unless you are among those testing positive).

Health authorities no longer are quarantining whole ships when a few -- or even a lot -- of passengers and crew test positive for COVID-19. The current protocol on most ships is to isolate COVID-19-positive passengers and crew but otherwise continue on with voyages as planned.

Your itinerary could change

While health authorities no longer are quarantining whole ships when a few passengers or crew test positive for COVID-19, the presence of the illness on board a vessel still could result in notable disruptions to your itinerary.

Cruise lines in recent weeks have faced a growing number of ports that are balking at allowing ships with COVID-19-positive passengers or crew to dock.

Several ships recently had to skip port calls in Mexico , for instance, after passengers and crew on board the vessels tested positive for COVID-19. The ports have since reopened after Mexico's Health Department overruled the decisions of local port officials.

Cruise ships also have had to cancel stops recently at the islands of Aruba, Bonaire and Curaçao, and at San Juan, Puerto Rico, due to local worries about COVID-19-positive passengers and crew on board and/or tighter COVID-19-related entry requirements.

Lines also are dealing with a small but growing number of destinations -- India and Hong Kong, for example -- that are at least temporarily closing to cruising completely, even for ships where no one has tested positive for COVID-19.

Viking on Sunday was forced to announce a major revision of its soon-to-begin, 120-day world cruise after India notified the line it was closing to cruise ships. Viking's 930-passenger Viking Star will begin its world cruise this week by heading south from Los Angeles to Central America and South America instead of sailing westward toward Asia, where it was scheduled to spend a significant amount of time in India.

Your cruise could be canceled on short notice

A growing number of cruise lines are canceling sailings on short notice, citing the disruptions caused by COVID-19. The world's largest cruise operator Royal Caribbean on Friday canceled soon-to-depart sailings on four of its 25 ships, including the next three departures of the world's largest ship, Symphony of the Seas .

Norwegian Cruise Line on Wednesday canceled soon-to-depart voyages on eight of its 17 ships.

Other lines canceling one or more sailings in recent days include Holland America , Silversea , Atlas Ocean Voyages, Regent Seven Seas Cruises, MSC Cruises , Costa Cruises and Oceania Cruises .

The cancellations come as lines struggle to maintain adequate staffing levels on some ships due to crew members testing positive. When crew test positive, they and their close contacts must stop working and isolate, even if asymptomatic, leaving shipboard venues short-staffed.

You probably won't be quarantined, stranded or stuck

As noted above, health authorities no longer are quarantining whole ships when a few -- or even a lot -- of passengers and crew test positive for COVID-19.

The current protocol on most ships is to quickly isolate COVID-19-positive passengers and their close contacts. But only the COVID-19-positive passengers are being isolated long term.

As my colleague Ashley Kosciolek experienced first-hand on a cruise in 2021, close contacts only are being isolated for a short period while they are tested for COVID-19. If they test negative, they typically are allowed out of their rooms to rejoin the rest of their fellow cruisers on board.

This means that many sailings are going ahead as planned, with little disruption, even when some passengers and crew on the trips test positive for COVID-19. I experienced this myself in late December when on a Silversea vessel where four passengers tested positive for COVID-19. Some passengers who were deemed close contacts of the passengers who tested positive were isolated for a short period while being tested for COVID-19. But the positive cases had little impact on most of the passengers on board the vessel, and the voyage went ahead as planned.

Such a protocol comes at the recommendation of the CDC, which has set guidelines for how cruise lines should respond to COVID-19-positive cases on board ships, and it has worked well for the past year .

Of course, if you do test positive for COVID-19 on a ship, you will, unfortunately, face what could be several days of isolation in a cabin on a ship or on land. If you are an American cruising overseas, you also won't be able to return to the U.S. until you have tested negative for COVID-19 (or until you recover from the illness and are cleared in writing to travel by a licensed healthcare provider or a public health official).

This is one of the biggest risks of taking a cruise right now, and one reason you may consider canceling a sailing scheduled in the short term (see the section on more-flexible cancellation policies below).

Most COVID-19 cases on ships aren't serious

Cruise lines are reporting that the vast majority of passengers testing positive for COVID-19 in recent weeks are asymptomatic or have mild symptoms.

All major cruise lines currently are requiring all or nearly all passengers to be fully vaccinated for COVID-19, with some also starting to require booster shots , to boot. This creates an onboard population that is far less likely to experience serious symptoms of COVID-19 than a cross-section of people on land, according to CDC data.

For all adults ages 18 years and older, the cumulative COVID-19-associated hospitalization rate is about eight times higher in unvaccinated persons than in vaccinated persons, according to the latest CDC data.

You'll face lots of new health protocols

If you haven't cruised since before the pandemic, you might be surprised by how many new health- and safety-related policies cruise lines have implemented to keep COVID-19 off ships.

For starters, there are the vaccine mandates noted above. No other segment of the travel industry has been as uniform in requiring almost every customer to be fully vaccinated against COVID-19.

Related: Will I need a COVID-19 vaccine to cruise? A line-by-line guide

As noted above, cruise lines also are requiring passengers to undergo COVID-19 tests before boarding ships -- a screening process that is keeping many COVID-19 positive people from ever stepping on board a vessel.

When COVID-19 is detected on a ship, cruise lines sometimes then test passengers multiple times to ensure it isn't spreading. On my recent trip to Antarctica, I underwent six COVID-19 tests in just eight days -- three in advance of stepping on board the vessel (including a PCR test required by Chile, where my trip began) and three while on board.

In addition, most cruise lines now are requiring passengers to wear masks at all times while in interior spaces of vessels, and they have stepped up cleaning regimens, improved air filtration systems on ships and made other onboard changes.

The CDC says to avoid cruising for now

On Dec. 30, the CDC added cruise ships to its list of "Level 4" destinations you should avoid visiting for now due to high levels of COVID-19.

For what it's worth, more than 80 countries around the world -- including a good chunk of all the places you might want to travel -- are on this list. So, the CDC is basically telling you that now isn't a good time to travel. Fair enough. But the warning shouldn't be seen as a call-out on any elevated risk to cruising as opposed to visiting other places, per se.

