Cruises

Good preparation helps travellers planning a cruise have a safe and healthy trip Cruises

 

Key Messages

Pre-trip preparation, including pre travel health advice, vaccines and malaria guidance in advance is a key strategy for effective cruise travel risk management.
Comprehensive travel health insurance is recommended for all cruise passengers.
Accidents, slips and trips can be a significant hazard.
Cruise passengers may under estimate extremes of temperature and the strength of the sun and need to be reminded of the importance of protecting themselves.
Food and water borne illness can be transmitted very quickly in enclosed environments such as cruise ships. Passengers should be advised to eat and drink sensibly and follow good food and water hygiene rules.
Respiratory infections such as influenza can also spread rapidly on cruise ships.

Overview

Cruises remain a popular holiday choice, with exotic or remote destinations becoming more common. Cruises bring together people from all over the world; travellers and crew, in crowded, semi-enclosed environments. Pre-travel advice and adequate preparation is essential in reducing the risk of health problems; being on-board can facilitate spread of person-to-person and food or waterborne illnesses. Trips ashore in tropical regions may expose passengers to different infections, including insect spread diseases [1].

Pre-travel preparation

Research

Risk management advice for cruise passengers should follow that of the general traveller and be tailored to individual requirements. Health professionals and passengers can check the TravelHealthPro website Country Information pages for travel advice, vaccines and malaria guidance for specific cruise destinations. For effective risk assessment to be complete, health professionals need to scrutinise the cruise itinerary carefully. Therefore it is reasonable to ask passengers to provide a clear itinerary, ideally a written/online copy of the official document provided by the cruise company.

Certain groups, such as pregnant women, the elderly, individuals with chronic health conditions or immunosuppression, require special consideration when contemplating cruise travel [1]. These individuals, and those with significant mobility problems, are advised to arrange a consultation with their doctor, nurse or a travel clinic prior to booking a cruise. This is to discuss any health concerns, consider suitability of destinations, and help them decide if a cruise is appropriate for them. 

Passengers should be advised to check the Foreign and Commonwealth Office website for destination specific foreign travel safety and security advice.

Emergency medical care and insurance

Medical care on cruises varies and most ships spend time at sea, remote from land. Treatment and medication aboard are not free and are not included in cruise packages.

Comprehensive travel insurance is essential for all cruise passengers. A full declaration of health conditions should be made, all destinations, equipment and planned activities should also be stated. Withholding details of medical history or trip details may mean travellers are not fully covered. Policies should be checked for coverage exclusions and must meet the costs of emergency medical treatment, including hospital charges, ambulance fees and medical evacuation from remote locations - evacuation by air ambulance can be very costly [2].

Passengers should be reminded to take good supplies of all regular medicines, including contraception. As trip delays can occur, more medication than required should be carried.

First aid kit

Passengers should be advised to carry a simple first aid kit, with basic equipment tailored to their needs and destinations, to help them deal with any minor injuries and illnesses. 

Insect repellents

Passengers should pack insect repellents, ideally creams or sprays containing DEET (N,N-diethyl-m-toluamide) at a concentration of at least 20%. This is particularly important in regions where malaria [3] and other insect spread illnesses like dengue, yellow fever and Zika are a risk. When both sunscreen and DEET insect repellents are needed, the DEET repellent should be applied after the sunscreen. A sunscreen with a sun protection factor (SPF) of 30 to 50 should be used to compensate for any DEET- induced reduction in protection [3].

Malaria

Many cruises only stop on land during the daylight hours, when malaria (Anopheles) mosquitoes rarely bite, so most cruise passengers do not require antimalarials. However, if the cruise itinerary indicates overnight stops in malarial areas or passengers are ashore overnight in risk regions, antimalarials may be recommended [3]. Passengers should take any recommended tablets as directed, finish the course, be meticulous about insect bite avoidance and get urgent medical attention for symptoms.

Sun, changing environments and extreme temperatures

Cruises can expose passengers to extremes of weather and temperature, so they should be advised to pack appropriate clothes, sturdy footwear, gloves, a hat and sunglasses.

High factor sunscreen (SPF 30 or above with a 4 or 5 star UVA rating) is also recommended. Limiting sun exposure and regularly applying a broad spectrum, high protection sunscreen helps protect against skin damage, with the associated risk of skin cancer. Further information is available here.

Travel sickness

Even individuals who do not normally get travel sick may experience it on a cruise. All travellers planning a cruise should be advised to get advice from their pharmacist about anti-sickness medication before travel.

Vaccines

As well as ensuring they have all recommended travel vaccines, cruise passengers should be in date for routine United Kingdom (UK) vaccines including the Mumps, Measles and Rubella (MMR) vaccine.

