what is the cruise ship illness

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What is norovirus and how do you treat it? What to know about the ‘cruise ship virus’

Summer travel has returned and people are flocking to cruises again, with more than 31.5 million passengers expected to sail in 2023.

But sometimes people get sick while onboard.

Upset stomach or nausea? It could be sea sickness. Food poisoning. Or maybe it’s norovirus, a contagious virus that often keeps you at the toilet for several days. Some people know it as the “cruise ship virus” because it’s often the cause of over 90% of diarrhea outbreaks on cruise ships, according to the Centers for Disease Control and Prevention.

So far, cruise lines have reported 13 separate norovirus outbreaks to the CDC through the six months ending in June. It’s the most number of reported norovirus outbreaks on cruise ships since 2012, when there were 16.

What is norovirus? And how do you treat it?

Here’s what to know:

What is norovirus?

▪ Sometimes known as the “stomach flu” or “stomach bug,” noroviruses are a very contagious virus that often causes vomiting, diarrhea, nausea and stomach pain. However, the virus is not related to the flu, which is caused by influenza.

How common is it?

▪ Norovirus is the “leading cause of vomiting and diarrhea and food-borne illness in the United States,” with more than 2,500 norovirus outbreaks reported every year, according to the CDC.

▪ The federal health agency says that the virus, on average, causes 19 to 21 million illnesses in the U.S. each year. While most people recover, the virus does cause about 900 deaths a year, mostly in adults 65 and older.

▪ While the virus has garnered the nickname “cruise ship virus,” in reality, norovirus outbreaks on cruise ships account for only 1% of all reported norovirus outbreaks, the CDC says. In fact, acute gastrointestinal illness is fairly uncommon on cruise ships, the agency says.

How does norovirus spread?

▪ Norovirus spreads easily and can make anyone ill, with symptoms usually lasting one to three days. The virus most often spreads in closed and crowded environments, such as hospitals, nursing homes, child care centers, school and cruise ships, according to the Mayo Clinic.

▪ You can get norovirus in a variety of ways, such as by eating or drinking contaminated food and drinks, touching an infected surface and then touching your mouth or having direct contact with someone ill from the virus, according to the CDC.

How is it treated?

▪ While there is no specific treatment to treat the illness, the CDC recommends drinking lots of water or other drinks, like sports drinks, that don’t have caffeine or alcohol to help avoid dehydration.

▪ The best way to reduce your risk of falling ill? Wash your hands often with soap and water. And while you might still have a closet full of hand sanitizer from the COVID days, keep in mind that hand sanitizer doesn’t work well against norovirus.

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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.

life preserver on wall of cruise ship pier

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 Norovirus Outbreaks

Here are listed latest cruise ship Norovirus outbreaks on passenger ships, with information what is and how to avoid Norovirus on cruise ships, CDC reports, and news updates.

From the following links, you can skip the intro and jump directly to illness outbreaks in 2024 , 2023 , 2022 , 2020 , 2019 , 2018 , 2017 , 2016 , 2015 , 2014 , 2013 , 2012 , also read about Zika virus , Seasickness , Hospital (shipboard infirmary) and Mercy Ships (hospital ship Africa Mercy) .

Note: The following CruiseMapper link provides information on Coronavirus/COVID outbreaks on cruise ships .

Norovirus outbreaks on cruise ships in 2024

Cruise norovirus outbreaks updates.

Norovirus on ships is spread through contaminated water, foods and surfaces (public restrooms, railings, doorknobs, handles, board games-cards-puzzles-toys, etc). Norovirus withstands chlorine, prolonged exposure outside the body, as well as temperature extremes. Like a virus, Norwalk can't be effectively treated with antibiotics, making it extremely difficult to eliminate in closed environments - like cruise vessels.

Norovirus may incubate up to 48 hours before the symptoms appear. This makes it difficult to restrict an outbreak. Noro symptoms include nausea, vomiting (kids more than adults, abdominal cramps, diarrhea, general weakness, low fever, headache, muscle aches. The illness could last up to 5 days (depending on the person's age, general health, and severity of the exposure to the virus. Recovered patients can still spread the virus for up to 2 weeks.

Quarantining the ill passengers and crew to their cabins is mandatory (at least for 48 hours) to slow the outbreak's spread. Failing to comply with the crew's orders results in fines or even discharge from the ship.

CruiseMapper's Norovirus survey is based on official data from CDC.gov (USA's "Centers for Disease Control and Prevention"). CDC's "Vessel Sanitation Program" assists the cruise tourism industry in preventing and controlling the transmission and spread of gastrointestinal illnesses (Norovirus, ETEC) on passenger ships calling on US seaports.

Cruise Ship Norovirus - CruiseMapper CruiseMinus

This program operates under the authority of the Public Health Service Act (fda.gov, "Quarantine and Inspection Regulations to Control Communicable Diseases"). CDC sanitation inspections on passenger ships are conducted twice a year. Scores of 86 are considered passing. Among the issues that CDC health inspectors usually find on board and report are:

food debris
dead insects
insect droppings
records indicating crewmembers (including cooks and galley staff) working while sick (suffering from gastrointestinal disorders or with acute gastroenteritis/AGE symptoms)
cracked/corroded equipment
soiled cutting boards
food served undercooked
lack of safety instruction signs.

CDC cruise ship Norovirus reports

Cruise ship outbreaks are reported (posted on the CDC website) when the illness incident meets the following criteria:

The ship falls within the purview of the Vessel Sanitation Program (VSP). This means if it carries 13+ passengers and has a foreign cruise itinerary with US ports of call in it. Keep in mind, that most departures are from US-based home ports.
The ship cruise itinerary length is between 3 and 21 days,
The ship carries 100+ passengers.
The percentage of infected passengers or crew (cases reported to the ship's med staff) during the cruise is 3% or more. This means small outbreaks on cruise ships will not be reported to the CDC.

CDC cruise ship inspection fees are payable by the shipowner. Fees are based on the vessel's size. VSP doesn't charge fees for consultations related to shipping facilities renovations or new ships. Inspection fees are as follows.

Small ships (under 3000 GT/gross tons) pay USD 1500 per inspection.
Small ships (between 3000-15000 GT) pay USD 3000 per inspection.
Medium ships (between 15000-30000 GT) pay USD 6000 per inspection.
Large ships (between 30000-60000 GT) pay USD 9000 per inspection.
Extra-large ships (between 60000-120000 GT) pay USD 12000 per inspection.
Mega-liners (above 120000 GT) pay USD 18000 per inspection.

Note: When the itinerary doesn't include US cruise ports, the ship is not required to report to CDC, thus no official illness outbreak report would be issued.

CDC ship illness outbreak investigations

VSP (abbrev "Vessel Sanitation Program") monitors CDC's observations on illness patterns for GI (gastrointestinal) outbreaks on passenger shipping vessels ( ferries and cruise ships ).

VSP conducts outbreak investigations only in cases with 3% or more passengers or crew reported sick with GI symptoms. VSP may also conduct outbreak investigations in cases of unusual GI illness patterns (even if the rate is less than 3%).
VSP conducts outbreak investigations only on vessels visiting ports in the USA or which are within 15 days of arriving at a US port.
When an outbreak occurs, VSP asks for ship logs and infirmary records of reported GI cases (symptoms and timing) and illness distribution (among passengers/crew, during each day of the cruise).
VSP staff usually boards the vessel for epidemiological assessment, interviews, distribution and analysis of illness questionnaires, monitoring cleaning procedures.
Lab investigations - the onboard med staff often collects stool, vomit, blood specimens, which are then sent to land-based labs to confirm the illness cause.

During the onboard illness outbreak, VSP requires the cruise company to activate the "Outbreak Prevention and Response Plan" (vessel's response to illness cases).

During an outbreak:

Cleaning and disinfection frequencies are Increased.
Self-service buffets are stopped.
All infected (pax/crew) are quarantined to their staterooms/cabins
Clinical specimens are collected for analysis.
Daily updates are provided to VSP (cases counts and measures reports)
All passengers and crew are alerted of the illness.
Upon boarding on the next scheduled cruise, passengers are notified about the previous voyage's outbreak.
Occasionally, VSP requires the company to notify port authorities and also to perform cleaning and disinfection in cruise port terminal buildings.

Illness outbreaks on cruise ships (annual statistics)

The following statistics show the number of cruise ship illness outbreaks in recent years. You can compare the number of reports (CDC and news media sources) and the total number of infected (passengers and crew).

In 2014, Time Magazine published the article "The 13 Worst Norovirus Outbreaks on Cruise Ships". In it, the overall winner was Princess Cruises with 5 epidemic illness outbreaks:

Coral Princess (February 2009, infected 271)
Crown Princess (January 2010, infected 396)
Crown Princess (February 2012, infected 363)
Sun Princess (July 2012, infected 216)
Ruby Princess (March 2013, infected 276)

Norovirus outbreaks 2023 reports

Norovirus outbreaks 2022 reports, norovirus outbreaks 2020 reports, outbreaks 2019 reports.

In the following table, you can see all 2019-reported Norovirus outbreaks on cruise ships. The listed statistical data is based on CDC or news media reports. It shows the number of sick passengers and crew (with the respective percentage to all), along with the corresponding CDC report pages (if available) as outgoing links.

Note: When the itinerary doesn't include US cruise ports, the ship is not required to report to CDC, thus no official illness report would be issued.

Outbreaks 2018 reports

In 2018, the number of reported illness outbreaks on cruise ships was 15. The total number of infected was 1177 (of those 1099 passengers and 78 crew).

Outbreaks 2017 reports

In 2017, the number of reported illness outbreaks on cruise ships was 21. The total number of infected was 2535 (of those 2450 passengers and 85 crew).

Outbreaks 2016 reports

In 2016, the number of reported illness outbreaks on cruise ships was 23. The total number of infected was 2504 (of those 2378 passengers and 126 crew).

Outbreaks 2015 reports

In 2015, the number of reported illness outbreaks on cruise ships was 23. The total number of infected was 2570 (of those 2458 passengers and 112 crew).

Outbreaks 2014 reports

In 2014, the number of reported illness outbreaks on cruise ships was 17. The total number of infected was 3559 (of those 3354 passengers and 205 crew).

Outbreaks 2013 reports

In 2013, the number of reported illness outbreaks on cruise ships was 22. The total number of infected was 2385 (of those 2249 passengers and 136 crew).

According to CDC, in 2013 from Norovirus and similar GI (gastrointestinal) illnesses suffered a total of 1409 passengers (which is 7,5% of all passengers on the inspected cruise vessels) and 96 crew/staff members (which is 1,2% of all). With nearly 12 million cruisers departing from USA and Canada ports in 2013, the Norovirus infection rate is ~0,01% of all passengers.
It should be noted, that in the past years on many CDC inspections was concluded the Noro virus illness source was off the ship.

Outbreaks 2012 reports

In 2012, the number of reported illness outbreaks on cruise ships was 34. The total number of infected was 5542 (of those 5079 passengers and 463 crew).

Norovirus on cruise ships

All important things you should know about the "cruise virus".

Why do Norovirus incidents happen on cruise ships? There are more than 21 million US cases reported annually, of which 1 mill related to kids. Outbreaks happen mostly during winter months and mainly in more crowded places with close quarters. Among those are schools, hospitals, nursing homes, dormitories, prisons, big resorts, bigger passenger ships (including cruise ferries ). Norovirus is often branded as "cruise ship virus" simply because on ships health officials are required to report every gastrointestinal illness incident. This means Norovirus outbreaks are reported more quickly on ships than on land. Just for comparison, the virus can afflict as many as 3000 people per day in only one big city, which is about the passenger capacity of a typical modern cruiser.

What is Norovirus infection? It's a very common, highly contagious, ruthlessly efficient and uncomfortably bad virus affecting the stomach and large intestines. Often called "stomach flu" (the med term is "Gastroenteritis") the infection results in massive vomiting and diarrhea. Sickness outbreaks are considered as such if the percentage of infected people is over 3%. The virus is not seasonal and usually not serious (in medical terms). It hits 1 in 5 people annually and is the cause of ~50% of all foodborne illness outbreaks in the USA and for ~90% of all non-bacterial gastroenteritis worldwide.

The virus is named after an outbreak in Norwalk (OH, USA). Numerous studies confirm that a quick application of hand sanitizer doesn't kill the Norovirus. It takes about 30 sec of hard rubbing with hot water and soap (including under the nails) to wash it. This virus also mutates (changing its strains). As to its efficiency - a mere 20 particles are enough to get you.

What causes Norovirus on cruise vessels is mainly contaminated food/water. When it comes to ships, it spreads mostly through physical contact with sick people or handling contaminated objects. This includes sharing food/utensils and poor hygiene (not washing hands after bathroom use). The virus also spreads fecally, so you can catch it into the onboard laundry, or while changing diapers, etc. However, many passengers likely can blame a sick crewmember for the virus. According to a survey based on 170 inspection records on ships that docked in Florida ports in 2012, on 59 cruises violations of the required illness reporting laws were reported. A total of 130 crew had gotten sick on those voyages and didn't report their illness in the required time period.

The symptoms are nausea, vomiting, diarrhea, indigestion, abdominal cramps. Also possible are mild fever and headache. It takes 1-2 days for the symptoms to appear. The illness lasts 1 to 4 days, but some people (especially elderly) may be contagious for up to 2 weeks after recovery.