Places on the Level 4 list currently include Canada, much of Europe and nearly every country in the Caribbean.

The cruise industry has been highly critical of the designation, arguing that cruise ships are far safer places to be right now than almost anywhere else, given their strict health protocols.

"The decision by the CDC to raise the travel level for cruise is particularly perplexing considering that cases identified on cruise ships consistently make up a very slim minority of the total population onboard — far fewer than on land — and the majority of those cases are asymptomatic or mild in nature, posing little to no burden on medical resources onboard or onshore," the main trade group for the industry, the Cruise Lines International Association, said in a statement to TPG.

You can cancel if you're worried (in many cases)

If you're booked on a cruise in the coming weeks, and you're having second thoughts, there's a good chance you can get out of your trip. Many lines continue to be far more flexible than normal about cancellations.

Take cruise giant Carnival Cruise Line . Its current flexible cancellation policy allows passengers to cancel as long as a public health emergency remains in effect and receive 100% of the cruise fare paid in the form of a future cruise credit. Passengers are also able to cancel if they test positive for COVID-19. (Proof of a positive test result is required.)

Another large line, Norwegian, just last week extended its pandemic-era Peace of Mind policy to allow passengers to cancel any sailing taking place between now and May 31. For now, the cancellation needs to be done by Jan. 31, and the refund would come in the form of a future cruise credit to be used on any sailing that embarks through Dec. 31.

That means you could call the line right now to back out of a cruise that is just days away. In normal times, you'd lose all your money if you backed out of a seven-night Norwegian cruise with fewer than 31 days' notice.

Planning a cruise? Start with these stories:

• A beginners guide to picking a cruise line
• The 5 most desirable cabin locations on any cruise ship
• The 8 worst cabin locations on any cruise ship
• A quick guide to the most popular cruise lines
• 21 tips and tricks that will make your cruise go smoothly
• 15 ways cruisers waste money
• What to pack for your first cruise

• Research article
• Open access
• Published: 12 April 2016

An epidemiological study of rates of illness in passengers and crew at a busy Caribbean cruise port

• Cathy Ann Marshall 1 ,
• Euclid Morris 2 &
• Nigel Unwin 3  

BMC Public Health volume  16 , Article number:  314 ( 2016 ) Cite this article

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The Caribbean has one of the largest cruise ship industries in the world, with close to 20 million visitors per year. The potential for communicable disease outbreaks on vessels and the transmission by ship between countries is high. Barbados has one of the busiest ports in the Caribbean. Our aim was to describe and analyse the epidemiology of illnesses experienced by passengers and crew arriving at the Bridgetown Port, Barbados between 2009 and 2013.

Data on the illnesses recorded were extracted from the passenger and crew arrival registers and passenger and crew illness logs for all ships and maritime vessels arriving at Barbados’ Ports and passing through its territorial waters between January 2009 and December 2013. Data were entered into an Epi Info database and most of the analysis undertaken using Epi Info Version 7. Rates per 100,000 visits were calculated, and confidence intervals on these were derived using the software Openepi.

There were 1031 cases of illness from over 3 million passenger visits and 1 million crew visits during this period. The overall event rate for communicable illnesses was 15.7 (95 % CI 14.4–17.1) per 100,000 passengers, and for crew was 24.0 (21.6–26.6) per 100, 000 crew. Gastroenteritis was the predominant illness experienced by passengers and crew followed by influenza. The event rate for gastroenteritis among passengers was 13.7 (12.5–15.0) per 100,000 and 14.4 (12.6, 16.5) for crew. The event rate for non-communicable illnesses was 3.4 per 100,000 passengers with myocardial infarction being the main diagnosis. The event rate for non-communicable illnesses among crew was 2.1 per 100,000, the leading cause being injuries.

Conclusions

The predominant illnesses reported were gastroenteritis and influenza similar to previous published reports from around the world. This study is the first of its type in the Caribbean and the data provide a baseline for future surveillance and for comparison with other countries and regions.

Peer Review reports

Cruising or travelling by boat or ship for leisure has become a major part of the world-wide tourism industry [ 1 ]. The Caribbean cruise industry is one of the largest in the world, responsible for over U.S. $2 billion in direct revenue to the Caribbean islands in 2012 [ 2 ]. Over 45,000 people from the Caribbean are directly employed in the cruise industry and 17,457,600 cruise passengers visited the islands in the 2011–2012 cruise year [ 2 ].

The main port of entry by sea in Barbados is the Bridgetown port and harbour which also houses the cruise terminal facility. Annually, hundreds of vessels and more than half a million passengers enter the Bridgetown Port. For example, in information given to the study team by the Port Authority, in 2013 alone, 374 vessels, 619,485 cruise ship passengers and 262,947 crew members traversed the Bridgetown Port.

Cruise ships in the modern era can be very large vessels which transport thousands of passengers and crew on a single trip. A typical cruise ship carries 2000 passengers and 800 crew, and the largest ships can have capacities in excess of 5000 passengers and 2000 crew [ 3 , 4 ]. Outbreaks of infectious disease aboard cruise ships are therefore of public health importance, given that ships are closed or semi-closed settings in which infection may easily be spread and may be difficult to control. This is further compounded by the facts that the average cruise lasts longer than 6 days, there are frequent group activities that increase passenger and crew contact and facilitate the spread of infection, and frequent stops are made where passengers can leave the ship and new passengers and crew can board, providing new reservoirs for infection [ 1 ].

Within the past five years epidemic prone diseases such as the pandemic (H1N1) in 2009 which originated in Mexico, the Middle East Respiratory Syndrome Corona Virus which was isolated in 2012 in Saudi Arabia, the Chikungunya virus which emerged in the Americas in Saint Maarten in December 2013 and the Ebola Virus in West Africa in March 2014, were introduced into non-endemic areas by travel [ 5 – 9 ]. These public health events further emphasise that international travel can quickly and extensively affect global health [ 10 – 13 ].

