International travel and health

Travel by sea

This section was prepared in collaboration with the International Society of Travel Medicine.

The passenger shipping industry (cruise ships and ferries) has expanded considerably in recent decades. In 2008, 13 million passengers worldwide travelled on cruise ships. Cruise itineraries cover all continents, including areas that are not easily accessible by other means of travel. The average duration of a cruise is about 7 days, but cruise voyages can last from several hours to several months. A typical cruise ship now carries up to 3000 passengers and 1000 crew.

The revised International Health Regulations (2005) address health requirements for ship operations. There are global standards regarding ship and port sanitation and disease surveillance, as well as response to infectious diseases. Guidance is given on provision of safe water and food, on vector and rodent control, and on waste disposal. According to Article 8 of the International Labour Organization Convention (No. 164) “Concerning Health Protection and Medical Care for Seafarers” (1987), vessels carrying more than 100 crew members on an international voyage of 3 days or longer must provide a physician for care of the crew. These regulations do not apply to passenger vessels and ferries sailing for less than 3 days, even though the number of crew and passengers may exceed 1000. Ferries often do not have an emergency room but a ship’s officer or a nurse is designated to provide medical help. The contents of the ship’s medical chest must be in accordance with the international recommendations and national laws for ocean-going trade vessels, but there are no special requirements for additional drugs for passenger ships.

The average traveller on a cruise line is 45–50 years of age. Senior citizens represent about one-third of passengers. Cruises of longer duration often attract older travellers, a group likely to have more chronic medical problems, such as heart and lung disease. More than half of all emergency visits to health clinics on board are made by passengers who are over 65 years of age; the most common health problems are respiratory tract infection, injuries, motion sickness and gastrointestinal illness. Extended periods away from home, especially days at sea, make it essential for passengers to stock up with sufficient medical supplies. Prescription medicines should be carried in the original packages or containers, together with a letter from a medical practitioner attesting to the traveller’s need for those medicines. Cruise ship travellers who may require particular medical treatment should consult their health-care providers before booking.

It is important to view a ship’s medical facility as an infirmary and not as a hospital. Although most of the medical conditions that arise aboard ship can be treated as they would be at an ambulatory care centre at home, more severe problems may require the patient to be treated in a fully staffed and equipped land-based hospital after stabilization on the ship. Knowledge of the type and quality of medical facilities along the itinerary is important to determine whether passengers or crew members can be sent ashore for additional care or need to be evacuated by air back to the home port. Most cruise vessels do not have assigned space for a dental office, and very few have a resident dentist.

The rapid movement of cruise ships from one port to another, with the likelihood of wide variations in sanitation standards and infectious disease exposure risks, often results in the introduction of communicable diseases by embarking passengers and crew members. In the relatively closed and crowded environment of a ship, disease may spread to other passengers and crew members; diseases may also be disseminated to the home communities of disembarking passengers and crew members. More than 100 disease outbreaks associated with ships have been identified in the past 30 years. This is probably an underestimate because many outbreaks are not reported and some may go undetected. Outbreaks of measles, rubella, varicella, meningococcal meningitis, hepatitis A, legionellosis, and respiratory and gastrointestinal illnesses among ship passengers have been reported. Such outbreaks are of concern because of their potentially serious health consequences and high costs to the industry. In recent years, influenza and norovirus outbreaks have been public health challenges for the cruise industry.