What is the treatment? What to do if you got it? Obviously, the first thing is to go to the ship's infirmary (medical center) and contact the doctor. You should drink plenty of water as dehydration is a side-effect of the illness. There is no real treatment for Norovirus - you just wait it out. A few years ago an experimental Norovirus vaccine (applied as nasal spray) was developed by the "Center for Infectious Diseases and Vaccinology" (Arizona State University). The new vaccine generates a good immune response.

How to avoid Norovirus on cruise ships?

Wash your hands often (hot water and soap), especially before/after eating and after using the bathroom
Limit physical contacts as much as possible, pack some extra soap, a personal disinfectant (Lysol, Pepto-Bismol), oral rehydration sachets and treatments for diarrhea
Avoid eating uncooked food (including salads and sandwiches) and food that cannot be washed (unless it can be peeled or shelled), drink only bottled liquids (preferably without ice), don't share drinks/utensils.
Drink lots of water.
Compensation for cruise illness. By contract, cruise lines are not required to compensate passengers who fall ill on cruises. However, they will compensate you if the itinerary was altered/canceled due to an illness outbreak. The deal may include up to 50% refund, up to 50% FCC (future cruise booking discount) or an option to cancel for a full refund plus reimbursement of airline change fees. If you have travel insurance, it covers cancellation due to illness. If you've been infected on the ship, it could also cover medical expenses and to compensate you for all days you're not on the ship before the cruise end.

The following "health advisory" list of recommended actions is often issued during gastrointestinal illness outbreak or on embarkation day (of the next scheduled voyage). It has important suggestions on how to avoid spreading the cruise ship virus infection.

It is critical that excellent standards of personal hygiene are maintained by all on board, as well as avoiding touching surfaces, such as handrails, door handles, elevator buttons, walls.
Report any observed evidence of vomiting or diarrhea that you may encounter on the ship.
Ensure that you minimize direct contact with others during this time, such as handshakes, etc.
Avoid touching your mouth.
Wash your hands frequently and thoroughly with soap for at least 20 sec and rinse them well under running water. Ensure that you follow this procedure every time you use the WC, after coughing or sneezing, and before eating, drinking or smoking.
Attempt to always use your own cabin toilet facilities.
In addition to hand washing, also use the alcohol hand gels provided where available, and in particular before eating in the self-serve buffet restaurant and outdoor food outlets.
Should you experience any symptoms of vomiting or diarrhea, return to your cabin and immediately report to the Medical Center or Front Office (Reception, if the infirmary is busy) by dialling 999.

Cruise ship virus procedures

What do they do about it? What actions do lines/operators/CDC actually take in response to a Norovirus cruise outbreak?

An "illness outbreak" is considered when 3% or more of all passengers report symptoms to the ship's med staff. In such cases, the CDC requires cruise lines to file a medical report.

The hotel staff is required to implement special cleaning and disinfection procedures for sanitizing the whole ship. To do that, they use stronger solvents, like Microbac, chlorine bleach, hydrogen peroxide. The Lido Deck's bistro/buffet service switches to manned stations. Often, salt-pepper shakers are taken off the tables. The crew starts offering precautionary tips. Sick passengers and crew are quarantined in their rooms, typically for at least 2 days. When Norovirus outbreaks can't be contained, cruise lines might also pull the ship out of service for a few days for sanitizing.

The CDC's "Vessel Sanitation Program" is for monitoring illness outbreaks on passenger ships carrying 100 or more guests on sailings from 3 to 21 days in length. The ship's medical staff is required by the CDC to maintain illness counts for each itinerary involving a stop at a US cruise port and to give CDC the number of all passengers/crew, plus the number of reported diarrhea cases during that voyage. This is done 24 hrs prior to arrival at any US port of call from a foreign port. And they file such reports even if the "illness number" is zero. This protocol only confirms that the CDC knows everything about it.

Other possible actions and results are red level ("Code Red") cleaning. The boarding/embarkation of new passengers is often delayed to permit more extensive disinfection of public areas and the cabins. Usually, a pre-embarkation health advisory is distributed to all boarding passengers. Additional med staff is sent to the ship in port to assist the disembarkation of infected passengers. Another possibility is the cruise ship to cancel all the itinerary's foreign ports of call and to return to its US home-port before the end of the voyage.

Some cruise lines offer hand-sanitizer dispensers near the ship's restaurants, Lido/pool deck areas and other more crowded public spaces in their effort to keep a lid on sickness outbreaks.

In February 2020, the shipowner cruise company Lindblad Expeditions announced the "Premium Purity" program with a shipwide cleaning system based on ACT CleanCoat technology. The program was rolled out fleetwide after a year trial. The innovative ship cleaning process is based on photocatalytic antibacterial spray that when activated by light kills viruses, bacteria, airborne microbes, mould. The disinfecting product and technology were developed by the Danish company ACT Global AS ( Copenhagen ). The spray is chemical-free, odourless, transparent and can be applied to all surfaces.

Zika virus on cruise ships

Zika virus (aka ZIKV) is a Flavivirus - from the genus of the viruses named West Nile, dengue, tick-borne encephalitis, yellow fever. These plus several other viruses may cause encephalitis (acute brain inflammation). In humans, Zika virus causes the Zika fever which is known to occur only within some equatorial regions. In 2014, Zika spread across the Pacific Ocean to French Polynesia, and soon to Easter Island. In 2015, Zika virus reached Central America, the Caribbean, and South America. In South America were recorded several pandemic outbreaks.

The most severe outbreaks were reported in Brazil, with an alarming surge in newborns with microcephaly. If the mother is infected, the virus may cause microcephaly in newborns. This is a neurodevelopmental disorder - babies are born with an underdeveloped head.

Generally, Zika is a mosquito-borne virus spread by Aedes aegypti (aka "yellow fever mosquito") and Aedes albopictus (aka "Asian tiger mosquito"). However, it became "cruise virus" since the decease can also result from intrauterine (contraceptive device), sexual intercourse, blood transfusion, lab exposure, organ/tissue transplantation, breast milk transmission.

In January 2016, the CDC issued travel guidance on affected countries and suggested using enhanced precautions and even postponing travel. Guidelines (specifically for pregnant women) were issued as well. Similar travel warnings were issued by other health agencies and governments. The CDC list of potentially dangerous for travel countries included (alphabetically) Barbados, Bolivia, Brazil, Cape Verde, Colombia, Ecuador, French Guiana, Guadeloupe, Guatemala, Guyana, Haiti, Honduras, Martinique, Mexico, Panama, Puerto Rico, Paraguay, Salvador, Samoa, St Maarten, Suriname, Venezuela.

Cruise lines should warn their pregnant passengers of the virus. Cruise ships publish daily health and safety instructions to their passengers on how to avoid mosquito bites. Zika symptoms are fever, skin rash, pain in joints, conjunctivitis (pink eye). It typically lasts from a few days to a week. For now, the illness cannot be prevented by drugs or vaccines.

"Cruise ship virus" politics

Virus outbreaks on cruise ships are actually not that uncommon. Such viral/bacterial outbreak incidents affect the vacation experience of thousands of people, being packed up in a floating resort for many days on end. In confined spaces with frequent passenger turnover (like big capacity cruise ships), it is easy for diseases to spread - whether food- or air-borne, or otherwise. However, there's a tendency to cover up the severity of this issue.

Some of the world's most famous passenger ships are listed in the virus outbreak statistics, yet one hears so little of it in mass media news. And there is no surprise in that since the "cruise illness" news are nothing but bad publicity for the companies - which is bad for a prosperous multi-billion dollar sea travel vacation business. All major cruise line companies will do their best to keep quiet about virus outbreaks on their ships. There are passenger testimonials about quarantined ships and how badly guests have been treated by the line. Virus outbreak news speaks of a lack of proper hygiene control, badly trained staff, bad ship management. The whole responsibility goes to the shipowner (cruise line company) and its management.

Major (in some cases epidemic) illness outbreaks are among the "biggies" that can bring down the brand's reputation on the market. Cruise illness issues often result in lower booking rates and cheaper prices - which is bad for the business.

So it comes as no surprise that when CDC reports an illness outbreak on some vessel, big media sources do not immediately (or ever) respond to the news. You may hear about it on your local radio station, or on your local cable operator, but not necessarily on ABC, CNN, and often not even on Yahoo and MSN news online. It's not about the passengers' health (never been) - it's about the big money that rules our world.

So keep your hands clean, keep your mind clear, always hope for the best. Bad, if meant to happen, will happen anyway, and nothing can change it.

Seasickness on cruise ships

Seasickness is physical disorientation as a result of conflicting signals received by the brain from different body senses. Our inner ear senses the ship's irregular motion, which our eyes can't see because the floor and walls are stable. Depending on individual balance, our ability to adjust to motions varies, so not everyone experiences seasickness.

Seasickness is one of the most common "cruise illnesses". Passengers sensitive to nausea or motion sickness should consult their doctors for medical recommendations prior to departure. Drugs (like Dramamine) are effective against seasickness. At the cruise ship's Infirmary, and also at Reception Desk is provided (free of charge) Meclizine. Know that the bigger the vessel the more stable it is. Also, motion in midship-located areas (including staterooms) is highly reduced in comparison to forward and aft areas.

Seasickness manifests in different ways and is always a result of the body's attempt to correct for the conflicting inputs received from its senses. Common symptoms are cold sweat, dizziness, drowsiness, headache, nausea. When such symptoms are noticed, passengers should take precautions to prevent intensifying the disorientation. The harder the symptoms, the longer the recovery.

If seasickness symptoms are accompanied by diarrhea or fever, passengers should immediately seek medical treatment for Norovirus and avoid spreading the illness to others.

How to prevent seasickness on cruise ships (tips)

Passengers prone to motion sickness are more likely to suffer seasickness. The following prevention tips can minimize discomfort, so before the cruise:

choose more sheltered routes (clam waters). Open sea and ocean waters are rough and have larger swells, thus river cruises are among your best choices.
Choose a large liner as larger vessels are more stable and motions are minimized.
Book centralized/midship stateroom and/or middle deck cabin, where motions are less noticeable.
Get a good sleep before the voyage - an energetic, well-rested body adjusts easier to new conditions.

During the cruise tips to divert seasickness symptoms include:

Get involved in onboard activities - this will occupy your mind while the inner ear adjusts to equilibrium changes.
Avoid napping or lying down - when the body is horizontal, the ship's motion is more pronounced.
Avoid eating unknown foods - you don't know how your stomach may react to new food/ingredients. Avoid alcohol and acidic-fatty-spicy foods. Stay well-hydrated by drinking plenty of water.
Walk around to adjust the body's equilibrium to the ship's motion. When on open decks, focus on the horizon to give your eyes and body similar inputs about any tilting or other motion. Depending on the symptoms' severity, it may take several hours.
Often get fresh air, take deep breaths, keep your lungs clear.
Some herbal remedies (in tablets or teas) also can ease the symptoms, including ginger and peppermint. Their efficacy varies by person, and are best used together with other prevention methods.

Search for medical assistance - consult the ship's physician if no actions provide relief.

Cruise ship hospital (medical care)

Cruise vessels are not "hospital ships".

Hospital ships are designated as floating medical facilities (hospitals).

Most hospital ships are navy vessels (operated by military forces) which are specifically built for use in war zones.

Attacking a hospital ship is considered a war crime, but enemy forces have the right to board them for inspections.

As of 2018, hospital ships have Brazil (6), China (5), Russia (6), USA (2), Spain (2), and India-Indonesia-Peru-Vietnam (x1).

The navies of USA, UK, Australia, China, France, Italy, Spain, Argentina, and Japan have some classes of military ships fitted with onboard hospitals.

For passengers with health concerns, medical care on cruise ships is a vital part of their travel planning. Most cruise vessels are equipped with either basic infirmary (a small clinic) or larger hospital where sick or injured passengers are treated and cared for by contractor physicians and nurses on 24-hour duty.

Shipboard hospitals as facilities and equipment vary by cruise line and vessel. Clinic's size usually depends on the ship's capacity (passengers plus crew). Generally, bigger and newer ships offer larger and better-equipped medical facilities and are served by bigger infirmary staff.

The ship's medical personnel are independent contractors. This is for limiting the cruise company's liability. There are no internationally specified regulations governing ship infirmaries and medical staffing. Each company has its own standards provided for its passengers' healthcare.

For finding the Infirmary you can use the ship deck plans . On most vessels, the medical facilities are located midship on a lower deck (for easier access and better stability) and usually among other crew facilities. Every passenger stateroom has the Infirmary's number - posted or by the cabin's phone.

Basic medical care on cruise ships

A cruise ship's medical facility can treat only passengers experiencing minor health issues - seasickness, scrapes, sunburns, etc. More severe medical emergencies can't be handled on the ship and usually require medevacs. Coast guard helicopter teams fly to the ship, hoist the passenger (accompanied by a spouse/relative and a crew nurse) and fly them to the nearest land hospital.

Infirmary's equipment and med supplies provide only emergency response and basic treatments in order to stabilize the passenger until transferred ashore.

In cases of severe emergencies, passengers with life-threatening illnesses or injuries are evacuated off the ship - either by boat (if in or near seaport) or by rescue helicopter dispatched from nearest coast guard or other station. In some cases, nearby ships with better medical facilities may assist.