Recent media emphasis on communicable disease in the Caribbean such as Chikungunya and Dengue Fever and the expressed global concern over the Ebola virus has heightened public awareness of the possibility of the spread of infectious disease through visitors to a country at its ports of entry.

Barbados has a public health monitoring system in place for entry at each of its ports which records data on all arriving passengers and crew and maintains a log of all diagnosed illnesses. This study provides an epidemiological description of the illnesses presenting at the Bridgetown Port and cruise terminal from 2009 to 2013, and illness rates of passengers and crew, by time of year, vessel and last port of call. This study is the first published analysis of the illnesses in passengers and crew aboard ships in the Caribbean from the perspective of a port health authority.

This is a retrospective descriptive study of rates of illness, making use of routine data sources of communicable and non-communicable illnesses reported by passengers and crew on vessels within the jurisdiction of the Barbados Port Health Department between January 2009 and December 2013.

Ethical approval to undertake this study was applied for before commencing the data collection in June 2014. Ethical approval was formally obtained by written correspondence from the Institutional Review Board (IRB) of the University of the West Indies on the 18 th May 2014.

Barbados is an independent nation with 286,000 inhabitants. It is a developing economy [ 14 ], a member of the United Nations conference of small island developing states [ 14 ], and has an estimated per capita gross national income of 14,880 US dollars [ 15 ]. Tourism is the major contributor to the economy. Bridgetown is the main shipping port of Barbados, through which 90 % of the goods used in the manufacturing and retail sectors of Barbados pass, and at which all cruise vessels dock.

The Barbados Port Health Department is the government agency responsible for enforcing the International Health Regulations (2005) and regulating public health conditions on vessels transiting through Barbados’ territorial waters.

This includes ships docking at Bridgetown and other Ports in Barbados. Environmental Health Officers (Port Health) are responsible for documenting sick passengers and crew on all vessels, whether visiting a port or simply passing through Barbados’ territorial waters. They do this by boarding all vessels and receiving from the responsible officer on board the total number of sick passengers and crew at the that time. Details that are collected include age, sex, and type of illness for each sick person. This is done as a legal requirement in compliance with International Health Regulations and the data is routinely collected for all ships and assists with disease surveillance efforts at the Bridgetown Port.

Data collection, abstraction and management

Data collected on sick individuals on board ship by the Port Health Officers were recorded during the time of the study in hard copy illness log books kept at the Bridgetown Port. The data recorded for each sick person in the log book include date, age, sex, type of illness and the name of the vessel. In a separate register the total numbers of passengers and crew on each vessel at the time of inspection were recorded. It should be noted that there is no breakdown by age and sex of the total numbers of passenger and crew.

Data were extracted from passenger and crew registers and illness logs and entered directly into an Epi Info 7 data entry form. Illness episodes were categorised into communicable and non-communicable, and within each of these into common diagnoses (the categorisation being based on a pilot study) or ‘other’. For each sick individual the following was abstracted: age, sex, name of vessel, number of passengers and crew on the vessel, and last Port of Call. Last Ports of Call were categorised into ports of the Organisation of Eastern Caribbean States, ports of other Caribbean islands, United States of America and all other ports of call.

Epi Info 7 was used for all analyses, with the only exception being the use of Openepi to calculate 95 % confidence intervals on the rates. Crude rates were calculated separately for passengers and crew, and expressed per 100,000 per year. Note that the rate is per 100,000 visits, as one individual, such as a crew member, may visit Barbados more than once over the course of a year. In describing the results, we highlight differences between two rates where the 95 % confidence do not overlap. Neither age and sex specific nor age adjusted rates could be calculated as the total numbers of passengers and crew, the denominators for the rates, were not available by sex or age group. Finally, vessels were ranked according to the number of communicable disease cases in passengers over the study period.

There were a total of 4,859,682 passenger and crew visits to Bridgetown Port and Cruise Terminal or through Barbadian territorial waters during the study period (2009–2013). Passengers and crew arrived on a variety of vessels including, cruise ships, yachts, cargo vessels, tankers, fishing vessels, tugs and research vessels. Seventy percent (70 %) of the visits were by passengers, representing 3,424,324 visits.

An overview of the total passengers and crew for the study period (2009–2013) is shown in Table  1 , including the last Port of Call for sick passengers. Over 50 % of sick passengers were aged over 60, with a median age over the study period of 64 years, while the sick crew were much younger with a median age of 31 years (Table  2 ). The majority (73 %) of the sick crew were male, compared to 48 % in passengers.

The overall event rate for communicable illnesses was 15.7 (95 % CIs 14.4–17.1) cases per 100,000 passengers whilst the overall event rate for crew was higher at 23.9 (21.6–26.7) cases per 100,000 (Tables  3 and 4 ). Gastroenteritis was the predominant illness experienced by passengers and crew, followed by influenza, and together these accounted for 87 % of all communicable disease events in crew and 93 % in passengers. . The rates of influenza recorded were higher (with non-overlapping 95 % confidence intervals) in the crew than the passengers and the rates of gastroenteritis were similar (with overlapping confidence intervals) in both groups.

It is notable that 61.3 % of all communicable diseases in passengers and crew were accounted for by only ten of the vessels over the five year period (Table  5 ), with one vessel contributing 27.5 % of all cases.

The overall event rate for non-communicable illnesses was 3.4 (2.9–4.1) per 100,000 passengers with myocardial infarction being the main non communicable illness experienced by passengers. Twenty one passengers died during the five year period, all as a result of non–communicable illness. The overall event rate for non-communicable illnesses among crew was 2.1 (1.5–3.0) per 100,000 with injuries accounting for the majority of illness in this category.

This study aimed to describe the rates of illnesses in passengers and crew at a busy Caribbean cruise port. Such data are scarce, and as far as we are aware, we provide the first published description from a Caribbean port, providing a baseline and comparison for further work.

The predominant type of illness experienced by passengers and crew over the five year period was of a communicable nature. Gastrointestinal illness was the leading cause of illnesses in this category followed by what was recorded as ‘influenza’.

