From COVID to gastro, why are cruise ships such hotbeds of infection?

Aerial shot of a cruise ship

Thea van de Mortel, Griffith University

Dual outbreaks of gastro and COVID on the Grand Princess cruise ship that docked in Adelaide on Monday have now been declared over by the doctor on board.

A spokesperson for Princess Cruises, which operates the ship, said a number of passengers had presented with symptoms on a previous voyage. But the ship has since been disinfected and the number of people who were ill when the ship arrived in Adelaide was said to be in single digits.

While this is positive news, reports of infectious outbreaks on cruise ships evoke a sense of deja vu. We probably all remember the high-profile COVID outbreaks that occurred on cruise ships in 2020.

So what is it about cruise ships that can make them such hotspots for infection?

First, what causes these outbreaks?

Respiratory infectious outbreaks on cruise ships may be caused by a range of pathogens including SARS-CoV-2 (the virus that causes COVID) and influenza viruses. These can be spread by respiratory droplets and aerosols released when people breathe, talk, laugh, cough and sneeze.

Historically, troop transport ships also helped to spread the lethal 1918 flu virus between continents.

Gastro outbreaks on cruise ships are similarly well documented. More than 90 per cent of cruise ship gastro outbreaks are caused by norovirus, which is spread from person to person, and through contaminated objects or contaminated food or water.

Gastro can also be caused by other pathogens such as bacteria in contaminated food or water.

What is the risk?

In 2020, around 19 per cent of Diamond Princess passengers and crew docked in Japan tested positive to COVID. Ultimately, nearly one in four Ruby Princess passengers and crew docked in Sydney tested positive.

However, COVID generally presents a lesser risk nowadays, with most people having some level of immunity from vaccination or previous infection. The outbreak on the Grand Princess appears to have been much smaller in scale.

A three-year study before COVID of influenza-like illness (which includes fever), acute respiratory illness (which doesn’t require fever to be present) and gastro on cruise ships found these were diagnosed in 32.7 per cent, 15.9 per cent and 17 per cent of ill passengers, and 10.9 per cent, 80 per cent and 0.2 per cent of ill crew, respectively.

An analysis of data from 252 cruise ships entering American ports showed the overall incidence of acute gastro halved between 2006 and 2019. Passenger cases decreased from 32.5 per 100,000 travel days to 16.9, and crew cases from 13.5 per 100,000 travel days to 5.2. This decline may be due to a combination of improved hygiene and sanitation standards.

The risk of getting sick with gastro was significantly higher on bigger ships and longer voyages. This is because the longer you are in close contact with others, the greater the chance of exposure to an infectious dose of viruses or bacteria.

A table with buffet food on a ship.
Buffets are one of the factors that can contribute to the risk of infection on a cruise. Solarisys/Shutterstock

Why are cruise ships infection hotspots?

On cruise ships, people tend to crowd together in confined spaces for extended periods. These include dining halls, and during social activities in casinos, bars and theatres.

The risk goes up when the environment is noisy, as more droplets and aerosols are shed when people are laughing, shouting or talking loudly.

Passengers may come from multiple countries, potentially bringing variants from different parts of the world. Influenza, which is usually seasonal (late autumn to early spring) onshore, can occur at any time on a cruise ship if it has international passengers or is calling at international ports.

Human behaviour also contributes to the risk. Some passengers surveyed following cruise ship gastro outbreaks indicated they were ill when they boarded the ship, or they became ill but didn’t disclose this because they didn’t want to pay for a doctor or be made to isolate, or they thought it wasn’t serious.

Those who became ill were more likely than those who did not to think that hand hygiene and isolation were not effective in preventing infection transmission, and were less likely to wash their hands after using the toilet. Given faecal contamination is a major source of norovirus transmission, this is concerning.

While there are usually a la carte dining options on board, many people will choose a buffet option. From personal experience, food tongs are handled by multiple people, some of whom may not have cleaned their hands.

What can help?

The Department of Health and Aged Care recommends cruise companies encourage crew and passengers to be up to date with flu and COVID vaccinations, and encourage anyone who becomes ill to stay in their cabin, or at least avoid crowded spaces and wear a mask in public.

They also recommend cruise ships have a plan to identify and contain any outbreaks, including testing and treatment capacity, and communicate to passengers and crew how they can reduce their transmission risk.

All passengers and crew should report any signs of infectious illness, and practice good hand hygiene and respiratory etiquette, such as covering their mouth if coughing or sneezing, disposing of used tissues, and washing or sanitising hands after touching their mouth or nose.

South Australia’s chief health officer has commended the Grand Princess crew for their infection protection and control practices, and for getting the outbreak under control.

Thea van de Mortel, Professor, Nursing, School of Nursing and Midwifery, Griffith University

This article is republished from The Conversation under a Creative Commons licence. Read the original article.

Have you ever become sick on a cruise? What did you get and how did you get better? Why not share your experience in the comments section below?

Also read: Why you might feel dizzy after a cruise

Written by The Conversation

The Conversation Australia and New Zealand is a unique collaboration between academics and journalists that is the world’s leading publisher of research-based news and analysis.

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  1. The Main Reason

    Arrogant people don’t wash their hands, touch food with hands in the buffet, refuse to sanitize, refuse to get tested for Covid and won’t stay in their stateroom when infected.

    This bad behaviour has been seen on ships. When you were allowed to eat and drink without your mask, they would walk around the ship with a drink in their hand. Crew were abused when passengers sneezed and were told to go to the medical centre and be tested.

    Mainly arrogant Americans who thought such things contravened their human rights..

  2. Why are you always try and give Cruises a bad name, the only reason that data is released by the Cruise Companies is because they have to give details by law, you never hear about Hotels, Airports, or any other place where people congregate tell how many people are sick with anything so, please give it a break and not be like the press that loves beating up the cruise ships.

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