Both emergency and basic care are available on the ship 24 hours a day. All treatments are paid. Outside regular opening hours fees are higher.

Like inland hospitals, medical treatments at sea are pricey. However, unlike on land, most basic travel insurance policies don't cover medical treatments on cruise ships as they are not from the patient's primary caregiver. Purchasing cruise travel insurance with health coverage (medical clauses) is highly recommended.

Shipboard medical service fees vary and are usually set by medical practitioners. General consultations incur costs similar to home visits. Prescription medications or other treatments cost extra. In most cruise ship hospitals, some supplies and medications are provided to passengers and crew for free - like aspirin, seasickness pills, small bandages.

Mercy Ships

"Mercy Ships" is a charity accredited by Better Business Bureau. It operates hospital ships since 1978 and also has currently the world's largest hospital ship (excluding navy vessels) - MV Africa Mercy.

The organization provides free humanitarian aid worldwide, including health care, community development, and health education projects, mental health, agriculture, and water development programs in mainly developing countries in Africa, Caribbean, South America, Oceania.

The organization's headquarters are in Garden Valley (Texas USA), with another 16 offices worldwide - in UK, Spain, Canada, Germany, France, Denmark, Switzerland, Belgium, Holland, Sweden, Norway, South Africa, Australia, New Zealand, South Korea.

Financial support and supplies are mainly through donations from medical companies (medications, supplies, equipment), corporations (fuel, food, building supplies), governments (port fees, drydock costs), general public and also by the crew (all volunteers on a rotational basis). The crew serves with short-term (2 weeks to 2 years) and long-term (min 2 years) contracts. Volunteer crew members occupy both medical (surgeons, dentists, nurses) and general jobs (deckhands, seamen, engineers, machinists, electricians, teachers, cooks, welders, plumbers, agriculturalists.

The crew on Mercy Ships pay all costs associated with their service - fees, travel expenses, passports, insurance, personal expenses.

As 95 of the world's top 100 largest megapolises are port cities, "hospital ships" could provide healthcare very quickly and more efficiently to large numbers of people.

MV Africa Mercy

MV Africa Mercy is a converted former rail ferry (1980-built as "Dronning Ingrid") drydock-refitted in 2007 at Cammell Laird shipyard (Hebburn, England).

The ship project started in March 1999 with the vessel's acquisition through a donation from Balcraig Foundation (UK), which purchased the boat for US$6,5 million.

Ferry's train deck was reconstructed and converted into a hospital. Project's total cost was over USD 62 million.

Vessel details include:

Volume/GT tonnage 16572 tons
LOA length 152 m (499 ft )
Width 23,7 m (78 ft)
Draft 6 m (20 ft)
Powerplant 4x BW main engines plus diesel generators
Propulsion two shafts with controllable pitch propellers
Speed 19 Kn/35 kph/22 mph
Passenger capacity 484
Crew capacity 450
Fleet of 28 vehicles (used in land-based operations)
Annual drydock maintenance and refurbishment are done in Durban (South Africa).

As for facilities and amenities, the hospital ship has 5 operating rooms, Intensive Care Unit, an ophthalmic unit, CT scanner, X-Ray, labs, recovery ward (82 beds), a daycare center, a school (for all ages), library, launderette, convenience store, restaurant, gymnasium, shops, Starbucks Cafe (donated), satellite communications.

Africa Mercy has a total of 126 staterooms for the staff/crew. They are located on upper decks and include cabins for families, couples and single cabins.

Land-based operations ("Field Service") include mobile clinics providing screening for potential surgery patients, healthcare, dental care, also mental health programs, infrastructure projects.

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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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C.D.C. Investigating Gastrointestinal Illness on Luxury Cruise Ship

The Queen Victoria was on its way to Honolulu from San Francisco on a 107-night world cruise when more than 150 people on board reported symptoms, officials said.

A large cruise ship being guided by a tugboat at dusk near the a pier.

By Johnny Diaz

The Centers for Disease Control and Prevention is investigating an outbreak on a luxury cruise ship after more than 150 people reported symptoms of gastrointestinal illness, including diarrhea and vomiting.

The ship, the Queen Victoria, operated by Cunard Line, departed Southampton, England, on Jan. 11 on a 107-night cruise that included recent stops in Florida and San Francisco, according to the company’s website . The ship is scheduled to arrive in Honolulu on Monday.

The C.D.C. said that, as of Thursday, 129 passengers and 25 crew members had reported being ill on the ship. The agency said 1,824 passengers and 967 crew members were aboard at the time of the outbreak.

The cause of the illnesses was unknown, the agency said.

In a statement, Cunard Line, which is based in Southampton, said that “a number of guests had reported symptoms of gastrointestinal illness” on the ship, which arrived in San Francisco on Tuesday after stops in Mexico, Guatemala, Panama and Aruba.

The cruise line “immediately activated their enhanced health and safety protocols to ensure the well being of all guests and crew on board and these measures have been effective,” the company said.

In response to the outbreak, the crew of the Queen Victoria have “increased cleaning and disinfection procedures” and have “isolated ill passengers and crew,” the C.D.C. said.

The agency said that it was remotely monitoring the situation, including “reviewing the ship’s outbreak response and sanitation procedures.”

The ship left San Francisco for Honolulu on Wednesday and was traveling off the west coast of the United States on Thursday, according to the ship-tracking website Cruise Mapper .

After it arrives in Hawaii on Monday, the ship’s scheduled stops include Fiji, New Zealand and Australia.

Though intestinal illness can spread quickly on cruise ships, outbreaks are infrequent, according to the C.D.C.

One high-profile outbreak took place in 2014, when 595 passengers and 50 crew members aboard Royal Caribbean’s Explorer of the Seas fell ill with bouts of vomiting and diarrhea, forcing the ship to return early to New Jersey.

Acute gastrointestinal illnesses, including the highly contagious norovirus, are associated with cruise ships because close quarters among passengers and crew members increase the amount of group contact, the agency said.

People who are infected when they board the ship may spread viruses to other passengers and crew.

Public health officials track illnesses on cruise ships so “outbreaks are found and reported more quickly on a cruise ship than on land,” the C.D.C. said.

Johnny Diaz is a general assignment reporter covering breaking news. He previously worked for the South Florida Sun Sentinel and The Boston Globe. More about Johnny Diaz

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.

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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Section 8 - Road & Traffic Safety
Section 8 - Motion Sickness

Cruise Ship Travel

Cdc yellow book 2024.

Author(s): Kara Tardivel, Stefanie White, Aimee Treffiletti, Amy Freeland

Cruise Ship Medical Capabilities

Illness & injury, infectious disease health risks, noninfectious health risks, travel preparation.

Cruise ship travel presents a unique combination of health concerns. Travelers from diverse regions brought together in the often crowded, semi-enclosed shipboard environment can facilitate the spread of person-to-person, foodborne, and waterborne diseases. Outbreaks on ships can be sustained over multiple voyages by crewmembers who remain onboard, or by persistent environmental contamination. Port visits can expose travelers to local diseases and, conversely, be a conduit for disease introduction into shoreside communities.

Some people (e.g., those with chronic health conditions or who are immunocompromised, older people, pregnant people) merit additional considerations when preparing for a cruise. Because travelers at sea might need to rely on a ship’s medical capabilities for an extended period, potential cruise passengers with preexisting medical needs should prepare accordingly by calling the cruise line’s customer service center to learn what type and level of health care services are (and are not) available on specific ships.

Medical facilities on cruise ships can vary widely depending on ship size, itinerary, cruise duration, and passenger demographics. Generally, shipboard medical centers can provide medical care comparable to that of ambulatory care centers; some are capable of providing hospitalization services or renal dialysis. Although no agency officially regulates medical practice aboard cruise ships, the American College of Emergency Physicians (ACEP) published consensus-based guidelines for cruise ship medical facilities in 1995, and updated the guidelines in 2013. ACEP guidelines , which most major cruise lines follow, state that cruise ship medical facilities should be able to provide quality medical care for passengers and crew; initiate appropriate stabilization, diagnostic, and therapeutic maneuvers for critically ill or medically unstable patients; and assist in the medical evacuation of patients in a timely fashion, when appropriate.

Cruise ship medical centers deal with a wide variety of illnesses and injuries; ≈10% of conditions reported to cruise ship medical centers are an emergency or require urgent care. Approximately 95% of illnesses are treated or managed onboard, with the remainder requiring evacuation and shoreside consultation for dental, medical, or surgical issues. Roughly half of all passengers seeking medical care are >65 years old.

Medical center visits are primarily the result of acute illness or injury. The most frequently reported diagnoses include respiratory illnesses (30%–40%); injuries from slips, trips, or falls (12%–18%); seasickness (10%); and gastrointestinal (GI) illness (10%); 80% of onboard deaths are due to cardiovascular events.

Infectious Disease Outbreaks

The most frequently reported cruise ship outbreaks involve GI infections (e.g., norovirus), respiratory infections (e.g., coronavirus disease 2019 [COVID-19], influenza), and other vaccine-preventable diseases (VPDs), such as varicella. Although cruise ships do not have public health authority, to reduce the risk of introducing communicable diseases, some ships conduct medical screening during embarkation to identify ill passengers, prevent them from boarding, or require isolation if permission to board is given.

Before travel, to help limit the introduction and spread of communicable diseases on cruise ships, prospective cruise ship travelers and their clinicians should consult the Centers for Disease Control and Prevention (CDC) Travelers’ Health website for updates on outbreaks and destination-specific travel health notices. People who become ill with a communicable disease before a voyage should consult their health care provider and delay their travel until they are no longer contagious. When booking a cruise, travelers should check the trip cancellation policies and consider purchasing trip cancellation insurance (see Sec. 6, Ch. 1, Travel Insurance, Travel Health Insurance & Medical Evacuation Insurance ).

Travelers who become ill during a voyage should seek care in the ship’s medical center; the onboard staff will provide clinical management, facilitate infection-control measures, and take responsibility for reporting potential public health events. For information on how to report travelers who become ill with suspected communicable diseases after they return home from a cruise, see Sec. 8, Ch. 8, Airplanes & Cruise Ships: Illness & Death Reporting & Public Health Interventions .

Gastrointestinal Illnesses

During 2006–2019, rates of GI illness among passengers on voyages lasting 3–21 days fell from 32.5 to 16.9 cases per 100,000 travel days. Despite the decrease, outbreaks continue to occur. CDC assists the cruise ship industry to prevent and control the introduction, transmission, and spread of GI illnesses on cruise ships. See information on cruise ship GI illnesses and updates on GI illness outbreaks involving ships with US ports of call, specifically.

On cruise ships, >90% of GI illness outbreaks with a confirmed cause are due to norovirus. Characteristics of norovirus that facilitate outbreaks include a low infective dose, easy person-to-person transmissibility, prolonged viral shedding, absence of long-term immunity, and the ability of the virus to survive routine cleaning procedures (see Sec. 5, Part 2, Ch. 16, Norovirus ). For international cruise ships porting in the United States during 2006–2019, an average of 12 norovirus outbreaks occurred each year.

Other Sources of Gastrointestinal Illness

GI outbreaks on cruise ships also have been caused by contaminated food or water; most outbreaks were associated with Campylobacter , Clostridium perfringens , or enterotoxigenic Escherichia coli .

Protective Measures

Travelers can reduce the risk of acquiring a GI illness on cruise ships by frequently washing hands with soap and water, especially before eating and after using the restroom. Travelers should call the ship’s medical center promptly, even for mild symptoms of a GI illness, and strictly follow cruise ship guidance regarding isolation and other infection-control measures.

Respiratory Illnesses

Respiratory illnesses are the most common medical complaint on cruise ships. During the pretravel visit, evaluate whether vaccines or boosters (e.g., COVID-19, influenza) are needed and emphasize the importance of practicing good respiratory hygiene and cough etiquette while onboard. As with GI illnesses, cruise ship passengers should report respiratory illness to the medical center promptly and follow isolation recommendations as instructed.

Coronavirus Disease 2019

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19, spreads more easily between people in close quarters, and multiple studies have concluded that transmission rates of SARS-CoV-2 among travelers on ships are much greater than in other settings. Cruise ship COVID-19 outbreaks can tax onboard medical and public health resources. Ship-to-shore medical evacuations to facilities capable of providing higher levels of medical care can present logistical challenges and pose additional risks to ill patients.

Cruise passengers and crewmembers who are not up to date with their COVID-19 vaccines are at increased risk for severe illness, hospitalization, medical evacuation, and death. Since cruising will always pose some risk of SARS-CoV-2 transmission, ensure that people planning cruise ship travel are up to date with their vaccinations, and assess their likelihood for developing severe COVID-19. For people at increased risk of severe COVID-19 regardless of their vaccination status (e.g., pregnant people, people who are immunocompromised), discuss the potential health hazards associated with cruise ship travel. CDC has developed recommendations and guidance designed to help cruise ship operators provide a safer and healthier environment for crewmembers, passengers, port personnel, and communities.

