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Don't let the norovirus ruin your next cruise or vacation

Robin Wulffson MD's picture
norovirus, gastroenteritis, cruise ship, prevention, treatment

For a number of years an unwelcome stowaway has ruined an ocean cruise for countless passengers. The culprit is the norovirus, which each year causes about 21 million illnesses, of which 70,000 require hospitalization. Although most cases resolve in a matter of days, approximately 800 people die from an infection each year, according to the Centers for Disease Control and Prevention (CDC).

The two latest outbreaks, which are most likely due to the norovirus, occurred on two large cruise ships. Last week, an outbreak sickened 194 passengers and 11 crew members aboard the
Cunard Line luxury cruise ship Queen Mary 2. That same week, 189 passengers and 31 crew members aboard the Emerald Princess, operated by Princess Cruise Lines, came down with symptoms attributed to the norovirus. Both ships are currently cruising the Caribbean.

According to the CDC, noroviruses are a group of related viruses. Infection with these viruses affects the stomach and intestines and causes gastroenteritis, which is an inflammation of the stomach and intestines. Everyone is susceptible to norovirus, and infection does not provide immunity; thus, an individual can be stricken more than once in a lifetime. Common symptoms are nausea, vomiting, and diarrhea. Other, less common symptoms may include low-grade fever, chills, headache, muscle aches, and general sense of fatigue. The illness often begins suddenly. Norovirus illness is not related to the flu (influenza), which is a respiratory illness caused by influenza virus.

As previously mentioned, a norovirus infection is usually not serious. And most individuals get better in one-to-two days. However, norovirus illness can be serious in young children, the elderly, and individuals with other health conditions; it can lead to severe dehydration, hospitalization and even death. The infection can be acquired from an infected person, contaminated food or water, or by touching contaminated surfaces.

Norovirus is a leading cause of disease from contaminated foods in the United States. Foods that are most commonly involved in foodborne norovirus outbreaks include leafy greens (such as lettuce), fresh fruits, and shellfish (such as oysters). However, any food item that is served raw or handled after being cooked can become contaminated with noroviruses. A major factor of rapid norovirus outbreaks on cruise ships is because the virus can quickly spread in contained, crowded places. Other locations at increased risk are long-term care facilities, daycare centers, schools, and hotels. Noroviruses can also be a major cause of gastroenteritis in restaurants and catered-meal settings if contaminated food is served.

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The virus is present in the vomit and stool of infected individuals. It can be acquired by:

  • Eating food or drinking liquids that are contaminated with norovirus (someone gets stool or vomit on their hands; then touches food or drink).
  • Touching surfaces or objects contaminated with norovirus and then putting your hand or fingers in your mouth.
  • Having direct contact with a person who is infected with norovirus (for example, when caring for someone with norovirus or sharing foods or eating utensils with them).

People with norovirus illness are contagious from the moment they begin feeling sick until at least three days after they recover. However, some people may be contagious for even longer. Currently, there is no vaccine or treatment for the infection beyond supportive measures such as anti-nausea medication, anti-diarrhea medicine, and fluids.

Cruise lines are well aware of the problem and take a number of steps to reduce infection. Before boarding, passengers must sign a statement that they are not ill at present (unfortunately, some lie). Hand sanitizers are placed at restaurant entrances. They are particularly prominent at cafeteria-style areas where contact between food handling utensils and multiple passengers is common. The captain and crew no longer shake hands in the welcome aboard receiving line. Hand contact with an infected person followed by touching the face or mouth––a sure-fire way to get the infection. Passengers are asked to present to medical center if they develop gastrointestinal symptoms. Those sickened are asked to isolate themselves in their cabin until they are non-contagious. They are also asked not to proceed ashore, and often, any shore excursion costs are refunded. Usually, room service is provided to affected passengers and every effort is made to make them as comfortable as possible.

I will now share my up close and personal experience with the norovirus. The first occurred several years ago on a Holland America Line Caribbean cruise. Many passengers were affected; however, my wife and I were not affected. We avoided contact with public objects such as stair rails and were meticulous regarding hand washing. The cruise line went to extreme measures to prevent spread of the virus. Stricken passengers, as well as their cabin mates, were taken off the ship and provided with transportation home. All bedding, linens, and draperies were burned. Despite these extraordinary measures, new infections continued to arise. The casino was shut down because contact with gambling chips was another source of infection. In general, however, most passengers fared well. The restaurants and shows were well attended. When we docked in Fort Lauderdale, the port area was swarming with the media, seeking out interviews with passengers on the “Plague Ship.”

My norovirus nightmare occurred on a subsequent cruise, also on a Holland America Ship. We cruised from Osaka, Japan to Hong Kong, China. A cruise highlight was an overnight stay in Beijing. The featured evening event was a Peking duck dinner, accompanied by a variety of Asian delicacies. In the center of each table was a large Lazy Susan loaded with goodies. A problem, which I overlooked, but my clever wife did not, was the lack of serving chopsticks accompanying each dish. Our fellow passengers plucked delectable morsels with their personal pair of chopsticks; then, ate and plucked intermittently. Double-dipping to the extreme! Shortly after returning to the ship, I was stricken. I developed a condition known by the British as “open both ends.” No further explanation necessary. We were quarantined to our stateroom and I received a “cabin call” from the ship’s nurse. The ship’s doctor was unable to perform this function because he was also a norovirus victim. Physician, heal thyself! My symptoms subsided after two miserable days. We missed a much-anticipated day trip to Shanghai (a return trip to that fascinating city is on our bucket list); however, we did enjoy the rest of the two-week cruise.

Take home message:
A norovirus infection is not uncommon on cruise ships and other public areas. The risk of infection can be markedly reduced by basic hygiene measures such as hand washing and avoiding close contact with other individuals. I have taken several trips to Asian nations and they take more precautions than we do in the US. In Singapore and Taiwan, after deplaning, a device resembling a radar gun device was aimed at me. It could detect an elevated body temperature. Asians commonly wear a surgical mask if they have a respiratory infection; thus, reducing the infection of others. Asians traditionally bow rather than shaking hands—another good practice in my opinion. Shaking hands in Western nations evolved from the concept that it was a sign that you were not armed and meant no harm to the other person.

Reference: CDC