Outbreaks of influenza can occur at any time of the year among cruise ship passengers [4, 5] so travellers should consider having an influenza vaccine before they go. In the UK, pregnant women, young children, anyone aged 65 years or older, and individuals with underlying long-term health conditions such as heart disease, respiratory disease or immunosuppression are offered influenza vaccine [6]. For cruise passengers not entitled to an NHS influenza vaccine, during the influenza season, the vaccine is available from travel clinics and high street chemists for a small fee.

Yellow fever

The cruise itinerary should be carefully studied to establish whether there is a risk of yellow fever. If the ship is stopping in yellow fever risk areas, cruise passengers need to get advice from a specialist yellow fever vaccination centre (this vaccine can only be given at these centres) as they may need yellow fever vaccine for personal protection.

Even if cruise passengers are not at risk of yellow fever during trips ashore, some countries may require proof of yellow fever vaccine if they have visited a country with a yellow fever risk. Specialist yellow fever clinics can advise on this issue. 

During travel

All passengers should make sure they are aware of the location of the ship’s medical facilities and are familiar with all emergency evacuation procedures as soon as they arrive on-board.

Individuals with pre-existing health problems should introduce themselves to the ship’s doctor and/or nurse, informing them of their medical history and any medication. If appropriate, a written health summary of their medical history, from the GP or hospital specialist, should be provided.

Passengers should report any symptoms or illnesses, especially diarrhoea and vomiting, promptly to the ship’s medical team and crew.

Bite avoidance

Insect-spread diseases such as chikungunya, dengue fever and Zika are common in many cruise destinations. Many of these insect-spread diseases cannot be prevented by drugs or vaccines, so careful insect bite avoidance is the only way travellers can protect themselves.

In some destinations, there may be a risk of rabies. Any cruise passengers are bitten, scratched or spat at by any animal, either or on-board or ashore, must get urgent medical attention from the ship’s medical facilities.

Food, water and alcohol

Outbreaks of diarrhoea and gastrointestinal infections, including Campylobacter jejuniE. coli, norovirus and Shigella sonnei have been reported on cruise ships [7]. Close contact with the crew and other passengers means infections can spread more easily [1]. Passengers can reduce their risk by following good food and water and personal hygiene precautions carefully both whilst on the ship and when ashore. This includes hand washing and using alcohol-based hand sanitisers when handwashing facilities are unavailable and is particularly important during and after shore visits.

Excessive food and alcohol consumption should be avoided and drinks should never be left unattended. Passengers should take the same care ashore as on the boat and remember alcohol strength can vary and local measures may be very generous.

Respiratory infections

Coughs, colds and respiratory infections can spread quickly on cruises, so passengers should follow good personal hygiene rules and avoid close contact with anyone with symptoms. In some situations, cruise ships may impose restrictions, such as isolating ill passengers [1].

Outbreaks of Legionnaires’ disease (a type of pneumonia caused by inhaling fine water sprays contaminated with bacteria) have been reported on cruise ships [1, 8] usually linked to whirlpools, hot tubs and spas [1]. If passengers have any concerns about the upkeep of on-board facilities they should avoid using them and report their concerns to cruise ship staff.

Safety

Falls, slips and trips are a hazard on cruises and can cause serious injury. Decks and stairs easily become wet and slippery. Passengers should take care, particularly in rough and stormy weather, and when getting on and off the ship. They should never sit on balcony or deck railings.

Care should be taken when swimming and passengers should be strongly advised never to swim at night or after drinking alcohol/taking drugs.

During trips ashore, passengers should be respectful of cultural sensitivities and mindful of their personal safety.

Sexual health

Alcohol or the novelty of being on holiday may lower inhibitions and increase the possibility of casual sex. Those travelling without a steady partner should be aware of the risks of casual sex, even when it is not planned. Reliable condoms should be carried and used to reduce the risks. Further information is available here.

Sun

Travellers may underestimate their risk of sun damage, especially in colder destinations. Snow and ice can increase sun exposure by reflecting UV rays. Cruise passengers should try to limit time they spend in the sun, cover up using high factor sun cream, clothes, sunglasses and a hat.

After travel

Cruise passengers should be reminded that if they have been prescribed antimalarial tablets, they must complete the course at home, even if they feel well. 

Returned cruise passengers with any symptoms, including a lasting cough, fever, flu-like illness, or persistent diarrhoea, must get medical advice, remembering to inform their doctor that they travelled on a cruise. If they have visited malaria risk areas the possibility of malaria must be considered, and, an urgent malaria test must be arranged. This is important even if they have completed an antimalarial course and have been home for a while.

First Published :   29 Jan 2018
Last Updated :   29 Jan 2018

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