Historically, influenza has been among the most often reported VPDs occurring on cruise ships. Because passengers and crew originate from all regions of the globe, shipboard outbreaks of influenza A and B can occur year-round, with exposure to strains circulating in different parts of the world (see Sec. 5, Part 2, Ch. 12, Influenza ). Thus, anyone planning a cruise should receive the current seasonal influenza vaccine ≥2 weeks before travel if vaccine is available and no contraindications exist. For people at high risk for influenza complications, health care providers should discuss chemoprophylaxis and how and when to initiate antiviral treatment.

See additional guidance on the prevention and control of influenza on cruise ships .

Legionnaires’ Disease

Less common on cruise ships, Legionnaires’ disease is nevertheless a treatable infection that can result in severe pneumonia leading to death (see Sec. 5, Part 1, Ch. 9, Legionnaires’ Disease & Pontiac Fever ). Approximately 10%–15% of all Legionnaires’ disease cases reported to CDC occur in people who have traveled during the 10 days before symptom onset. Clusters of Legionnaires’ disease associated with hotel or cruise ship travel can be difficult to detect, because travelers often disperse from the source of infection before symptoms begin. Data reported to CDC during 2014–2015 included 25 confirmed cases of Legionnaires’ disease associated with cruise ship exposures.

In general, Legionnaires’ disease is contracted by inhaling warm, aerosolized water containing the bacteria, Legionella . Transmission also can sometimes occur through aspiration of Legionella -containing water. Typically, people do not spread Legionella to others; a single episode of possible person-to-person transmission of Legionnaires’ disease has been reported. Contaminated hot tubs are commonly implicated as a source of shipboard Legionella outbreaks, although potable water supply systems also have been culpable. Improvements in ship design and standardization of water disinfection have reduced the risk for Legionella growth and colonization.

Diagnosis & Reporting

People with suspected Legionnaires’ disease require prompt antibiotic treatment. When evaluating cruise travelers for Legionnaires’ disease, obtain a thorough travel history of all destinations during the 10 days before symptom onset to assist in identifying potential sources of exposure, and collect urine for Legionella antigen testing. Most cruise ships have the capacity to perform this test, which detects L. pneumophila serogroup 1, the most common serogroup.

Perform culture of lower respiratory secretions on selective media to detect non– L. pneumophila serogroup 1 species and serogroups. Culture also is used for comparing clinical isolates to environmental isolates during an outbreak investigation. Notify CDC of any travel-associated Legionnaires’ disease cases by sending an email to [email protected]. Quickly report all cases of Legionnaires’ disease to public health officials, who can determine whether a case links to previously reported cases and work to stop potential clusters and new outbreaks.

Other Vaccine-Preventable Diseases

Although most cruise ship passengers come from countries with routine vaccination programs (e.g., Canada, the United States), many of the crew are from low- or middle-income countries where immunization rates can be low. Outbreaks of hepatitis A, measles, meningococcal disease, mumps, pertussis, rubella, and varicella have all been reported on cruise ships. The majority (82%) of these outbreaks occur among crewmembers; prior to the COVID-19 pandemic, varicella was the most frequently reported VPD. Other VPDs (e.g., pertussis) occur more often among passengers.

Each cruise line sets its own policies regarding vaccinations for its crew; some have limited or no requirements. Thus, all passengers should be up to date with routine vaccinations before travel, as well as any required or recommended vaccinations specific for their destinations. People of childbearing age should have documented immunity to measles, rubella, and varicella (either by vaccination or titer) before cruise ship travel.

Vectorborne Diseases

Some cruise ship ports of call include destinations where vectorborne diseases (e.g., dengue, Japanese encephalitis, malaria, yellow fever, Zika) are known to be endemic. In addition, new diseases can surface in unexpected locations; chikungunya was reported for the first time in the Caribbean in late 2013, with subsequent spread throughout the region and numerous other North, Central, and South American countries and territories. Zika was first reported in Brazil in 2015, and subsequently spread across the Caribbean and Latin America, sparking concern because of its association with microcephaly and other congenital abnormalities in the fetus. For disease-specific information, see the relevant chapters of Section 5.

For guidance on how to avoid bites from mosquitoes and other disease-transmitting arthropod vectors, both onboard and while on shore at ports of call, see Sec. 4, Ch. 6, Mosquitoes, Ticks & Other Arthropods . For specific details on yellow fever vaccination and malaria prevention, see Sec. 2, Ch. 5, Yellow Fever Vaccine & Malaria Prevention Information, by Country .

Stresses of cruise ship travel include varying weather and environmental conditions, and unaccustomed changes to diet and levels of physical activity. Despite modern stabilizer systems, seasickness is a common complaint, affecting up to 25% of travelers (see Sec. 8, Ch. 7, Motion Sickness ). Note that travel is an independent risk factor for behaviors such as alcohol and illicit drug use and misuse (see Sec. 3, Ch. 5, Substance Use & Substance Use Disorders ), and unsafe sex (see Sec. 9, Ch. 12, Sex & Travel ).

Cruise ship travelers have complex itineraries due to multiple short port visits. Although most port visits do not include overnight stays off ship, some trips offer travelers the opportunity to venture off the ship for ≥1 night. These excursions can complicate decisions about exposures and the need for specific antimicrobial prophylaxis, immunizations, and other prevention measures. Boxes 8-04 and 8-05 summarize recommended cruise travel preparations and healthy behaviors during travel for health care providers and cruise ship travelers.

Box 8-04 Healthy cruise travel preparation: a checklist for health care providers

Risk assessment & risk communication.

☐ Discuss itinerary, including season, duration of travel, and activities at ports of call. ☐ Review the traveler’s medical and immunization history, allergies, and any additional health needs. ☐ Discuss relevant travel-specific health hazards and risk reduction. ☐ Provide travelers with documentation of their medical history, immunizations, and medications.

VACCINATION & RISK MANAGEMENT

☐ Provide routinely recommended (age-specific), required (yellow fever), and recommended vaccines. ☐ Discuss safe food and water precautions. ☐ Discuss insect bite prevention. ☐ Provide older travelers with a baseline electrocardiogram, especially those with coronary artery disease.

MEDICATIONS BASED ON RISK & NEED

☐ Consider prescribing malaria chemoprophylaxis if itinerary includes stops in malaria-endemic areas. ☐ Consider prescribing motion sickness medications for self-treatment.

Box 8-05 Healthy cruise travel preparation: a checklist for travelers

☐ Carry prescription drugs in original containers with a copy of the prescription and a physician’s letter. ☐ Check the Centers for Disease Control and Prevention (CDC) Outbreak Updates for International Cruise Ships website for gastrointestinal outbreaks. ☐ Consider purchasing additional insurance coverage for overseas health care and medical evacuation. ☐ Consult medical and dental providers before cruise travel. ☐ Consult CDC Travelers’ Health website for travel health notices . ☐ Defer travel while acutely ill. ☐ Evaluate the type and length of the planned cruise in the context of personal health requirements. ☐ Notify the cruise line of additional health needs (e.g., dialysis, supplemental oxygen, wheelchair). ☐ Pack Environmental Protection Agency (EPA)–registered insect repellent; consider treating clothes and gear with permethrin. ☐ Pack sunscreen.

DURING TRAVEL

☐ Avoid contact with people who are ill. ☐ Follow safe food and water precautions when eating off ship at ports of call. ☐ Maintain good fluid intake and avoid excessive alcohol consumption. ☐ Practice safe sex. ☐ Report all illnesses to ship’s medical center and follow their recommendations. ☐ Use insect bite precautions during port visits, especially in vectorborne disease–endemic areas or areas experiencing outbreaks of vectorborne diseases (e.g., Zika, yellow fever) ☐ Use sun protection. ☐ Wash hands frequently with soap and water; if soap and water are not available, use ≥60% alcohol–based hand sanitizer.

POST TRAVEL

☐ See CDC’s latest post-cruise health guidance regarding coronavirus disease 2019.

Travelers with Additional Considerations

Travelers with chronic illnesses and travelers with disabilities who have additional needs (e.g., dialysis, supplemental oxygen, wheelchairs) should inform their cruise line before traveling. Highly allergic travelers and travelers with underlying medical conditions should carry a file that contains essential, pertinent health information (e.g., allergies, blood type, chest radiograph [if abnormal], chronic conditions, electrocardiogram, medication list, primary and/or specialty care provider contact information). Travelers also should bring any medications recommended by their health care provider (e.g., an epinephrine auto-injector) to help facilitate care during a medical emergency. For detailed information on preparing travelers who have additional considerations for international travel, including severe allergies, chronic illness, disabilities, or immune compromise, see Section 3.

Pregnant Travelers

Most cruise lines have policies that do not permit people to board after their 24th week of pregnancy. Contact cruise lines directly for specific guidance before booking. For additional information on preparing pregnant people for international travel, see Sec. 7, Ch. 1, Pregnant Travelers .

Insurance Coverage

All prospective cruise travelers should verify coverage with their health insurance carriers and, if not included, consider purchasing additional insurance to cover medical evacuation and health services received onboard cruise ships and in foreign countries (see Sec. 6, Ch. 1, Travel Insurance, Travel Health Insurance & Medical Evacuation Insurance ).

The following authors contributed to the previous version of this chapter: Kara Tardivel, Stefanie B. White, Krista Kornylo Duong

Bibliography

Hill CD. Cruise ship travel. In: Keystone JS, Kozarsky PE, Connor BA, Nothdurft HD, Mendelson M, editors. Travel medicine, 4th edition. Philadelphia: Saunders Elsevier; 2019. pp. 377–82.

Jenkins KA, Vaughan GHJ, Rodriguez LO, Freeland AL. Acute gastroenteritis on cruise ships—United States, 2006–2019. MMWR Morb Mortal Wkly Rep. 2021;70(6):1–19.

Kordsmeyer A-C, Mojtahedzadeh N, Heidrich J, Militzer K, von Münster T, Belz L, et al. Systematic review on outbreaks of SARS-CoV-2 on cruise, navy and cargo ships. Int J Environ Res Public Health. 2021;18(10):5195.

Millman AJ, Kornylo Duong K, Lafond K, Green NM, Lippold SA, Jhung MA. Influenza outbreaks among passengers and crew on two cruise ships: a recent account of preparedness and response to an ever-present challenge. J Travel Med. 2015;22(5):306–11.

Mouchtouri VA, Lewis HC, Hadjichristodoulou C. A systematic review for vaccine-preventable diseases on ships: evidence for cross-border transmission and for pre-employment immunization need. Int J Environ Res Public Health. 2019;16(15):2713.

Payne DC, Smith-Jeffcoat SE, Nowak G, Chuwkwuma U, Geibe JR, Hawkins RJ, et al. SARS-CoV-2 infections and serologic responses from a Sample of U.S. Navy service members—USS Theodore Roosevelt, April 2020. MMWR Morb Mortal Wkly Rep 2020;69(23):714–21.

Peake DE, Gray CL, Ludwig MR, Hill CD. Descriptive epidemiology of injury and illness among cruise ship passengers. Ann Emerg Med. 1999;33(1):67–72.

Rice ME, Bannerman M, Marin M, Lopez AS, Lewis MM, Stamatakis CE, et al. Maritime varicella illness and death reporting, U.S., 2010–2015. Travel Med Infect Dis. 2018;23:27–33.

Rocklöv J, Sjödin H, Wilder-Smith A. COVID-19 outbreak on the Diamond Princess cruise ship: estimating the epidemic potential and effectiveness of public health countermeasures. J Travel Med. 2020;27(3):taaa030.

Stamatakis CE, Rice ME, Washburn FM, Krohn KJ, Bannerman M, et al. Maritime illness and death reporting and public health response, United States, 2010–2014. J Travel Med Inf Dis. 2017;19:16–21.

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Norovirus Outbreaks on Cruise Ships: How to Avoid Getting Sick on Vacation

There have been 13 norovirus outbreaks on cruise ships in 2023.
Experts note that the highly congested environment, as well as the fact that people have not been exposed to as many illnesses due to the COVID-19 pandemic, are likely the reason for the increased norovirus numbers.
Experts recommend maintaining proper hygiene habits and contacting the ship’s medical facility as soon as you don’t feel well in order to avoid spreading illnesses while at sea.

Multiple cruise lines are experiencing norovirus outbreaks.

There have currently been 13 norovirus outbreaks on cruise ships in 2023. The most recent outbreak occurred on a Viking Cruises ship, which traveled from Iceland and docked in New York City. About 13% of its passengers and several crew members became ill with the virus while on board.

With more than 31 million passengers worldwide expected to set sail this year, experts told Health that these highly-congested environments—along with the fact that people have not been exposed to a normal amount of illnesses due to the pandemic—could be the reasons for the increased numbers.

“Loosening of restrictions after the COVID-19 pandemic makes us more susceptible to picking up viruses after several years in seclusion,” Sanjiv Shah, MD, MPH , an infectious disease specialist and chief medical officer for MetroPlusHealth, New York City’s public health insurance program, told Health.

“Children who have been able to avoid the virus during the pandemic are now being exposed to viruses that tend to peak during the school year,” he said. “While norovirus is higher this year, the numbers are not a big outlier compared to pre-pandemic levels.”

Getty Images / Michael Dunning

What Is Norovirus?

Norovirus is the most common cause of gastroenteritis and foodborne illness . Though people often call it the “ stomach flu ,” it has nothing to do with flu, Brian Labus, PhD, MPH, REHS , an expert in infectious diseases, told Health .