Rates of infectious disease in crew were similar to those in passengers but the crew presented with a higher percentage of influenza. This may be as a result of more ideal conditions for the spread of respiratory infections such as the more confined living quarters that crew members generally occupy [ 16 ]. Overall rates of infectious disease in crew and passengers were similar and the pattern of infectious disease is similar to previous published reports, with influenza or influenza-like illness being one of the most significant communicable diseases in maritime health on passenger cruise ships as well as cargo ships [ 17 , 18 ]. Influenza-like illness outbreaks have been previously reported on cruise ships in Australia, Canada and the USA [ 19 – 22 ].

Outbreaks of gastroenteritis are also well documented occurrences on cruise ships [ 23 – 25 ] and the rates of gastroenteritis were similar in passengers and crew in our study. Even though one may expect to find higher rates of gastroenteritis in the passengers, the similar rates may be as a result of both passengers and crew practising prevention measures such as hand-washing before meals, using hand sanitizers placed in dining areas and the early reporting of symptoms. There were non-communicable illnesses recorded during the study period in both passengers and crew such as diabetes and ischaemic heart disease. The rates of the non-communicable diseases in both passengers and crew were much lower than those for communicable diseases. Acute physical injury rather than chronic illness represented the major category of non-communicable medical conditions in the crew and this likely reflects the fact that crew are generally, on average, younger than the passengers on cruise ships. While we can’t confirm age differences in passengers and crew from our data, not having the ages of all of them, the ages of those experiencing illnesses is clearly very different (Table  2 ).

It is relevant to note that a relatively small number of vessels provided the majority of cases of communicable diseases, with 10 vessels accounting for over 60 % of all report cases. It is likely that this fact represents a combination of vessel size and frequency of visit to the port. Attack rates did differ markedly between those vessels, with some appearing to favour the spread of communicable disease outbreaks more than others. Better monitoring of outbreaks and attack rates by vessel should make it possible for port health authorities to identify those vessels that may need to review their approaches to preventing and containing outbreaks.

Before concluding we note some of the limitations of this study. These include the fact that we were unable to calculate age and sex specific rates of illness in passengers and crew, as only total numbers were available. We were not able therefore to adjust for differences in age and sex composition between passengers and crew or between different vessels. It was observed as shown in Table  2 , that on average passengers are older than the crew and taking age into account may have given greater insight into differences in risk between these two groups. Another limitation is that the data rely on what is reported by the vessels medical officer, and although reporting of cases is a legal requirement it is possible that reporting thresholds differed between vessels and for passengers and crew and under-reporting is therefore a possibility. Finally, we note that when it comes to the comparison of individual vessels, we do not have a record of their number of passengers and crew on the occasions when no cases of illness were reported. We were unable therefore to compare true event rates between individual vessels.

Despite the above shortcomings we believe that we have provided the first description of rates of illness from the perspective of a Port Health Authority in the Caribbean, rather than previous reports which are based on individual vessels. The study therefore provides a baseline for future work from this perspective.

The findings of this study show a high predominance of infectious diseases such as gastroenteritis and influenza-like illness in both passengers and crew passing through a busy Caribbean cruise port and highlight the need for continuous surveillance at points of entry.

This study is the first of its kind to be undertaken in the Caribbean and provides a base-line for future studies. This is important due to the fact that the Caribbean is a major cruise destination in global terms and the industry is projected to become larger in future years.

Further research is required to determine the origins of the illnesses, whether the illnesses were introduced by boarding passengers, or were endemic among the crew or related to the environment on the vessels.

Having a robust system of disease surveillance, along with periodic and scheduled review of data collected, can play a crucial role in limiting disease spread through the cruise ship terminal. The benefits of sound public health policies in this regard would also potentially benefit the many passengers and crew aboard cruise ships.

Ethics, consent and permissions

Written ethical approval was obtained from the Institutional review Board of the University of the West Indies on the 18 th May 2014. Written consent and approval to extract and use the data for the study was given by the Barbados Port Health Authority and the Ministry of Health in Barbados.

Abbreviations

Institutional Review Board

Organisation of Eastern Caribbean States

United States of America

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The Barbados Port Health Authority

This study is a retrospective descriptive study of rates of illness experienced by passengers and crew arriving at the Bridgetown Port, Barbados between 2009 and 2013.

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Cathy Ann Marshall

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Euclid Morris

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The three named authors CM, EM, NU were all involved in the conceptualisation and design of the study. CM undertook the data collection and the initial drafting of the manuscript. EM and NU performed bio-statistical analysis and the redrafting of the report towards producing the final manuscript. The three named authors CM, EM and NU are in agreement to be accountable for all aspects of the work.

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Marshall, C.A., Morris, E. & Unwin, N. An epidemiological study of rates of illness in passengers and crew at a busy Caribbean cruise port. BMC Public Health 16 , 314 (2016). https://doi.org/10.1186/s12889-016-2991-3

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Cruise Ship Travel

CDC Respiratory Virus Guidance has been updated. The content of this page will be updated soon.

While cruising is a popular way to travel, there are some health concerns to be aware of. Find out more about health issues on cruises and steps you can take to stay safe and healthy during your trip.

If you are feeling sick before your voyage, do not travel and ask your cruise line about rescheduling or reimbursement options. If you feel sick during your voyage, report your symptoms to the ship’s medical center and follow their recommendations.

