The COVID-19 pandemic has drastically altered our lives, including the way we travel. Prior to 2020, cruising was one of fastest growing sectors of tourism in Australia and globally. The emergence of COVID-19 impacted greatly on the sector.
Today, as the cruise industry regains speed, travellers face a new landscape shaped by enhanced health protocols, heightened awareness of infectious disease and a continued collective desire to stay healthy while cruising.
What is it about cruising that makes it different to other travel scenarios?
The big difference is the number of people that occupy a defined space. We can travel as an individual, or a couple or even in small to medium size groups. The group can be reasonably large (bus tours), but it is never the size of a small town, and you are never restricted to a single location.
The average number of passengers for a cruise ship is 3000 but some can be up to 10,000 (Icon of the Seas). Another aspect relates to location. A cruise isn’t hemisphere related even though it might be in Antarctica, the Pacific or Mediterranean. Cruises compromise people from all over the world and unfortunately many people travel with baggage relating to their hemisphere of residence. We often see it in an early spike of influenza cases in Australia when northern hemisphere students arrive for the start of the academic year in February and March. They can bring with them a northern hemisphere influenza. These outbreaks are often self-limited during an Australian summer, but it can be a major issue on a cruise.
COVID-19 and influenza are not the only showstoppers on a cruise. Common diagnoses on cruise ships include other respiratory illnesses, such as RSV and milder “cold viruses”, gastrointestinal illnesses like norovirus, injuries and motion sickness.
In several studies investigating cruise ship gastrointestinal outbreaks, sick passengers were surveyed, and many admitted that they fell ill before they boarded or became ill during travel and didn’t disclose to staff nor consulted with on-board medical services, due to fears of being isolated to their cabin.
Before travel, it’s important to understand how respiratory and gastro bugs are transmitted from person to person, and how to best protect yourself prior to departure and during travel.
Key Messages from the COVID-19 Pandemic
Many cruise operators have “taken onboard” many of the key messages from the COVID-19 pandemic to make healthy cruising possible.
These include:
- New approaches to communications using apps. Passengers can receive and acknowledge important pre-departure safety messages without having to attend group musters
- Greatly improved air ventilation to staterooms and public areas using new technology. Complete air changes of 10-14 times per hour. This is almost in line with air travel and much greater than what is required for work offices and schools. It would be much superior to a standard home.
- Increased use of sanitising agents in shared spaces and staterooms. Much attention is given to surfaces exposed to regular handling.
- Reduced numbers on a table when dining with some operators recommending members of the same group to eat together.
- Increased “distancing” measures in sun lounging areas
Travellers should be aware of the most common health issues experienced on cruise ships, how to self-manage and when it’s appropriate to seek on-board medical support. Keep in mind, while medical services are available on-board, they are expensive. A well-stocked medical kit is crucial for cruising. It may be a welcome saviour for unexpected gastrointestinal symptoms, a urinary tract infection or a sinus infection.
Routine vaccines are just as important as ‘destination-specific’ vaccines. The yearly flu vaccine is often overlooked by travellers, but it and the COVID-19 vaccine are the more important vaccines for cruise travel.
For those over the age of 70 years, or frequent travellers under the age of 70, should consider the shingles vaccine.
Research shows the risk of infectious illness is significantly higher on larger cruise ships and longer voyages. The longer you’re in close contact with large groups of people, the greater the chance of exposure to an infectious virus or bacteria.
Consider having a “check-up” with your family doctor even if you consider yourself free of any health concerns. A check-up is sensible if you have any pre-existing health issues, particularly those related to either the cardiovascular or respiratory systems. If you are taking medications, make sure you have enough for the trip plus a buffer of at least 2 to 4 weeks. Consider the possibility of a delayed return through illness or an accident. This was a major issue during the pandemic when travellers were forced to isolate for a period and unable to fly home. If you require more medication than is usually dispensed in a single prescription, ask for a regulation 49. This allows for more to be supplied from the pharmacy. It is also important to carry a health summary if you have multiple health issues. Specialist letters can be very valuable if you have a chronic health issue. Do not travel without appropriate insurance and make sure it covers any pre-existing health issue. Consider anything which may cause mobility issues. Accidents are common while cruising and many relate to joints and balance. Improving your personal exercise tolerance is also important for any form of travel. You may think you will be vegging out for most of the time but don’t be surprised if you find yourself wanting an occasional shore visit to appreciate a change in scenery.
Vaccinations aren’t always high on the list of priorities when cruising. They are often only considered when there is mention of a required vaccine like yellow fever. This might be the case when travelling from ports in Africa or South America. It is more the routine vaccines that should be considered when cruising. Influenza and COVID-19 vaccines are very important. Why would you take the risk of being a “persona non grata” within a group when you can so easily achieve a degree of protection. It is accepted that neither vaccine prevents you from passing the bug on to another person but being asymptomatic is surely a good thing. There is also evidence that your length of infectivity is reduced by vaccination. There are several other travel vaccines which may be recommended but their use would be dictated by what you intend to do regarding shore visits. Hepatitis A vaccination should be considered for anyone visiting countries with water and sanitation issues.