“You have to swallow the virus to get sick,” Labus, an assistant professor in the Department of Epidemiology and Biostatistics at the UNLV School of Public Health, said. “That can be through consuming contaminated food or touching a contaminated surface and then touching your mouth or not washing your hands before you eat.”

Norovirus, which causes inflammation of the stomach or intestines, typically causes diarrhea , vomiting, nausea, and stomach pain Bernadette Boden-Albala, DrPH, MPH , director and founding dean of the Program in Public Health at the University of California Irvine told Health . Other symptoms can include fever, headache, and body aches.

Typically, norovirus lasts for one to three days, though you can spread the illness for a few days after.

“Infected people spread the virus widely and make it difficult for public health officials to contain the virus,” Boden-Albala said.

Why the Number of Norovirus Outbreaks Increased

The exact cause for the increase in the number of norovirus cases is not clear, but the increasing demand for cruises could be one explanation for the rise in reported cases, said Labus.

During COVID, the options for cruises were limited, but now that restrictions have been lifted , more people are deciding to take that cruise they had been putting off.

People also are more likely to get sick now since pandemic restrictions have been lifted. For the past few years, people have not been exposed to as many common viruses and illnesses and now that exposure is rising, illnesses are bound to rise as well.

It also is possible the numbers for norovirus on cruise ships appear more alarming than they truly are.

On cruise ships, health officials are legally required to track any illnesses that occur, while this same reporting is not required on land. For this reason, the Centers for Disease Control and Prevention note that outbreaks are reported more frequently on sea than on land.

“The risk of getting norovirus each year is about 1 in 15 [but] a cruise passenger has about a 1 in 5,500 risk of getting norovirus,” Sally Andrews, vice president of strategic communications and public affairs for the Cruise Lines International Association told Health .

Environments Where Norovirus Spreads Quickly

According to Shah, norovirus spreads rapidly anywhere there are large groups of people, like school classrooms, family gatherings, and weddings.

Cruise ships in particular have many of the conditions that make people susceptible to norovirus—close quarters, enclosed spaces, communal dining, and high turnover of passengers.

“The virus is often associated with cruise travel simply because health officials are required to track illnesses on ships,” Shah said. “The CDC estimates only about 1% of annual U.S. norovirus cases happen on cruise ships. Rates are much higher in schools, nursing homes, hospitals, and restaurants, which collectively account for about 91% of cases.”

Minji Kang, MD, an assistant professor and infectious disease specialist in the Department of Internal Medicine at UT Southwestern Medical Center added that norovirus can also be brought onboard by contaminated food or water, or passengers who were infected while ashore.

Yes, Cruise Ships Have Strategies to Prevent Outbreaks

Because norovirus outbreaks can flare up in the close quarters of a ship, the cruise industry has had norovirus prevention programs in place for nearly 20 years, Labus said. “They have the right chemicals needed to control it and the plans and training for how to use them appropriately.”

Cruise ships also have plans for how to deal with ill guests to ensure that they are not infecting other passengers, he said. “It’s important to let the ship’s medical staff know if you are sick so that they can protect the rest of the passengers.”

According to the American College of Emergency Physicians (ACEP), every cruise ship must have a place to isolate any passengers who have a contagious disease. This step helps them minimize the risk of spreading the disease to others.

What’s more, the CDC has established a rigorous Vessel Sanitation Program (VSP) to help prevent the overall spread of illnesses on cruise ships. Not only do they inspect a cruise ship’s medical center, but they also monitor their portable water systems, dining rooms, housekeeping procedures, heating, ventilation, air conditioning (HVAC) systems, and more.

If a cruise ship does not do well on its inspection—or gets an 85% or lower—it cannot set sail until it corrects the issues.

Staying Healthy While on a Cruise

While there have been 13 outbreaks of norovirus on cruise ships this year, Labus explained that not every cruise passenger is going to be exposed to the virus. Still, taking certain steps to prevent the likelihood of getting sick is never a bad idea.

“The most important measure to prevent the spread of norovirus is to wash your hands with soap and water for at least 20 seconds,” said Kang. “This should be done before eating and drinking, brushing one’s teeth, and after going to the bathroom, touching high-hand contact surfaces, and taking care of a sick person.”

She noted that hand sanitizers do not work well against norovirus and that they are not a substitute for handwashing.

For extra peace of mind, you can also research your cruise line prior to booking.

To see how your specific cruise line performed on its VSP inspections, you can visit the CDC website and search their portal. This site also lists any corrective actions taken to remedy any issues. You can even look for cruise lines that have scored a perfect 100.

If you do happen to get sick while on a cruise, Boden-Albala recommends that you follow CDC guidelines and report your illness to the ship’s medical facility as soon as possible. “[You also should] rest and drink plenty of water to rebuild your immunity system and prevent dehydration.”

Even though you may be tempted to conceal your illness, you would be doing a great disservice to the other passengers and the crew on the cruise by keeping it a secret.

“While staying in your cabin [for a day or two] may not make for the best vacation,” Shah said, “it’s important to take precautions to avoid infecting others.”

Centers for Disease Control and Prevention. Outbreak updates for international cruise ships .

Cruise Lines International Association. State of the cruise industry 2023 .

Centers for Disease Control and Prevention. Symptoms of norovirus .

Centers for Disease Control and Prevention. Facts about noroviruses on cruise ships .

Cruise Lines International Association. Norovirus on cruise ships .

American College of Emergency Physicians. Healthcare guidelines for cruise ship medical facilities .

Centers for Disease Control and Prevention. Vessel sanitation program: inspection infographic .

Centers for Disease Control and Prevention. Advanced cruise ship inspection search .

Centers for Disease Control and Prevention. Cruise ship inspection scored 100 .

VSP Outbreak Investigations

Learn what we do during investigations of gastrointestinal illness outbreaks on cruise ships.

The Vessel Sanitation Program (VSP) monitors our surveillance system to observe illness patterns for gastrointestinal illness on cruise ships.

VSP conducts outbreak investigations when 3% or more of the ship’s passengers or crew members report they are sick with symptoms of gastrointestinal illness. We may also conduct an outbreak investigation if an unusual gastrointestinal illness pattern or characteristic is found (even if the illness rate is less than 3%).

We conduct outbreak investigations on ships sailing in the United States or within 15 days of arriving at a U.S. port.

Investigators seated at a table discussing findings

What does VSP do in an outbreak investigation?

During an outbreak investigation, VSP works with cruise ship staff and the cruise line to determine the cause of illness.

When an outbreak occurs, we ask for logs and records, including gastrointestinal illness surveillance logs, so we can closely examine the reported cases. The surveillance logs include information such as specific symptoms and the date and time the illness occurred. By reviewing the logs, we can determine the following:

How many passengers and crew are sick on the ship.
When illness started and how long it lasted.
How many people are sick on each day of the voyage.
Symptoms of people who are sick.

The objectives of an investigation are to

Determine the magnitude of illness aboard the ship.
Identify the pathogen causing the illness.
Identify risk factors associated with the illness.
Formulate control measures to prevent or stop the spread of illness.

By determining the cause of an outbreak, VSP can help the cruise line develop effective intervention strategies to prevent a recurrence of the outbreak.

During an outbreak, VSP staff may board a cruise ship to do one or more of the following:

Epidemiologic assessment to look at the spread or pattern of gastrointestinal illness, interview passengers and crew members, and analyze questionnaires with details on recent crew and passenger activities.
Targeted environmental health assessment to investigate specific areas to check for exposure and routes of illness transmission and to monitor the ship’s outbreak prevention and response plan procedures. Targeted environmental health assessments are based on preliminary findings from the epidemiologic assessment. For example, if water is suspected as the source of illness, VSP gives more attention to reviewing places on and off the ship where people could have been exposed to contaminated water.
Laboratory investigation to confirm the cause of illness. Medical staff may collect stool, vomit, or blood specimens to send to a land-based laboratory.

What does VSP require cruise lines to do during outbreaks?

Cruise lines are required to activate their outbreak prevention and response plans and make every effort to gain control of the outbreak. These plans

Indicate trigger points that initiate a ship’s response to cases of illness.
Identify overall outbreak management strategies.
Include detailed infection control procedures for each area of the ship.

Cruise line control measures include the following:

Increasing daily cleaning and disinfection frequencies.
Stopping high-risk activities, such as self-service buffets and handshaking.
Isolating ill people.
Collecting clinical and/or environmental specimens for analysis.
Providing daily updates to VSP that include case counts and reports of what the ship has done to establish control.
Alerting passengers and crew of the illnesses onboard.
Providing information about proper handwashing.
Notifying new passengers about the outbreak before they get on the ship.

VSP may also ask cruise lines to

Notify port authorities.
Delay bringing passengers on board for the next voyage.
Establish cleaning and disinfection procedures in terminal buildings.

Where can I find information about a specific outbreak?

We post all outbreak summaries on our website.

How can I protect myself from gastrointestinal illness?

Use proper handwashing techniques throughout your voyage, but especially after using the bathroom and before eating.
Avoid any food or water that you think may be contaminated.
Avoid raw or undercooked shellfish.
Avoid unnecessary direct hand contact with surfaces such as public toilet room door handles.
Avoid unnecessary close contact with ill persons.
See our tips for healthy cruising .
Inspection Reports
About Inspections
Cruise Ship Outbreak Updates
About Noroviruses on Cruise Ships
VSP Operations Manual [PDF – 5 MB]
VSP Construction Guidelines [PDF – 4 MB]
Illness Prevention Information
Publications

Exit Notification / Disclaimer Policy

The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website.
Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website.
You will be subject to the destination website's privacy policy when you follow the link.
CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website.

How common is norovirus on cruise ships? Here’s why you shouldn’t worry

What's sneaky, super contagious and bound to cause diarrhea and vomiting? If you answered "norovirus," you'd be correct. But what is it, and why is it often associated with cruises?

An excessive number of news reports exist for norovirus cases on ships, making it seem to the unsuspecting public that cruise vessels are dirty or you're likely to get sick if you sail . I'm here to set the record straight.

Find out why norovirus is unfairly labeled a cruise ship illness, what cruise lines do to minimize onboard spread and whether you should be worried about it on your next voyage.

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

What is cruise ship norovirus?

Norovirus is the most common of several viruses that cause severe gastrointestinal illness or acute gastroenteritis. Symptoms may include diarrhea and vomiting, as well as abdominal cramping, headaches, muscle aches and fever — an unpleasant experience any time but especially when you're on vacation.

Norovirus is highly contagious and spreads when you touch a contaminated surface and then put your fingers in or near your mouth, such as when eating without washing your hands. It's also frequently spread through contaminated food, sometimes earning it the nickname "food poisoning," even though there are many pathogens that can cause foodborne illnesses. You might also hear it generically called a stomach bug or the stomach flu despite the fact that noroviruses are not the same as flu viruses.

How does norovirus spread on cruise ships?

What causes norovirus on cruise ships, anyway? Norovirus spreads easily in close quarters, such as those found on cruise ships. Although it can spread from person-to-person contact, on vessels, it's most commonly passed when passengers fail to wash their hands after coming in contact with high-touch areas, such as handrails, elevator buttons and serving utensils in the onboard buffets.

Infected passengers who don't wash their hands after coughing, sneezing or using the restroom are the reason those surfaces become contaminated in the first place. To avoid both spreading your own germs and picking up the germs of others, wash your hands frequently, especially before eating, for at least 20 seconds with soap and warm water, making sure to scrub around your fingernails and between your fingers.

Contaminated food is also a cause, but it's not as common on ships, where the staff is meticulously trained to follow health and safety guidelines for sanitation. Standards are enforced by the U.S. Centers for Disease Control and Prevention. (See the next section for more.)

What do cruise ships do to prevent norovirus outbreaks on board?

Cruise lines employ crews dedicated to keeping public areas and high-touch surfaces clean. Galley crews and waiters receive extensive training on food safety and handling.

Lines also screen passengers for signs of illness at embarkation. They ask passengers who feel ill during their cruises to report symptoms to the medical center and keep themselves isolated in their cabins.

On ships where outbreaks occur, the crew conducts a deep cleaning of the ship after passengers have disembarked and before the next sailing begins. In cases where outbreaks are particularly severe, subsequent sailings could be canceled to allow for more thorough sanitization.

Additionally, the CDC's Vessel Sanitation Program, implemented in the 1970s, subjects all passenger ships carrying 13 or more people to random, unannounced inspections if they wish to call on ports in the United States.

As part of the program, ships are required to adhere to stringent health and safety protocols that dictate everything from the cleaning of high-touch areas to how food is stored in freezers, refrigerators and galleys.

VSP inspectors board ships and conduct thorough checks to ensure compliance, and the standards are high. A score of less than 86 out of 100 is considered failing. You can find a list of the most recent inspection scores and lists of violations for each ship on the VSP website .

Should you worry about getting norovirus on a cruise?

The short answer is no. "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 " Facts About Noroviruses on Cruise Ships " page.

Based on the math, you have less chance of catching a gastrointestinal illness on a ship than at many places you're likely to visit on land.

The CDC estimates only about 1% of all annual U.S. norovirus cases happen on cruise ships. The numbers are greatest in nursing homes, hospitals, schools and restaurants, which collectively account for about 91% of cases.

In a study of acute gastroenteritis cases from 2006 to 2019 (before the cruise industry's COVID-19 shutdown), the CDC found that the number of cases on ships decreased over those 14 years. It also noted that the number of cases tends to be higher on larger ships and on voyages of a week or longer.