Common Health Concerns During Cruise Travel and what You Can Do to Prevent Illness

• Respiratory illnesses like influenza , COVID-19 , and the common cold. Get your annual flu shot and get up to date on your COVID-19 vaccines . Check directly with your cruise line about their COVID-19 testing or vaccination protocols before travel. If you have a weakened immune system , talk with your healthcare provider about your cruise travel plans. Wash your hands frequently or use hand sanitizer . When you cough or sneeze, cover your nose and mouth with a tissue to prevent spreading germs. Consider wearing a mask in crowded or poorly ventilated indoor areas.
• Norovirus. Symptoms of vomiting and diarrhea, primarily caused by outbreaks of norovirus, have been reported. To prevent norovirus , wash your hands with soap and water before eating and after using the bathroom, changing diapers, or touching things that other people have touched, such as stair railings. Avoid touching your face. For more information, visit CDC’s  Vessel Sanitation Program  website.
• Seasickness. Cruise ship passengers may experience seasickness or motion sickness. If you know you get seasick or think you may be likely to get seasick, talk to your healthcare provider about medicine to reduce your symptoms. Some common medications, including some antidepressants, painkillers, and birth control pills, can make seasickness worse.
• Sunburns. Apply sunscreen with SPF 15 or higher when traveling. Protecting yourself from the sun isn’t just for tropical beaches—you can get a sunburn even if it’s cloudy or cold.
• Bug bites. On your trip, use insect repellent and take other steps to avoid bug bites. Bugs, including mosquitoes and ticks, can spread diseases such as malaria, yellow fever, Zika, dengue, chikungunya, and Lyme. Many ships visit ports where these diseases are a concern.

Before Your Trip

Check CDC’s destination pages for travel health information . Check CDC’s webpage for your destination to see what vaccines or medicines you may need and what diseases or health risks are a concern at your destination.

Make sure you are up to date with all of your routine vaccines . Routine vaccinations protect you from infectious diseases  that can spread quickly in groups of people. Outbreaks of chickenpox, influenza, and COVID-19 have been reported on cruise ships.

Many diseases prevented by routine vaccination are not common in the United States but are still common in other countries. Crew members and fellow travelers often board a cruise ship from destinations where some diseases are more common than in the United States or where vaccination is not routine.

Make an appointment with your healthcare provider or a travel health specialist  that takes place at least one month before you leave. They can help you get destination-specific vaccines, medicines, and information. Discussing your health concerns, itinerary, and planned activities with your provider allows them to give more specific advice and recommendations.

Plan for the Unexpected

Prepare for any unexpected issues during your cruise ship travels with the following steps:

Prepare a  travel health kit  with items you may need, especially those items that may be difficult to find at your destination. Include your prescriptions and over-the-counter medicines in your travel health kit and take enough to last your entire trip, plus extra in case of travel delays. Depending on your destination you may also want to pack a mask ,  insect repellent , sunscreen (SPF15 or higher), aloe, alcohol-based hand sanitizer, water disinfection tablets, and your health insurance card.

Get travel insurance.  Find out if your health insurance covers medical care abroad. Travelers are usually responsible for paying hospital and other medical expenses out of pocket at most destinations. Make sure you have a plan to  get care overseas , in case you need it. Consider buying  additional insurance  that covers health care and emergency evacuation, especially if you will be traveling to remote areas.

If you need medical care abroad, see Getting Health Care During Travel .

After Travel

If you traveled and feel sick, particularly if you have a fever, talk to a healthcare provider and tell them about your travel. Avoid contact with other people while you are sick.

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Over 250 Cruise Ship Passengers Reported Sick With Possible Norovirus

C oncerns regarding health and safety on cruise ships have heightened by the news that more than 250 people on board the P&O ship Ventura became sick with symptoms similar to norovirus. This highly contagious virus is known for causing gastroenteritis. The Ventura embarked on a 14-night voyage to the Canary Islands on May 11. It has since been the subject of enhanced sanitation protocols to curb the spread of the illness.

Norovirus, often dubbed the “winter vomiting bug,” is notorious for its rapid spread in enclosed environments like cruise ships , hospitals, and schools. It causes symptoms such as vomiting, diarrhea, fever, and abdominal pain, which can be unpleasant for those affected. According to reports , the Ventura is almost at total capacity, with just under 3,000 passengers on board. Such a number makes the outbreak all the more concerning.

Disease Outbreaks on Cruise Ships

P&O Cruises and the Southampton Port Health Authority verified the virus’s presence. Passengers exhibiting symptoms had to isolate in their cabins to prevent further spread. The recent outbreak is not an isolated incident. The cruise industry has faced similar challenges in the past, with the Centers for Disease Control and Prevention (CDC) reporting several outbreaks aboard different cruise lines earlier this year. Notably, the Radiance of the Seas and Sapphire Princess saw almost 200 passengers sickened by the norovirus in April alone.

The outbreak on the Ventura prompted a response from health authorities, with Southampton Port Health Authority working alongside the UK Health Security Agency (UKHSA) to assist with the ship’s return. The UKHSA had already noted an unusual spike in norovirus cases nationwide in April. Cruise ships are particularly susceptible to norovirus due to the close quarters in which passengers live, dine, and socialize . The virus can spread rapidly through contaminated food, surfaces, or contact with an infected person.

This latest outbreak has led to calls for increased vigilance and adherence to hygiene protocols among passengers and crew. Critics argue that more must be done. They suggest cruise lines should be very transparent about health risks. They should also take greater preventative measures. In response to the current situation, P&O Cruises has apologized to affected passengers and reiterated that their well-being is the highest priority.

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Public Health Responses to COVID-19 Outbreaks on Cruise Ships — Worldwide, February–March 2020

Weekly / March 27, 2020 / 69(12);347-352

On March 23, 2020, this report was posted online as an MMWR Early Release.

Please note: This report has been corrected .

