Disease Transmission and Passenger Behaviors during a High Morbidity Norovirus Outbreak on a Cruise Ship, January 2009

Abstract

Person-to-person transmission, including an incident of public vomiting during boarding, likely contributed to this high morbidity outbreak. Infirmary surveillance detected only 60% of acute gastroenteritis (AGE) cases involved in this outbreak. Adjustments to outbreak reporting thresholds may be needed to account for incomplete voluntary AGE reporting and to more rapidly implement control measures.

Norovirus

“…Norovirus outbreaks have also been reported in land-based resorts (157,158). Risk factors for disease acquisition are similar to those reported during cruise ship outbreaks, such as sharing rooms with previously affected persons and witnessing episodes of public vomiting (101,158).…”

“…The CDC Vessel Sanitation Program maintains a list of gastrointestinal outbreaks of public health significance in vessels sailing for 3 to 21 days, carrying 100 or more passengers, and on which 3% or more of passengers or crew report diarrheal symptoms to onboard medical staff during the voyage (156). Shared living and dining quarters, in addition to passenger and crew disincentives for reporting illness, have been implicated in outbreaks (101). Norovirus outbreaks have also been reported in land-based resorts (157,158).…”

Mapping Broadly Reactive Norovirus Genogroup I and II Monoclonal Antibodies

“…In the United States, NoVs cause 19 to 21 million cases each year (4,5). NoV outbreaks have been identified in children (6), the elderly (7), military personnel (8,9), immunocompromised individuals (10), restaurant patrons (11,12), travelers to developing countries (13,14), passengers of cruise ships (15), residents of health care facilities such as nursing homes (16,17) and hospitals (18), and other populations housed in close quarters (19). The increasing incidence of NoV infections emphasizes the need to quickly detect and identify the causative agent, because early diagnosis of NoV infection can be crucial in the effective control of outbreaks and can decrease the secondary attack rate (20).…”

Norovirus outbreaks on commercial cruise ships: a systematic review and new targets for the public health agenda

“…Thirteen of these were subsequently excluded because they did not meet the inclusion criteria: five because they were reports of outbreaks on military ships, and eight because data about the location and the characteristics of the outbreak were not available. Twenty-two articles (Morillo et al 2012;Wikswo et al 2011;Vivancos et al 2010;Xerry et al 2009;Boxman et al 2009;Xerry et al 2008;Chimonas et al 2008;Verhoef et al 2008a, b;Takkinen 2006;Koopmans et al 2006;Ferson and Ressler 2005;Isakbaeva et al 2005;Widdowson et al 2004;Gallimore et al 2003;CDC 2002;Minooee and Rickman 1999;McEvoy et al 1996;Koo et al 1996;Herwaldt et al 1994;Khan et al 1994) met the inclusion criteria and were thus included in our review.…”

“…Six studies (10 vessels) described the infection rate for passengers and crewmembers, separately, which ranged from 19 to 74 % and from 1.5 to 30 %, respectively. Three studies reported only the global infection rate (passengers and crewmembers together) which ranged from\1 to 41 % (Verhoef et al 2008a;Widdowson et al 2004;Wikswo et al 2011). In the studies performed by Vivancos et al, Neri et al, and the CDC, data were obtained by consulting the ship's medical team and by analyzing the lists of passengers routinely collected by travel companies (see Table 2) (Vivancos et al 2010;Neri et al 2008;CDC 2002).…”