"The rate of … illness on cruise ships decreased during 2006-2019 for passengers and crew," the report says. That's good news for cruisers.

During that time frame, approximately 127 million passengers sailed on the 252 cruise ships under VSP jurisdiction. Of those 127 million cruisers, 26,450 reported symptoms of gastrointestinal illness while on board. It sounds like a large number, but it amounts to just 0.02% (two one-hundredths of one percent) of cruisers throughout those 14 years, with the total number of cases decreasing from 4,507 in 2006 to 1,201 in 2019.

If you'd like to check out the outbreak information, you can find a detailed list of ships that have had acute gastroenteritis outbreaks (many of which were caused by norovirus), listed by year, about halfway down the CDC's outbreak page .

For more details on how to keep yourself healthy on board, visit TPG's story on how to avoid getting sick on a cruise .

Why are there so many cruise norovirus reports on the news?

The simple answer is that cruise ships are required to report cases of acute gastroenteritis to the CDC, even when the numbers are low. In contrast, other entities — schools, nursing homes, hospitals and restaurants — are not.

"Health officials track illness on cruise ships. So outbreaks are found and reported more quickly on a cruise ship than on land," reads the CDC's facts page .

Specifically, the medical staff from each cruise ship must submit a report with the number of ill passengers within 24 to 36 hours of its arrival at a U.S. port from a foreign port, even when no cases of gastrointestinal illness are present. They must also submit reports if 2% or more of the passengers and crew become ill and the ship is scheduled to visit a U.S. port within 15 days. If the number hits 3% or more, cases must be reported to the CDC even if the ship is not scheduled to call on a U.S. port within the next 15 days.

That means data for norovirus on cruise ships is more readily available than for other entities. It's easy to make norovirus case numbers sound alarming, but context matters. For example, 100 cases on a single ship might seem like a lot, but on a vessel like Oasis of the Seas, which carries more than 5,400 passengers, 100 cases are only about 2% of the onboard population.

Bottom line

Should you be worried about catching norovirus or another gastrointestinal illness when you cruise? The CDC says cruises account for some of the lowest case numbers in the U.S. annually.

Your chances of finding yourself confined to your room and hunched over a toilet for a week are slim when you sail, especially if you take common-sense precautions like washing your hands and not sharing drinks, utensils and other items that easily spread germs.

Have more cruise questions? TPG has answers:

Are cruises safe? Here's what you need to know before you sail
Packing for a cruise? These items aren't allowed on board
Man overboard: Cruise ship overboards and how they happen
What is baked Alaska, and why is it paraded around cruise ships?
What are the largest cruise ships in the world?
Gentlemen hosts: These men cruise to make sure single ladies have a great time
What is the Jones Act and how does it affect cruise ships?
What is a lido deck on a cruise ship?
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2023 is the year of getting sick on a cruise

The reported occurrence of gastrointestinal diseases on cruises is worse than pre-covid.

Holland America’s Nieuw Amsterdam, a cruise ship that, according to the company’s site , “celebrates historic New York City with an inspired design and art collection,” is currently traveling along the western coast of Canada for a 14-day tour to Alaska and back.

For tickets starting at $2,699 per-person , double occupancy rate, 1,970 passengers get to enjoy a spa treatments, fine meals, and pickleball at sea. For 160 of them, and 26 members of its 813-person staff, the journey also featured a gastrointestinal illness.

They aren’t alone. The Nieuw Amsterdam outbreak is the 11th to occur this year. It’s a sign—if not the most desirable one—that things are back to pre-covid levels: This is the highest number of outbreaks recorded on ships since 2018, and even then it took the whole year to get to 11.

Norovirus and more

As part of its Vessel Sanitation Program (VSP), the Centers for Disease Control and Prevention (CDC) tracks occurrences of gastrointestinal disease on board, which cruises are required to report. The cases are reported before arriving to the US from a foreign port, or whenever 3% or more of cruise passengers or crew are ill.

So far this year, 1,503 people—1,321 passengers, and 182 crew members—have come down with gastrointestinal illnesses on cruises that had the US as part of their itinerary. Most of the infections are still of unknown origin, while in three cases the outbreaks were identified as norovirus, which is a relatively common cause of gastrointestinal disease on cruises. Norovirus survives on surfaces, and it can spread easily on ships where rooms are close, buffets proliferate, and people share confined spaces.

Though it was one of the largest of the year, the outbreak on the Nieuw Amsterdam was mild, and all sick individuals were quarantined. Only on the Princess Cruises’s Ruby Princess , which had a norovirus outbreak during its mid-February trip, were there were more cases, with 234 passengers and 34 members of the crew becoming ill. Data on outbreaks on cruises is available starting from 1994, and the rate of incidence has diminished significantly since it reached a peak in the early 2000s, when outbreaks regularly surpassed 20 per year.

The number of outbreaks might also be a sign that ridership on cruise ships is returning to pre-pandemic levels. In 2019, nearly 15 million people took cruises in the US , while that number was down to only 2 million in 2021, and about 5 million in 2022.

Illness on cruises isn’t as common as it is on land

Gastrointestinal disease of this type isn’t usually serious serious—though it’s hardly fun, especially at sea. But it’s hardly exclusive to cruises: The vast majority of outbreaks happen on land, and every year there are around 2,500 outbreaks of norovirus recorded in the US, causing up to 21 million cases .

As the CDC notes , millions of people travel on cruises every year, making less than a dozen outbreaks a relatively minor concern. “Health officials track illness on cruise ships. So outbreaks are found and reported more quickly on a cruise ship than on land,” says the CDC.

Still, it’s helpful to follow basic health precautions to limit the chance of getting sick, including reporting any illness that occurs prior to joining a voyage, or while on board, frequent and washing hands , and leaving the area if someone is sick.

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Are cruises safe? Here’s what you need to know about cruise ship security and safety

I f you've watched the news at any point over the past several years, it's likely you've seen disturbing stories about cruise ship norovirus or COVID-19 outbreaks and passengers "falling" overboard. Combine that with reports of sexual assault and fistfights, and it's no surprise you might be wondering whether cruise ships are safe.

Here, I'll address some prospective passengers' biggest concerns and offer tips and advice on cruise ship safety so you can maintain peace of mind on your voyage.

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

Are cruise ships safe?

Let's cut right to the chase: Yes, cruise ships are generally safe as long as you use common sense and remember that vessels are not impervious to accidents, illness or people who just don't know how to behave. As with any place you might live or visit ashore, there are risks, but those risks can be mitigated if you keep a few simple tenets top of mind.

The key thing to recognize is that you should maintain the same level of awareness, self-control and vigilance as you would anywhere else. When you're in your hometown, would you invite a complete stranger into your bedroom, leave your wallet unattended in plain sight or allow your very young child to run around unsupervised? If the answer is no, you shouldn't be doing those things on a cruise ship, either. (And if the answer is yes, I have questions.)

Although you have power over the above, sometimes circumstances are beyond your control. Perhaps the weather is bad, or something mechanical goes wrong with the vessel. Cruise ships are equipped with advanced navigational equipment to avoid storms, and engine room contingencies allow onboard operations to continue, even if the ship's speed or propulsion is affected.

Ships also employ entire onboard teams of engineers and mechanics who are able to fix problems on the spot, as well as crew members trained to fight fires. The bridge — the ship's main control center — is constantly in touch with shoreside teams who provide additional assistance.

With that, here's a bit more advice on how to make your sailing safer, followed by answers to some of your most burning safety-related queries.

Cruise safety tips

Cruise ship safety measures are in place on every vessel in every major cruise line's fleet. However, there are some extra tips you can follow to stay safe on a cruise.

Pay attention during the muster drill. Muster drills are a pain, and nobody likes them. However, they tell you what to do in case of an emergency, so it behooves you to pay attention. The information offered during them — including where your muster station is and how to properly don a life jacket — could end up saving your life.
Keep a close eye on your keycard. Treat it the same as you'd treat a credit card or your keys. It grants access to your cabin and also serves as your onboard charge card for purchases. If you lose it, report it to guest services immediately so they can deactivate the old one and issue you a replacement.
Lock up your valuables. Keep your jewelry, passports, wallets, electronics and other important items locked in your cabin safe when you aren't using them, and don't leave them lying unattended in public areas.
Don't invite strangers to your cabin. Don't tell them your cabin number or otherwise divulge sensitive personal information. If you're cruising by yourself, also use caution when telling people you're alone.
Supervise your children. Allowing young children to roam the ship alone without an adult or member of the youth club staff is not only potentially unsafe but also can be an annoyance to other passengers.
Avoid drinking so much alcohol that you lose your wits. It could lead to slipping and falling or cause you to engage in unsafe behaviors, such as entering crew areas or climbing on railings. It also could make you more susceptible to theft or assault. Plus, hangovers can really put a damper on the next day's fun.
Steer clear of crew-only areas, and never stand on furniture or climb anywhere you aren't supposed to be. Restricted areas are restricted for a reason, and entering them can result in injury or death.
Don't assume everyone on your sailing is trustworthy. Simply being on the same ship doesn't mean your fellow passengers are on the up and up. Most are, but some might not be. Treat strangers with the same level of scrutiny as you would in any other environment.

Are there police on cruise ships?

Do cruise ships have police? Is there security on cruise ships? Again, the answer is yes. Cruise ship police officers are more like security guards, many of whom serve as law enforcement officers or members of the military in their countries of residence when they aren't working on board.

Cruise security guards have the authority to break up fights and mitigate passenger hostility, drunkenness and other inappropriate behavior. They also have the authority to place rowdy, violent or otherwise dangerous passengers in the ship's jail, known as a brig .

Serious rule violations could warrant cruisers' removal from the ship at the next port of call and notification of authorities. However, maritime law is dicey and often unclear when it comes to which country has jurisdiction over crimes that happen in international waters.

Will I get sick on a cruise?

Getting sick on a cruise is a possibility, as it is anywhere you go. However, ships are held to high cleanliness standards that are dictated and monitored by the U.S. Centers for Disease Control and Prevention via the Vessel Sanitation Program, which was implemented in the 1970s.

The VSP requires all passenger ships that carry more than 13 people to submit to random, unannounced inspections if they wish to visit ports in the U.S. The requirements are rigorous, and any score lower than 86 out of 100 is considered failing. (Scores and lists of infractions for all ships can be found on the VSP website .)

Prior to the COVID-19 pandemic, the biggest health threat on ships was norovirus , which manifests as a highly contagious gastrointestinal illness that's easily spread through food contamination and surface contact in close quarters.

After the coronavirus shut down the industry, cruise lines further strengthened their protocols to include safeguards against airborne pathogens. They included social distancing and mask-wearing requirements , as well as the enhancement of air filtration systems. Other measures included contact tracing protocols, mandatory vaccination requirements and the expansion of onboard medical facilities and staff.

Many of the COVID-19-related policies — including requirements for mask-wearing and mandatory vaccination — have been relaxed, but the lines are able to reinstate them quickly if needed.

In addition to following cruise ship wellness policies, there are other ways you can minimize your chances of becoming ill when you sail. The best way to avoid both catching and transmitting germs is to wash your hands, particularly before eating and after using the restroom or coming in contact with high-touch surfaces like handrails and elevator buttons.

Hand sanitizer is plentiful on ships, too; while it's great for use between trips to the sink, it shouldn't be a substitute for thorough and frequent hand-washing. Additionally, when you cough or sneeze, do so into your upper arm or the crook of your elbow.

With regard to seasickness , toss a couple of remedies into your bag when you're packing. Tried-and-true options include Dramamine or Bonine pills, acupressure bands, ginger candies and behind-the-ear patches. In a pinch, seek out a green apple or ginger ale from the buffet or room service.

Also make sure you're getting plenty of rest, staying hydrated, wearing sunscreen with an appropriate SPF and knowing your limits when it comes to alcohol.

Above all, if you're feeling ill before embarkation, don't cruise. Take advantage of your travel insurance 's cancel for any reason coverage (if that's included in your particular policy) to get your money back and avoid spreading sickness to others.

Can you fall off a cruise ship?

Yes, it's possible to fall off a cruise ship , but it doesn't happen without effort. To help ensure passenger safety, cruise vessels' cabin balconies and outdoor decks have railings that are roughly chest height on an average-size person. Thick metal or Plexiglas panels or metal bars are positioned under the railings to prevent people from slipping through. Even so, it's important to keep a close watch on young children at all times.

Most people who go overboard fall because they were inebriated, entered a restricted area or engaged in behavior they shouldn't have — such as standing on railings or furniture or climbing between balconies — or a combination thereof.

It's not possible for someone to slip on a wet deck or trip over a door frame and simply fall off a cruise ship.

Do cruise ships have enough lifeboats?

Yes, they do. Following the sinking of the Titanic, which didn't have enough lifeboats for everyone, the international maritime community developed Safety of Life at Sea standards. Under SOLAS, passenger ships are now required to carry enough lifeboats for all passengers. They are outfitted with navigation and communications equipment and basic necessities required for survival until help arrives.

Additionally, ships are required to hold muster drills for all cruisers prior to the start of each voyage, even for passengers who have cruised before. During the drills, guests learn what to do and where to report in the event of an emergency. They also learn what the emergency signal sounds like and how to put on a life jacket. (Ships must also carry enough life jackets for everyone, including specially designed ones for children and pets.)