Leah F. Moriarty, MPH 1 ; Mateusz M. Plucinski, PhD 1 ; Barbara J. Marston, MD 1 ; Ekaterina V. Kurbatova, MD, PhD 1 ; Barbara Knust, DVM 1 ; Erin L. Murray, PhD 2 ; Nicki Pesik, MD 1 ; Dale Rose, PhD 1 ; David Fitter, MD 1 ; Miwako Kobayashi, MD, PhD 1 ; Mitsuru Toda, PhD 1 ; start highlight Paul T. Cantey, MD 1 ; end highlight Tara Scheuer, MPH 3 ; Eric S. Halsey, MD 1 ; Nicole J. Cohen, MD 1 ; Lauren Stockman, MPH 2 ; Debra A. Wadford, PhD 2 ; Alexandra M. Medley, DVM 1 ,4 ; Gary Green, MD 5 ; Joanna J. Regan, MD 1 ; Kara Tardivel, MD 1 ; Stefanie White, MPH 1 ; start highlight Clive Brown, MD 1 ; end highlight Christina Morales, PhD 2 ; Cynthia Yen, MPH 2 ; Beth Wittry, MPH 1 ; Amy Freeland, PhD 1 ; Sara Naramore, MPH 3 ; Ryan T. Novak, PhD 1 ; David Daigle, MPH 1 ; Michelle Weinberg, MD 1 ; Anna Acosta, MD 1 ; Carolyn Herzig, PhD 1 ; Bryan K Kapella, MD 1 ; Kathleen R. Jacobson, MD 2 ; Katherine Lamba, MPH 2 ; Atsuyoshi Ishizumi, MPH, MSc 1 ; John Sarisky, MPH 1 ; Erik Svendsen, PhD 1 ; Tricia Blocher, MS 2 ; Christine Wu, MD 3 ; Julia Charles, JD 1 ; Riley Wagner, MPH 1 ; Andrea Stewart, PhD 1 ; Paul S. Mead, MD 1 ; Elizabeth Kurylo, MCM 1 ; Stefanie Campbell, DVM 1 ; Rachel Murray, MPH 1 ; Paul Weidle, PharmD 1 ; Martin Cetron, MD 1 ; Cindy R. Friedman, MD 1 ; CDC Cruise Ship Response Team; California Department of Public Health COVID-19 Team; Solano County COVID-19 Team ( View author affiliations )

What is already known about this topic?

Cruise ships are often settings for outbreaks of infectious diseases because of their closed environment and contact between travelers from many countries.

What is added by this report?

More than 800 cases of laboratory-confirmed COVID-19 cases occurred during outbreaks on three cruise ship voyages, and cases linked to several additional cruises have been reported across the United States. Transmission occurred across multiple voyages from ship to ship by crew members; both crew members and passengers were affected; 10 deaths associated with cruise ships have been reported to date.

What are the implications for public health practice?

Outbreaks of COVID-19 on cruise ships pose a risk for rapid spread of disease beyond the voyage. Aggressive efforts are required to contain spread. All persons should defer all cruise travel worldwide during the COVID-19 pandemic.

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An estimated 30 million passengers are transported on 272 cruise ships worldwide each year* ( 1 ). Cruise ships bring diverse populations into proximity for many days, facilitating transmission of respiratory illness ( 2 ). SARS-CoV-2, the virus that causes coronavirus disease (COVID-19) was first identified in Wuhan, China, in December 2019 and has since spread worldwide to at least 187 countries and territories. Widespread COVID-19 transmission on cruise ships has been reported as well ( 3 ). Passengers on certain cruise ship voyages might be aged ≥65 years, which places them at greater risk for severe consequences of SARS-CoV-2 infection ( 4 ). During February–March 2020, COVID-19 outbreaks associated with three cruise ship voyages have caused more than 800 laboratory-confirmed cases among passengers and crew, including 10 deaths. Transmission occurred across multiple voyages of several ships. This report describes public health responses to COVID-19 outbreaks on these ships. COVID-19 on cruise ships poses a risk for rapid spread of disease, causing outbreaks in a vulnerable population, and aggressive efforts are required to contain spread. All persons should defer all cruise travel worldwide during the COVID-19 pandemic.

During February 7–23, 2020, the largest cluster of COVID-19 cases outside mainland China occurred on the Diamond Princess cruise ship, which was quarantined in the port of Yokohama, Japan, on February 3 ( 3 ). On March 6, cases of COVID-19 were identified in persons on the Grand Princess cruise ship off the coast of California; that ship was subsequently quarantined. By March 17, confirmed cases of COVID-19 had been associated with at least 25 additional cruise ship voyages. On February 21, CDC recommended avoiding travel on cruise ships in Southeast Asia; on March 8, this recommendation was broadened to include deferring all cruise ship travel worldwide for those with underlying health conditions and for persons aged ≥65 years. On March 13, the Cruise Lines International Association announced a 30-day voluntary suspension of cruise operations in the United States ( 5 ). CDC issued a level 3 travel warning on March 17, recommending that all cruise travel be deferred worldwide. †

Diamond Princess

On January 20, 2020, the Diamond Princess cruise ship departed Yokohama, Japan, carrying approximately 3,700 passengers and crew ( Table ). On January 25, a symptomatic passenger departed the ship in Hong Kong, where he was evaluated; testing confirmed SARS-CoV-2 infection. On February 3, the ship returned to Japan, after making six stops in three countries. Japanese authorities were notified of the COVID-19 diagnosis in the passenger who disembarked in Hong Kong, and the ship was quarantined. Information about social distancing and monitoring of symptoms was communicated to passengers. On February 5, passengers were quarantined in their cabins; crew continued to work and, therefore, could not be isolated in their cabins ( 6 ). Initially, travelers with fever or respiratory symptoms and their close contacts were tested for SARS-CoV-2 by reverse transcription–polymerase chain reaction (RT-PCR). All those with positive test results were disembarked and hospitalized. Testing was later expanded to support a phased disembarkation of passengers, prioritizing testing of older persons, those with underlying medical conditions, and those in internal cabins with no access to the outdoors. During February 16–23, nearly 1,000 persons were repatriated by air to their home countries, including 329 persons who returned to the United States and entered quarantine or isolation. § , ¶

The remaining passengers who had negative SARS-CoV-2 RT-PCR test results,** no respiratory symptoms, and no close contact with a person with a confirmed case of COVID-19 completed a 14-day ship-based quarantine before disembarkation. Those passengers who had close contact with a person with a confirmed case completed land-based quarantine, with duration determined by date of last contact. After disembarkation of all passengers, crew members either completed a 14-day ship-based quarantine, were repatriated to and managed in their home country, or completed a 14-day land-based quarantine in Japan.

Overall, 111 (25.9%) of 428 U.S. citizens and legal residents did not join repatriation flights either because they had been hospitalized in Japan or for other reasons. To mitigate SARS-CoV-2 importation into the United States, CDC used temporary “Do Not Board” restrictions ( 7 ) to prevent commercial airline travel to the United States, †† and the U.S. Departments of State and Homeland Security restricted travel to the United States for non-U.S. travelers.