Respiratory tract infections are the commonest health issue in travel. They are very common when cruising and an outbreak often starts just after an infected person boards the ship. The index case can also be crew. Fortunately, most illnesses are annoying rather than debilitating but even a mild sore throat or nasal congestion can impact on enjoyment. Respiratory tract infections usually spread by droplet infection. If the infected individual does the right thing with his/ her hands and observes good cough and sneeze etiquette, then spread from person to person can be limited. This is often not the case so it is important to be as vigilant as you might be on a city bus or train. Keep your distance and make sure you attend to your own hand hygiene. Reducing your exposure to respiratory tract infections should start a week or so before travel. Avoid busy shopping centres, public transport travel (especially in winter) and ask your family and close friends to give you a wide berth if they are sick are some of the things you might consider. Looking after unwell grandchildren just before a cruise isn’t sensible and hopefully family will understand your reasons.
Cleaning, cleaning, cleaning. People with gloves and cleaning agents. Gleaming bench tops and banisters. The air is full of fragrant smells.
Gastro outbreaks have always been a concern on cruise ships and the culprit is often a Norovirus. It takes only a single particle to cause vomiting and diarrhoea. Once on board, it can spread quickly to others via objects in public areas. First line of prevention is education of passengers and crew. Personal hygiene and environmental sanitation are the main ways to reduce the risk of an outbreak. While hand gels and alcohol are useful and convenient, it must be remembered that soap and water is always a better option.
Diarrhoea caused by contaminated food is much less likely, but it is possible for a passenger to be exposed during a land excursion. Reporting the illness as soon as possible and following medical advice can limit any potential exposure to travel companions and other passengers. Using your own bathroom and not public ones is very important.
It would be unusual to cruise and spend most of your time indoors. Cruising is very much about activities outside, particularly those related to water. These activities can put you at risk of sunburn.
It can take just 10 minutes at certain times of the day (11am to 3pm) for certain skin types to experience serious sun exposure. Exposure to UV light is highest closest to the equator and much cruising takes place in these regions. Reflected light should not be underestimated.
Sunscreens are classified according to their Sun Protection Factor (SPF). This is a measure of how well your skin is protected. An SPF of 50% is estimated to block out 98% of UVB radiation – not 100%. The protection time must be considered in line with your skin type. Sunscreens should be used at least 20 minutes before sun exposure and every 2 hours after swimming or vigorous exercise. More on sun protection.
Ear infections are also common in those undertaking frequent water activities in tropical climates. It mostly occurs when contaminated water is retained in the ear canal for periods of time. It is more likely to occur if there is a mechanical obstruction like wax in the canal. Contaminated water is very unlikely on a ship, but exposure can occur with trips ashore to water sources which might be contaminated by sewage. Keeping your canals dry with acetic acid drops after exposure can help to avoid a canal infection. Some individuals seem prone to outer ear infections. It is possible they come from areas of cold-water exposure (eg southern Australia) and have bony outgrowths in their canals. These can result in water also being retained in their ear canals.
It seems strange to discuss mosquito bites in an article on cruising. If cruising was just about cruising without ports of call, then mosquito exposure would be unlikely. However, cruising is very much about seaports and these areas are often places where vector-borne disease is a concern.
Dengue fever is a major concern in many areas of the world as are Chikungunya and Zika. These diseases are transmitted by daytime biting mosquitos which like urban areas with contaminated water. The mosquitos can breed in small vessels of water under pot plants, in upturned canoes, in ponds and along canals. Peak biting usually occurs an hour either side of sunup and sundown, just when a cruise ship might be about to dock of leave. Clothing and repellents are the mainstay of disease prevention. Repellents containing at least 30% DEET or 20% Picaridin are usually recommended. See Mosquito avoidance measures.
The cruise ships of 2024 are vastly different to those of even 20 years ago. Their advanced technology systems provide increased stability even when the seas are rough. It might not be good enough for the Drake passage between Argentina and Antarctica, but it is for most of the world’s cruising regions. Unfortunately, there are some people, who only have to look at a ship and they will experience motion sickness. It is likely they experience similar issues in cars and buses and have done so since childhood. It doesn’t mean these individuals should exclude cruising from their bucket list. With careful planning the effects of motion sickness can be minimised. Cabin location is important. Make sure it’s midship. A balcony might also help with access to fresh air. Prevention should be aimed at reducing the effect of movement on your sensory system and the use of targeted medications.
If you have used medications in the past and you have had no issues with them, then make sure you have them in a medical kit and know how to use them. If you have had unpleasant side effects and are concerned, speak to your local pharmacy. There are a number of proprietary brands available, but you could also consider using one from a compounding pharmacy. It is important to trial any new medication prior to travel. A popular medication, cinnarizine, is not available in Australia but available in many jurisdictions overseas. It might be possible to source it in the country where you start the cruise. It is widely available in the UK and Europe.
A medical kit is a “must take” on any type of trip. We know 50% travellers will experience a health problem in a 2 week stay. While this might not apply to cruising it still makes sense to have control over something which might impact on your ability to travel. Do not be lulled into a false sense of security by access to medical services on a ship. They can be expensive, and they can be places where sick people congregate. Being able to manage annoying, minor medical problems with medications which you are familiar with can circumvent more serious issues and inconvenience.
Written by Dr Bob Kass