Do cruise ships have doctors?

Yes, all big mainstream oceangoing cruise ships have trained medical staff on board, usually a combination of doctors and nurses. Many cruise lines increased the number of medical professionals on their ships following the onset of COVID-19.

Cruise ship medical centers are equipped to perform basic stabilization in the event of accidents, illness and other emergencies. They are not full hospitals, though, which means beds are limited, and they lack more complex treatment capabilities. They are designed to keep passengers stabilized and comfortable until they can be sent to a nearby land-based hospital.

They can, however, treat things like seasickness, cuts and bruises and other minor ailments without the need to offload passengers. They are also now equipped to conduct COVID-19 testing and isolation, and ventilators are on hand in the event that any serious cases arise.

Note that because they are never far from land-based medical care, most river cruise vessels do not have onboard medical staff. Additionally, medical care can be expensive on cruise ships that do offer it. It's generally not covered by regular health insurance, so always purchase a travel insurance policy.

Bottom line

So, are cruises dangerous? The answer is, generally, no. They're safe if you follow the same common-sense practices you'd use anywhere else. It's easy to let your guard down when you're having a great time on vacation, but remember: Cruise ships are like floating cities, which means they aren't immune to potential dangers.

Cruise ship safety is the responsibility of both the cruise line and individual passengers. Make sure to exercise an appropriate level of vigilance by protecting your valuables, refraining from inviting strangers to your cabin or giving out too much personal information, paying attention to muster drills, frequently washing your hands, keeping an eye on your children, staying out of restricted areas and knowing your limits when it comes to alcohol consumption.

Have more cruise questions? TPG has answers:

Packing for a cruise? These items aren't allowed on board
Man overboard: Cruise ship overboards and how they happen
What is baked Alaska, and why is it paraded around cruise ships?
What are the largest cruise ships in the world?
Gentlemen hosts: These men cruise to make sure single ladies have a great time
What is the Jones Act and how does it impact cruise ships?
What is a lido deck on a cruise ship?
What's a cruise cabin guarantee and will it save you money?
What's the difference between a cruise ship concierge and a butler?

Editorial disclaimer: Opinions expressed here are the author’s alone, not those of any bank, credit card issuer, airline or hotel chain, and have not been reviewed, approved or otherwise endorsed by any of these entities.

Cruises see a fair amount of overboard incidents: Are ships equipped?

Mental health crises can happen anywhere. But what happens if you're stuck in the middle of the ocean?

Between 2009 and 2019, there were 212 overboard incidents – when a guest or crew member goes over the edge of a ship – according to statistics compiled for Cruise Lines International Association by consulting firm G.P. Wild (International) Limited. "In discussions with cruise line representatives, they indicated that in every case where the cause of the (overboard) was established following a careful investigation it was found to be the result of an intentional or reckless act," the report said, noting that motives could not be determined in some cases.

There were also numerous reports of suspected suicides among crew trapped at sea during the COVID-19 pandemic. And while cruise lines have protocols and services in place to support to guests and crew members, some experts say they are lacking.

Cruise ships feature a range of amenities, from roller coasters and go-kart tracks to spas and dining, but passengers may not always know where to find mental health resources on board.

‘It’s really, really, really needed’

Cruise ships may be designed to prioritize fun and relaxation, but not everyone responds the same to that approach.

For some passengers, being around family members or away from their day-to-day routine can be stressful, said Dr. Tia Dole, Chief 988 Suicide & Crisis Lifeline Officer at Vibrant Emotional Health. “But for other people who might have been struggling with their mental health … going on a vacation actually takes you out of your environment, it makes you feel better,” she said.

The widespread presence of alcohol and gambling in onboard casinos may also prove challenging for some travelers, said Dr. Michelle Riba, a clinical professor at the University of Michigan Medical School's Department of Psychiatry and former president of the American Psychiatric Association.

"People have to be self-reflective and talk to their loved ones about how problematic it might be to be on a ship where there's easy access to that," she said.

And when it comes to the kinds of overboard incidents that appear in news reports with some frequency, she said jumping into the water has perhaps been featured prominently in films and TV shows, and cruises may provide another "access point" to impulsive suicides.

Travis Heggie, a professor at Bowling Green State University who studies tourist health and safety issues, said it's difficult to draw concrete comparisons, however, between rates at sea and on land due to a lack of comprehensive statistics. Riba added that it would be hard to compare the two, given varying demographics and other factors.

Still, suicide on cruise ships is a “growing concern” for Heggie, among both guests and crew. He has recommended adding mental health care to cruise ship infirmaries in his research .

“It’s really, really, really needed,” he said.

Dole also emphasized that “the reasons why people die by suicide are as unique as a fingerprint” and said it’s important not to generalize.

"The circumstances that lead up to completed suicide, and the things that sort of push people over the edge are incredibly unique," she said.

Do cruise ships have mental health resources?

If passengers find themselves in need of mental health support during a cruise, some lines do have resources available.

Passengers sailing with Carnival Corp., the parent company of brands including Carnival Cruise Line, Princess Cruises and Holland America Line, can contact onboard medical staff “who are available 24/7 for mental health support and other medical needs,” a spokesperson for the company said in an email.

“With a referral from the shipboard medical team, guests may also access tele-psychiatrist services for face-to-face consultations with these licensed specialists within 24 hours if needed,” the spokesperson added. The consultations are offered through a third-party company that connects passengers with U.S.-based psychiatrists (the company did not respond to USA TODAY’s request for comment).

While training in mental health care varies among onboard medical staff, they can “fulfill recommendations made by the psychiatrists.” There is a pharmacy on board with many medications used to treat mental health problems, and those not carried on the vessel can be ordered in a port.

Like other medical care, passengers have to pay for any costs associated with mental health services. “Travel insurance coverage varies by provider and typically covers acute-need services but usually includes limitations for pre-existing illnesses,” the spokesperson said. “We urge travelers to contact travel insurance providers directly for specific terms and conditions.”

Crew members can also see psychiatrists via telehealth with a referral from the onboard medical team. The company also has an employee assistance program that allows them to access free mental health services.

Royal Caribbean Group, another major cruise line operator, and Cruise Lines International Association, the industry’s leading trade group, did not answer questions regarding onboard mental health resources before publishing. Norwegian Cruise Line Holdings Ltd. did not respond to a request for comment.

Cruise ships may also quarantine passengers deemed to be a threat to themselves or others, according to Michael Winkleman, a maritime attorney with Lipcon, Margulies & Winkleman, P.A.

“Our team of onboard medical professionals safeguards the health and well-being of our guests and crew (including mental health), which may include placing a patient under secure watch in the medical center or in a cabin depending on the risk,” the Carnival Corp. spokesperson said.

While there are major differences – namely, being in the middle of the ocean – Winkleman said there are some commonalities between cruise lines’ approach and that of hotels or resorts, which often do not have on-site mental health providers. “They are just expecting to provide a fun, safe vacation for their guests,” he said.

Crises on cruises, like an overboard incident, for example, may also get outsized attention given their setting, Heggie added. "People are expecting to go and have a good time and have the vacation or holiday mindset, and, 'Oh, something bad happened.' "

However, Winkleman said he thinks cruise lines “could do a lot more” to provide mental health support to crew, many of whom work rigorous schedules on months-long contracts.

How passengers can care for their mental health

Travelers can take proactive steps to care for their mental health before a trip if need be. If passengers have a mental health provider, Dole recommends speaking with them beforehand and making sure they have any medication they might need.

Passengers can also reach out to their therapists mid-cruise to schedule a session as needed – though state laws regarding telehealth vary and could prevent them from accessing care. “But generally speaking, it's really about where the person resides,” Dole said. “So (if) you're on a work trip, and you're like, ‘I need to see my therapist,’ they'll see you.”

Riba noted that it may be more difficult to coordinate than at home with spotty cell service and possible time differences.

The 9-8-8 Suicide & Crisis Lifeline also works in U.S. states as well as territories like Puerto Rico and the U.S. Virgin Islands.

How safe are cruise stops?: Travel advisories are only one marker for destinations

Checking in with your fellow travelers can also be helpful. Dole said, “One of the biggest clues someone is struggling” is a change in behavior. Typically, that takes the form of withdrawal, but it could also manifest in people engaging in risky or dangerous behaviors.

“‘I noticed something is different,’” she suggested saying. “‘Is there something happening that you feel comfortable talking to me about?’ And that that's not going to make people be defensive as much as, ‘What's wrong? Are you okay? What's happening?’”

Dole recommended framing the question in a way that avoids sounding judgmental or accusatory. “But actually asking the question, especially for young people, can save someone's life,” she said.

If you or someone you know may be struggling with suicidal thoughts, you can call 988 any time day or night, or chat online. Crisis Text Line also provides free, 24/7, confidential support via text message to people in crisis when they dial 741741.

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

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17 reported hurt after river cruise ship hits a concrete passageway on the Danube in Austria

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Seventeen passengers were hurt when a Bulgarian river cruise ship lost steering and hit the sides of a lock on the Danube in Austria, the apa news agency reported Saturday. Eleven of the injured were taken to hospitals.

The ship with 142 passengers aboard, most of them from Germany, temporarily lost power to its electronics system and became unsteerable as it passed through narrow locks at 9:45 p.m. Friday, apa reported.

The ship’s power was restored but not before the bow and stern struck the concrete sides of the lock passage near the town of Aschach, a few miles upriver from Linz.

The ship sustained minor damage and continued to its next port. The cause of the loss of electrical power was under investigation.

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Breaking news, here’s the ‘ridiculous’ rule on cruise ships that travelers are blasting as a ‘rip-off’.

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When it comes to drinking on board a cruise ship , there is a rule that has even the most dedicated cruisers scratching their heads, claiming it is a “rip-off.”

Drink packages are a common offering on cruises, allowing guests to pay upfront to have the cost of alcoholic drinks at bars and restaurants on board the ship covered.

But there is often a catch – and it can be a terribly frustrating one.

If one person wants to purchase the drinks package, everyone in the same stateroom has to, despite the packages being charged per person, per day and strictly not allowed to be shared.

Two glasses of champagne placed on a railing overlooking a cruise ship at sunset

Australian couple Christine and Dave Russell, who have been going on multiple cruises a year for the past decade, found out how pesky the rule was when Ms. Russell decided to stop drinking 12 months ago.

It meant on three Carnival cruises , Mr. Russell had to miss out on purchasing the drinks package because Ms. Russell would have been forced to pay $111 ($72 USD) a day.

“When you times that by two and only one person drinks, it’s a lot of money,” she told news.com.au.

“I’m not going to drink $100 a day in soft drink. I don’t generally drink soft drink anyway, I only ever drink water.”

Ms. Russell described the rule as “frustrating” and “annoying.”

The Carnival cruise ship Valor heads up the Mississippi River in New Orleans, Wednesday, April 8, 2020

Carnival’s policy is that its “Cheers!” drinks package, including up to 15 alcoholic drinks a day and other non-alcoholic beverages, must be purchased by each adult assigned to the same stateroom.

No sharing is permitted.

News.com.au reached out to a number of major cruise lines that sail in Australia with similar conditions – including Carnival Cruise Line, P & O Cruises, Cunard, Princess Cruises, Celebrity Cruises and Royal Caribbean – and not one could give a reason.

Carnival Australia, which is the parent company of seven cruise brands in Australia and New Zealand, including Carnival, P & O, Cunard and Princess, instead said it took its Responsible Service of Alcohol seriously and drink packages were optional.

“Our beverage packages are completely optional, and guests have the freedom to purchase beverages individually at competitive prices, allowing them to customise their cruise experience according to their personal preferences,” a Carnival Australia spokesperson said.

A sign is shown at the entrance to the headquarters of Carnival Cruise Lines in Doral, Florida

“Our beverage package conditions align with general industry standards which have been in place for many years, and mirror other hospitality industries when opting for a set menu or drinks package.

“Guests who are pregnant or don’t drink alcohol do not have to buy a beverages package, and we offer a wide selection of non-alcoholic beverages.”

Adam Glezer of Consumer Champion , who advocates for Australian customers with issues in the travel industry, told news.com.au the rule was “unreasonable” and “a profit making exercise.”

While he believes drink packages on cruises are a brilliant idea, he said cruise companies should not be pressuring people to buy them if they don’t want to.

Mr. Glezer, who is a cruiser himself, said it was “disappointing but not surprising” the cruise companies had failed to give a reason for the rule.

“They haven’t given a reason because there’s no explanation that would paint them in a decent light,” he said.

“I’m fighting for this to be changed because a drinks package should be optional per individual.”

“If someone drinks, they should be able to purchase the drinks package without others in the cabin being obliged to purchase the same package.”

“I’ve met a number of people that have been quite annoyed by the situation.”

He believes a cruise company who decides to buck tradition and “get rid of the ridiculous rule will have an edge on their opposition.”

Virgin Voyages and Disney Cruise Line, which had their first seasons in Australia this summer, have both ditched traditional drink packages.

Virgin instead allows guests to pre-pay their “Bar Tab” and get bonus on-board credit for doing so.

It promotes its offering as being different to other cruise brands, with “no restrictive drink packages with unreasonable rules here”.