Among 3,711 Diamond Princess passengers and crew, 712 (19.2%) had positive test results for SARS-CoV-2 ( Figure 1 ). Of these, 331 (46.5%) were asymptomatic at the time of testing. Among 381 symptomatic patients, 37 (9.7%) required intensive care, and nine (1.3%) died ( 8 ). Infections also occurred among three Japanese responders, including one nurse, one quarantine officer, and one administrative officer ( 9 ). As of March 13, among 428 U.S. passengers and crew, 107 (25.0%) had positive test results for COVID-19; 11 U.S. passengers remain hospitalized in Japan (median age = 75 years), including seven in serious condition (median age = 76 years).

Grand Princess

During February 11–21, 2020, the Grand Princess cruise ship sailed roundtrip from San Francisco, California, making four stops in Mexico (voyage A). Most of the 1,111 crew and 68 passengers from voyage A remained on board for a second voyage that departed San Francisco on February 21 (voyage B), with a planned return on March 7 (Table). On March 4, a clinician in California reported two patients with COVID-19 symptoms who had traveled on voyage A, one of whom had positive test results for SARS-CoV-2. CDC notified the cruise line, which began cancelling group activities on voyage B. More than 20 additional cases of COVID-19 among persons who did not travel on voyage B have been identified from Grand Princess voyage A, the majority in California. One death has been reported. On March 5, a response team was transported by helicopter to the ship to collect specimens from 45 passengers and crew with respiratory symptoms for SARS-CoV-2 testing; 21 (46.7%), including two passengers and 19 crew, had positive test results. Passengers and symptomatic crew members were asked to self-quarantine in their cabins, and room service replaced public dining until disembarkation. Following docking in Oakland, California, on March 8, passengers and crew were transferred to land-based sites for a 14-day quarantine period or isolation. Persons requiring medical attention for other conditions or for symptoms consistent with COVID-19 were evaluated, tested for SARS-CoV-2 infection, and hospitalized if indicated. During land-based quarantine in the United States, all persons were offered SARS-CoV-2 testing. As of March 21, of 469 persons with available test results, 78 (16.6%) had positive test results for SARS-CoV-2. Repatriation flights for foreign nationals were organized by several governments in coordination with U.S. federal and California state government agencies. Following disinfection of the vessel according to guidance from CDC’s Vessel Sanitation Program, remaining foreign nationals will complete quarantine on board. The quarantine will be managed by the cruise company, with technical assistance provided by public health experts.

On February 21, five crew members from voyage A transferred to three other ships with a combined 13,317 passengers on board. No-sail orders §§ were issued by CDC for these ships until medical logs were reviewed and the crew members tested negative for SARS-CoV-2.

Additional Ships

The Diamond Princess and Grand Princess had more than 800 total COVID-19 cases, including 10 deaths. During February 3–March 13, in the United States, approximately 200 cases of COVID-19 were confirmed among returned cruise travelers from multiple ship voyages, including the Diamond Princess and Grand Princess, accounting for approximately 17% of total reported U.S. cases at the time ( 10 ). Cases linked with cruise travel have been reported to CDC in at least 15 states. Since February, multiple international cruises have been implicated in reports of COVID-19 cases, including at least 60 cases in the United States from Nile River cruises in Egypt ( Figure 2 ). Secondary community-acquired cases linked to returned passengers on cruises have also been reported (CDC, unpublished data, 2020).

Public health responses to COVID-19 outbreaks on cruise ships were aimed at limiting transmission among passengers and crew, preventing exportation of COVID-19 to other communities, and assuring the safety of travelers and responders. These responses required the coordination of stakeholders across multiple sectors, including U.S. Government departments and agencies, foreign ministries of health, foreign embassies, state and local public health departments, hospitals, laboratories, and cruise ship companies. At the time of the Diamond Princess outbreak, it became apparent that passengers disembarking from cruise ships could be a source of community transmission. Therefore, aggressive efforts to contain transmission on board and prevent further transmission upon disembarkation and repatriation were instituted. These efforts included travel restrictions applied to persons, movement restrictions applied to ships, infection prevention and control measures, (e.g., use of personal protective equipment for medical and cleaning staff), disinfection of the cabins of persons with suspected COVID-19, provision of communication materials, notification of state health departments, and investigation of contacts of cases identified among U.S. returned travelers.

Cruise ships are often settings for outbreaks of infectious diseases because of their closed environment, contact between travelers from many countries, and crew transfers between ships. On the Diamond Princess, transmission largely occurred among passengers before quarantine was implemented, whereas crew infections peaked after quarantine ( 6 ). On the Grand Princess, crew members were likely infected on voyage A and then transmitted SARS-CoV-2 to passengers on voyage B. The results of testing of passengers and crew on board the Diamond Princess demonstrated a high proportion (46.5%) of asymptomatic infections at the time of testing. Available statistical models of the Diamond Princess outbreak suggest that 17.9% of infected persons never developed symptoms ( 9 ). A high proportion of asymptomatic infections could partially explain the high attack rate among cruise ship passengers and crew. SARS-CoV-2 RNA was identified on a variety of surfaces in cabins of both symptomatic and asymptomatic infected passengers up to 17 days after cabins were vacated on the Diamond Princess but before disinfection procedures had been conducted (Takuya Yamagishi, National Institute of Infectious Diseases, personal communication, 2020). Although these data cannot be used to determine whether transmission occurred from contaminated surfaces, further study of fomite transmission of SARS-CoV-2 aboard cruise ships is warranted.

During the initial stages of the COVID-19 pandemic, the Diamond Princess was the setting of the largest outbreak outside mainland China. Many other cruise ships have since been implicated in SARS-CoV-2 transmission. Factors that facilitate spread on cruise ships might include mingling of travelers from multiple geographic regions and the closed nature of a cruise ship environment. This is particularly concerning for older passengers, who are at increased risk for serious complications of COVID-19 ( 4 ). The Grand Princess was an example of perpetuation of transmission from crew members across multiple consecutive voyages and the potential introduction of the virus to passengers and crew on other ships. Public health responses to cruise ship outbreaks require extensive resources. Temporary suspension of cruise ship travel during the current phase of the COVID-19 pandemic has been partially implemented by cruise lines through voluntary suspensions of operations, and by CDC through its unprecedented use of travel notices and warnings for conveyances to limit disease transmission ( 5 ).

