Journal Article

Disease Transmission and Passenger Behaviors during a High Morbidity Norovirus Outbreak on a Cruise Ship, January 2009

Mary E. Wikswo, Jennifer Cortes, Aron J. Hall, George Vaughan, Christopher Howard, Nicole Gregoricus and Elaine H. Cramer

in Clinical Infectious Diseases

Published on behalf of Infectious Diseases Society of America

Volume 52, issue 9, pages 1116-1122
Published in print May 2011 | ISSN: 1058-4838
Published online May 2011 | e-ISSN: 1537-6591 | DOI: http://dx.doi.org/10.1093/cid/cir144
Disease Transmission and Passenger Behaviors during a High Morbidity Norovirus Outbreak on a Cruise Ship, January 2009

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Background. Norovirus continues to pose a significant burden on cruise ships, causing an average of 27 confirmed outbreaks annually over the past 5 years. In January 2009, the report of a suspected norovirus outbreak among passengers on a cruise ship prompted an investigation.

Methods. A retrospective cohort study among passengers was conducted on board the ship. Questionnaires about health care–seeking behaviors, hygiene practices, and possible norovirus exposures were placed in every cabin. Stool samples from several ill passengers were tested for norovirus by quantitative reverse-transcriptase polymerase chain reaction (RT-qPCR) and confirmed by sequence analysis.

Results. Of 1842 passengers, 1532 (83.2%) returned questionnaires, and 236 (15.4% of participants) met the case definition. Of these, 95 (40%) did not report to the infirmary. Case passengers were significantly more likely to have an ill cabin mate (relative risk [RR] = 3.0; P < .01) and to have witnessed vomiting during boarding (RR = 2.8; P = .01). Over 90% of all passengers reported increased hand hygiene practices following the outbreak; 38% of ill passengers and 11% of well passengers decreased participation in public activities. Of 14 samples tested, 12 were positive for norovirus by RT-qPCR; 5 of these were confirmed by sequence analysis and typed as GII.4 Minerva.

Conclusions. Person-to-person transmission, including an incident of public vomiting during boarding, likely contributed to this high morbidity outbreak. Infirmary surveillance detected only 60% of acute gastroenteritis (AGE) cases involved in this outbreak. Adjustments to outbreak reporting thresholds may be needed to account for incomplete voluntary AGE reporting and to more rapidly implement control measures.

Journal Article.  3934 words.  Illustrated.

Subjects: Infectious Diseases ; Immunology ; Public Health and Epidemiology ; Microbiology

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