Disney’s deals include packages of bottled wine and a refillable beer mug offering, where guests receive a 21 oz glass mug and can refill it for the cost of a 16 oz beer at any bar on the ship that serves draft beer.

Royal Caribbean has a slightly different take on the traditional rule that the same drink package must be purchased by those staying together.

If a guest within the stateroom does not drink alcohol then a ‘Refreshment Package’ must be purchased, including soft drinks, coffees, tea, juices and non-alcoholic cocktails.

Travelers have shared mixed reactions to cruise drink packages online, with some warning it is not worth it and others explaining how they got their money’s worth.

The Carnival Magic is seen docked in Ocho Rios, Jamaica during day three of the ShipRocked cruise on Tuesday, Feb. 6, 2024

One Australian TikTok user, who goes by the handle “jasmintiexo,” created a detailed breakdown of every drink she ordered on a eight day Royal Caribbean cruise.

It showed she was able to get $US1151.50 (about $1760) worth of drinks for $US520 (about $795).

See how major cruise brands in Australia apply the rule on drink packages below.

Carnival Cruise Line

If purchasing the “Cheers!” alcoholic drinks package each adult assigned to the same stateroom must purchase it too, starting at $111($72 USD) per person, per day.

There is a limit of 15 alcoholic drinks a day.

Colorful holiday cocktails on cruise ship

If the drinks package is part of an offer you have received from Carnival, then it is applicable to the 1st and 2nd adults in the cabin only; if the 2nd passenger is not 18 years of age, then the “Bottomless Bubbles” package (soft drink and juice) will be assigned at $7.50 (about $5 USD) per day.

Carnival Cruise Line told news.com.au: “If one of the guests sailing together chooses not to purchase a package, they always have the option to enjoy beverages ala carte.”

Celebrity Cruises

Guests must purchase the same drink package for all guests of legal drinking age in the same stateroom. Packages may not be shared.

A non-alcoholic drink package will be added instead for teens 13 to 17 years old, pregnant guests, and recovering alcoholics or guests with a medical issue that does not allow them to consume alcohol.

Alcoholic drink packages start at $US89 ($136) per person, per day.

Each adult assigned to the same stateroom must purchase the same drinks option.

Sharing is not permitted.

On a five to 14 night cruise, the “Beers, Wines and Spirits” package starts at $US72 ($110) per person, per day.

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P & O Cruises

If two or more guests aged over 18 years are sharing a cabin all guests must purchase the same drinks package.

There is a limit of 15 alcoholic drinks a day. Sharing drink packages is not allowed.

Alcoholic drink packages start at $99 ($65 USD) per person, per day.

Princess Cruises

The requirement for alcoholic drink packages to be purchased by more than one guest is not included in the updated terms and conditions.

However in its FAQ, Princess Cruises states third and fourth guests in the same stateroom are not required to purchase or be defaulted to the selected package of first and second guests in a stateroom, implying the first two guests must purchase the same package.

Alcoholic drinks are limited to 15 beverages a day and must not be shared.

The alcoholic drink packages start at $110 ($72 USD) per person, per day.

Royal Caribbean

If purchasing the “Deluxe Beverage Package” it is required that it is purchased by all guests of legal drinking age in the same stateroom.

Packages cannot be shared.

If a guest within the stateroom does not drink alcohol then a “Refreshment Package” must be purchased.

This includes soft drinks, coffees, tea, juices and non-alcoholic cocktails.

Prices can change depending on the sailing.

The alcoholic drinks package is said to cost between $US56 ($86) to $US105 ($161) per person, per day, and the “Refreshment Package” costs $US29 ($44) per person, per day (both excluding gratuity).

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Ukraine war latest: Moscow 'very likely' behind GPS disruptions; Russian personnel 'killed or injured' in Ukrainian strikes

Ukraine conducted "coordinated strikes" on a military airbase inside Russia overnight, a Ukrainian military source has told Sky News. The operation, which took place early this morning, included attacks against Russian SU-34 fighter-bombers.

Sunday 7 April 2024 16:08, UK

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Ukraine conducts 'coordinated strikes' on military airbase inside Russia, source tells Sky News
As many as 20 airfield personnel 'killed or injured' | 'Six Russian warplanes destroyed'
Explained: What is the Morozovsk airfield?
Russia 'very likely responsible' for Baltic GPS disruptions, Germany says
Kyiv denies Russian forces have reached eastern town | Moscow claims control of another village
Explained: How the war has strayed outside Ukraine's borders
Big picture : What's happening with war?

While we haven't been able to bring you live updates on the war in Ukraine today, we have been keeping an eye on the key moments.

Here's a round-up of what has happened today:

Zelenskyy's stark warning

Late last night, Volodymyr Zelenskyy warned his country could run out of air defence missiles if Russia continues to launch long-range bombing attacks.

The warning was the starkest yet from the Ukrainian president, who has been urging allies for weeks to speed up the delivery of military assistance.

In an interview shown on Ukrainian TV, he said his forces have enough for the moment, but they were already having to make difficult choices about what to protect.

"If they keep hitting [Ukraine] every day the way they have for the last month, we might run out of missiles, and the partners know it," he said.

Attack at Zaporizhzhia

Russian authorities in control of the Zaporizhzhia power plant have reported a drone strike at the facility, the UN nuclear watchdog has said.

Moscow has claimed Ukraine struck the dome above the shutdown reactor at the site, but radiation levels have remained stable.

It was not immediately clear what weapon was used against the nuclear plant, which was taken by Russian forces shortly after their full-scale invasion of Ukraine in 2022.

The International Atomic Energy Agency (IAEA) said it had been informed by the Russian-run plant that a drone had detonated at the site, and the information was "consistent" with IAEA observations.

The plant remains close to the front lines, and both Ukraine and Russia have repeatedly accused the other of attacking the plant and so risking a possible nuclear disaster.

One dead in Belgorod

A woman has died after shrapnel from a downed Ukrainian drone hit a car travelling in Russia's Belgorod region, a local governor has said.

Four more people, including two children, were wounded after air defences shot down four Ukrainian drones, Vyacheslav Gladkov said.

Belgorod region, which borders Ukraine, has come under regular attack from Kyiv's forces in retaliation to Russia's invasion.

We've not been able to bring you live updates on the war in Ukraine today, so here is what has been happening.

Eight people have been killed in two Russian strikes on the northeastern Ukrainian city of Kharkiv, local authorities say.

The strikes took place early this morning and in the afternoon.

Ukraine's national police said the attack was launched by drones, but local officials said missiles and bombs were used.

"As of this morning, there are 6 dead and 10 wounded as a result of the night strike on Shevchenkivskyi district," Kharkiv mayor Ihor Terekhov said on Telegram.

At least nine high-rise buildings were struck, along with administrative buildings, a shop, a petrol station, and a service station.

Here are more updates from today:

Tajikistan has rejected a Russian claim that Ukraine's embassy in the Tajik capital is recruiting mercenaries to fight against Russia
A kamikaze drone hit a military facility used by pro-Russian separatists in Moldova's breakaway region of Transnistria
The Ukrainian army's commander-in-chief said his forces are still in control of the town of Chasiv Yar despite attempts by Russian forces to break through their defences.

That's it for our coverage for today, but before we go - let's recap the day's key happenings.

Airbase strikes

By far the biggest story of the day is regarding overnight Ukrainian strikes on an airfield inside Russia - news we broke exclusively here at Sky News via our Ukraine producer Artem Lysak and security and defence editor Deborah Haynes.

Ukrainian sources have since indicated that as many as 20 Russian service personnel were killed or wounded in the attack on Morozovsk airfield in Rostov.

Up to eight aircraft were damaged, while as many as six were destroyed completely, Ukrainian sources claimed.

The airbase has been the staging post for Russian bombings on the frontline since the beginning of the full-scale invasion in 2022.

It is home to the 559th Bomber Aviation Regiment within the 1st Guards Composite Aviation Division.

This unit has three squadrons of SU-34s which are regularly used to bomb Ukrainian forces on the frontline.

Claim that nuclear plant targeted again

Russia has once again claimed that Ukraine has tried to attack the Zaporizhzhia nuclear power plant.

Critical infrastructure was not thought to have been damaged despite the drone attack, state media quoted the plant's Moscow-installed management as saying.

Both Ukraine and Russia have accused the other of trying to create a nuclear disaster by attacking the plant - which has been under Moscow's control since the early days of the war.

Separately - and not thought to be linked to the war in Ukraine - authorities in the far eastern Russian city of Khabarovsk have declared an emergency after radiation was detected in the area.

No one has been injured or exposed to radiation and there is no risk to public health, TASS quoted the local branch of Russia's consumer safety watchdog as saying.

Russian advances?

Russia reported advances in two areas of Donetsk.

The defence ministry said Russian troops had reached the suburbs of the town of Chasiv Yar - which was denied by Ukraine.

Kyiv did note fighting in the area, however.

Additionally and without providing details or evidence, the ministry said troops had also captured the village of Vodyane, which is just northwest of Donetsk city and slightly southwest of Avdiivka.

Ukraine is yet to respond to the claims regarding Vodyane.

Lord Cameron will travel to the US next week where he will urge politicians to approve a package of military aid for Ukraine.

The foreign secretary said he would meet with Republican House Speaker Mike Johnson to urge him to pass the bill - which he has held up for months.

"Britain has put forward its money for Ukraine this year, so has the European Union. America needs to do it," he said on X.

"Speaker Johnson can make it happen in Congress. I am going to go see him next week and say we need that money, Ukraine needs that money."

The bill, worth some $95bn (£75bn), was approved by the Democrat-led Senate on 13 February, but has faced stiff opposition in the Republican-controlled House of Representatives.

Both houses of Congress must approve the bill before President Biden can sign it into law.

Some $60bn (£47bn) of the package is allocated for military aid for Ukraine alone.

However, former president Donald Trump and his Republican allies in Congress want funding directed toward domestic issues such as border control, rather than on foreign wars.

Several Russian personnel have been expelled from the NATO headquarters, secretary-general Jens Stoltenberg has said.

It is not clear when the expulsions took place.

"We realised that they were carrying out activities that were not actually diplomatic work, but intelligence work," Mr Stoltenberg told Bild .

He did not say how many had been expelled, nor offer any detail as to what intelligence they had gathered while at the NATO headquarters, which is located in Brussels.

A Moscow court has placed an 11th suspect in last month's concert hall attack in pre-trial detention, Russian officials have said.

The suspect, Muhammad Zoir Sharipzoda, a Tajik national, is accused of committing a terrorist act, the court said.

At least 144 people were killed when the so-called IS-K targeted the venue - which is just outside Moscow - at the end of last month.

This morning, Russia's investigative committee claimed it had recovered images from the phone of one of the shooters, which it said may indicate a connection between the Ukraine war and the attack (see 8.29am post).

Ukraine has strenuously denied any involvement after repeated Russian accusations, including from Vladimir Putin, that Kyiv was involved or aware of the attack in some capacity.

The West has similarly dismissed suggestions Kyiv was involved and several leaders have accused Russia of using the attack as an excuse to expand its operations in Ukraine.

At least two people have died and six have been injured by a Russian attack in Zaporizhzhia, the head of Ukraine's military administration for the region has said.

A nine-year-old boy was among the injured, while the dead are a man and a woman of unspecified age, Ivan Fedorov said on Telegram.

The boy's mother, 36, was also injured, alongside young men in their 20s and a man and woman in their 50s.

Mr Fedorov did not say how the attack was carried out, and Russia has not commented on the claims.

He shared this unverified image of the damage purportedly caused by the attack, but offered no details as to what the building was.

As we reported in our 2.50pm post, Russia has claimed today that Ukraine has been trying to hit the nuclear power plant in Zaporizhzhia with drones.

As we've been reporting throughout today, Ukraine launched a coordinated drone attack on an airbase inside Russian territory overnight.

Ukrainian sources have indicated that as many as 20 Russian service personnel were killed or wounded in the attack on Morozovsk airfield in Rostov.

This footage shows the attack...

In the latest in a string of accusations of a similar nature, Russia has again claimed that Ukraine has tried to attack the Zaporizhzhia nuclear power plant.

"The Ukrainian armed forces hit the territory of the Zaporizhzhia nuclear power plant with several UAVs (drones)," Russian state media outlet TASS cites the station's Moscow-installed management as saying.

However, critical infrastructure is not thought to have been damaged, it added.

Ukraine has not responded to the latest accusations from Moscow - which are unverified.

Russia is "very likely" to have been behind a series of disturbances affecting GPS navigation in the Baltic region, the German defence ministry has claimed.

The ministry pointed to the Russian enclave of Kaliningrad as a source of the problem.

"The persistent disruptions to the global navigation satellite system are very likely of Russian origin and are based on disruptions in the electromagnetic spectrum, including those originating in the Kaliningrad Oblast," a spokesperson said.

However, the spokesperson did not offer any details as to how Berlin came to its conclusions and the Russian embassy in the country has not responded to a request for comment.

Similarly last month, a government source said that Russia was believed to have jammed the satellite signal on an aircraft used by UK Defence Secretary Grant Shapps when it flew close to Kaliningrad.

Kaliningrad is a Russian territory wedged between Lithuania and Poland on the coast of the Baltic Sea.

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Box 8-04 Healthy cruise travel preparation: a checklist for health care providers