Acknowledgments

Staff members responding to COVID-19 outbreaks on cruise ships; Japan’s Ministry of Health, Labour and Welfare; California Department of Public Health; cruise ship passengers; Princess Cruises; Christina Armantas, Matthew Bacinskas, Cynthia Bernas, Brandon Brown, Teal Bullick, Lyndsey Chaille, Martin Cilnis, Gail Cooksey, Ydelita Gonzales, Christopher Kilonzo, Chun Kim, Ruth Lopez, Dominick Morales, Chris Preas, Kyle Rizzo, Hilary Rosen, Sarah Rutschmann, Maria Vu, California Department of Public Health, Richmond and Sacramento; Ben Gammon, Ted Selby, Solano County Public Health; Medic Ambulance Service; NorthBay HealthCare; Sutter Solano Medical Center; Kaiser Permanente Vallejo Medical Center; Kaiser Permanente Vacaville Medical Center start highlight ; field teams at repatriation sites; National Institute of Infectious Diseases, Japan end highlight .

CDC Cruise Ship Response Team

Casey Barton Behravesh, CDC; Adam Bjork, CDC; William Bower, CDC; Catherine Bozio, CDC; Zachary Braden, CDC; Mary Catherine Bertulfo, CDC; Kevin Chatham-Stephens, CDC; Victoria Chu, CDC; Barbara Cooper, CDC; Kathleen Dooling, CDC; Christine Dubray, CDC; Emily Curren, CDC; Margaret A. Honein, CDC; Kathryn Ivey, CDC; Jefferson Jones, CDC; Melissa Kadzik, CDC; Nancy Knight, CDC; Mariel Marlow, CDC; Audrey McColloch, CDC; Robert McDonald, CDC; Andrew Klevos, CDC; Sarah Poser, CDC; Robin A. Rinker, CDC; Troy Ritter, CDC; Luis Rodriguez, CDC; Matthew Ryan, CDC; Zachary Schneider, CDC; Caitlin Shockey, CDC; Jill Shugart, CDC; Margaret Silver, CDC; Paul W. Smith, CDC; Farrell Tobolowsky, CDC; Aimee Treffiletti, CDC; Megan Wallace, CDC; Jonathan Yoder, CDC.

California Department of Public Health COVID-19 Team

Pennan Barry, California Department of Public Health; Ricardo Berumen, III, California Department of Public Health; Brooke Bregman, California Department of Public Health; Kevin Campos, California Department of Public Health; Shua Chai, California Department of Public Health; Rosie Glenn-Finer, California Department of Public Health; Hugo Guevara, California Department of Public Health; Jill Hacker, California Department of Public Health; Kristina Hsieh, California Department of Public Health; Mary Kate Morris, California Department of Public Health; Ryan Murphy, California Department of Public Health; Jennifer F. Myers, California Department of Public Health; Tasha Padilla, California Department of Public Health; Chao-Yang Pan, California Department of Public Health; Adam Readhead, California Department of Public Health; Estela Saguar, California Department of Public Health; Maria Salas, California Department of Public Health; Robert E. Snyder, California Department of Public Health; Duc Vugia, California Department of Public Health; James Watt, California Department of Public Health; Cindy Wong, California Department of Public Health.

Solano County COVID-19 Team

Meileen Acosta, Solano County Department of Public Health; Shai Davis, Solano County Department of Public Health; Beatrix Kapuszinsky, Solano County Department of Public Health; Bela Matyas, Solano County Department of Public Health; Glen Miller, Solano County Department of Public Health; Asundep Ntui, Solano County Department of Public Health; Jayleen Richards, Solano County Department of Public Health.

Corresponding author: Leah F. Moriarty, [email protected] , 770-488-7100.

1 CDC COVID-19 Response Team; 2 California Department of Public Health; 3 Solano Public Health, Fairfield, California; 4 Epidemic Intelligence Service, CDC; 5 Sutter Medical Group of the Redwoods, Santa Rosa, California.

All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

* Not including river cruises.

† Warning level 3: avoid non-essential travel due to widespread ongoing transmission: https://wwwnc.cdc.gov/travel/notices/warning/novel-coronavirus-china .

§ Quarantine was used for persons who were exposed; isolation was used for persons who had positive test results for SARS-CoV-2.

¶ Movement for one person with resolved COVID-19 was not restricted.

** Based on Japanese testing procedures, which at the time included taking one oropharyngeal swab.

†† Travel restrictions were lifted when persons had either completed a 14-day monitoring period without symptoms or had met clinical criteria for release from isolation. https://japan2.usembassy.gov/pdfs/alert-20200227-diamond-princess.pdf .

§§ CDC has the authority to institute a no-sail order to prevent ships from sailing when it is reasonably believed that continuing normal operations might subject newly arriving passengers to disease.

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Abbreviation: N/A = not applicable.

FIGURE 1 . Cumulative number of confirmed coronavirus disease 2019 (COVID-19) cases* by date of detection — Diamond Princess cruise ship, Yokohama, Japan, February 3–March 16, 2020

Source: World Health Organization (WHO) coronavirus disease (COVID-2019) situation reports. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/ .

* Decline in cumulative number of cases on February 13 and February 25 due to correction by WHO for cases that had been counted twice.

FIGURE 2 . Cruise ships with coronavirus disease 2019 (COVID-19) cases requiring public health responses — worldwide, January–March 2020

Suggested citation for this article: Moriarty LF, Plucinski MM, Marston BJ, et al. Public Health Responses to COVID-19 Outbreaks on Cruise Ships — Worldwide, February–March 2020. MMWR Morb Mortal Wkly Rep 2020;69:347-352. DOI: http://dx.doi.org/10.15585/mmwr.mm6912e3 .

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