Preliminary guidelines for the prevention and control of influenza-like illness among passengers and crew members on cruise ships
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Preliminary guidelines for the prevention and control of influenza-like illness among passengers and crew members on cruise ships

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      During the 1972 through 1993 influenza seasons in the United States, an average of 20,000 deaths and more than 100,000 hospitalizations each year resulted from complications of influenza infection. Although influenza has been reported on cruise ships in the past, seldom have prospective control measures interrupting influenza transmission been reported. In late summer 1997, an influenza outbreak among elderly passengers at high risk for complications from influenza and crew members was investigated on board a cruise ship. Disease transmission was successfully interrupted by instituting surveillance, cohorting ill persons, vaccinating crew members, and initiating antiviral chemoprophylaxis of both crew members and passengers. Although this voyage took place in the northern hemisphere during the summer, influenza A likely was introduced on board the ship by travelers from the southern hemisphere, where influenza activity was in season. As service providers to passengers, crew members served as a reservoir for influenza infection and transmitted disease to passengers on subsequent cruises. In summer 1998, a large influenza A outbreak among travelers (including cruise ship passengers) and tourist industry workers occurred in Alaska and the Yukon Territory. Public health agencies identified the outbreak after they were alerted about increased respiratory illness and pneumonia activity by cruise line operators and by passengers who became ill after returning home. In contrast to the 1997 outbreak, it was not possible to control this outbreak because it had already become widespread among land and sea travelers. Cases of illness among tourists to Alaska abated only after the tourist season ended and tour operators and cruise ships left the region.

      Such summertime outbreaks among travelers and crew members on cruise ships suggest that traveling in large groups may pose a risk for exposure to influenza viruses in regions of the world where influenza is not in seasonal circulation, particularly if the group contains travelers from areas of the world where influenza viruses are in seasonal circulation. Reported outbreaks highlight the need to develop criteria for determining when an outbreak is occurring and for effective surveillance protocols so that early, targeted prevention efforts may be instituted. Efforts aimed at prevention and control of respiratory diseases, in particular of influenza, among travelers and tourist industry workers should focus on key travel destinations that serve both as a conduit and gathering point for travelers, where disease amplification may occur. Cruise ships are an example of this type of unique environment.

      The following preliminary guidelines for the prevention and control of influenza-like illness among passengers and crew members on cruise ships were developed by the Centers for Disease Control and Prevention based on many years of experience in controlling influenza outbreaks in nursing homes and on the experience with travel-related influenza outbreak investigations in 1997 and 1998. While more work is needed to determine the epidemiology of influenza among travelers, these preliminary guidelines are intended to provide a practical approach for influenza prevention and control measures on board cruise ships.

      The following CDC staff members prepared this report: Ulana R. Bodnar, Katherine L. Fielding, Ava W. Navin, Susan A. Maloney, Martin S. Cetron, Surveillance and Epidemiology Branch, Division of Quarantine; Carolyn B. Bridges, Keiji Fukuda, Influenza Branch, Division of Viral and Rickettsial Diseases; Jay C. Butler, Arctic Investigations Program.

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