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Norovirus Transmission on Cruise Ship

Elmira T. Isakbaeva,* Marc-Alain Widdowson,*† R. Suzanne Beard,* Sandra N. Bulens,*† James Mullins,* Stephan S. Monroe,* Joseph Bresee,* Patricia Sassano,‡ Elaine H. Cramer,* and Roger I. Glass*

An outbreak of norovirus gastroenteritis affected passengers on two consecutive cruises of ship X and con- tinued on 4 subsequent cruises despite a 1-week sanitiza- tion. We documented virus transmission by food and person-to-person contact, persistence of virus despite san- itization onboard, introduction of new strains, and seeding of an outbreak on land.

We describe an investigation of a norovirus gastroen- teritis outbreak aboard a cruise ship affecting 6 con- secutive cruises and the use of sequence analysis to determine modes of virus transmission. Noroviruses (NoV), are the most common cause of infectious acute gastroenteritis and are transmitted feco-orally through food and water, directly from person to person and by environmental contamination (1). These viruses are often responsible for protracted outbreaks in closed settings, such as cruise ships, nursing homes, and hospitals (2,3).

On November 20, 2002, cruise ship X recorded an ele- vated number of persons with acute gastroenteritis symp- toms reporting to the ship’s infirmary (84 [4%] of 2,318 passengers) during a 7-day vacation cruise from Florida to the Caribbean. According to federal regulations, when the incidence of acute gastroenteritis among passengers and crew exceeds 3%, an outbreak is defined and requires a for- mal investigation (4). The outbreak continued on the subse- quent cruise (cruise 2), after which the vessel was removed from service for 1 week of aggressive sanitization. Despite cleaning, gastroenteritis also developed in 192 (8%) of 2,456 passengers and 23 (2.3%) of 999 crew on the follow- ing cruise (cruise 3). To determine the source of this contin- uing outbreak and to better understand the mechanisms of NoV transmission, we began an investigation on cruise 1 and collected stool specimens from persons with gastroen- teritis on this cruise and the next 5 cruises.

*Centers for Disease Control and Prevention, Atlanta, Georgia, USA; †Atlanta Research and Education Foundation, Atlanta, Georgia, USA; and ‡Bucks County Department of Health, Doylestown, Pennsylvania, USA

The Study

We surveyed all 2,318 passengers on cruise 1 to deter- mine dates of illness onset, symptoms, cabin locations, activities, and food consumption. We also performed a sanitary inspection of the ship. We suspected that initial infection among passengers on cruise 1 originated from a common food or water source and then continued to spread from person to person. Therefore, we conducted a case- control study with all passengers in whom illness devel- oped early in the cruise (days 3 and 4) after embarkation (defined as day 1) and also with passengers who became ill later (day 5). Controls were systematically selected among passengers who reported no symptoms of gastroenteritis throughout the entire cruise. We continued to monitor the number of cases of acute gastroenteritis on the subsequent 5 cruises and collected fecal specimens from ill persons on all 6 cruises. During our shipboard investigation, we also obtained stool specimens from ill persons in a long-term care facility affected by an outbreak of acute gastroenteri- tis, in which the index patient was a passenger who returned ill to the facility after disembarking from cruise 1. All stool specimens were tested for NoV by reverse tran- scription–polymerase chain reaction, as previously described (5). The positive amplicons were sequenced, and sequences were compared for genetic diversity.

The outbreak began abruptly on day 2 of cruise 1 and continued on cruise 2 with new passengers. Despite saniti- zation of the ship for 1 week after cruise 2, illness was also reported among passengers on cruise 3 (Figure 1). On the subsequent cruises (4–6), the number of ill persons report- ing to the infirmary remained above background levels but below 3%. Of the 2,318 surveyed passengers on cruise 1, 1,276 (55%) returned questionnaires, of these, 212 case- passengers and 265 control-passengers were enrolled in our study. We identified that eating breakfast at restaurant A on

Figure 1. Number (%) of cases of acute gastroenteritis among 513 passengers and 74 crew by date of symptom onset reported to the infirmary on 6 consecutive cruises of ship X, November 2002–January 2003. Arrows indicate start and end of each cruise.

154 Emerging Infectious Diseases • • Vol. 11, No. 1, January 2005

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