Cruise Ship Travel: Health Recommendations
Cruise ships are a popular type of leisure travel with people having images of the “Love Boat”. The reality can be quite different. I have worked as Chief Medical Officer on several large cruise ships. The following is a brief description of what it is like, for both passenger and doctor.
Staff
The captain is the master of the ship and runs the ship according to International Law and the rules of the cruise line. He is also in charge of medical evacuations. Most lines employ people from all over the world. We had crew from China, Philippines, Indonesia, Caribbean countries, South America, Europe, and Australia. Even though we sailed from a U.S. port, most crew (including many officers) spoke little English. The captain and other officers were Italian; apparently the cruise line had an agreement with the Italian government. Language was a major problem but everyone adjusted.
The Medical Department
Depending on the size of the ship, there is one or more doctor(s) and at least 2 nurses. Medical staff may be from anywhere in the world but generally speak English. The infirmary is open during regular office hours for both passengers and crew, and 24 hours for emergencies. Each ship’s infirmary has different capabilities, but generally there are IV fluids, splints, ACLS (advanced cardiac life support) medications and a defibrillator. The medical staff can perform minor procedures, treat accidents, dispense medications and begin treatment for cardiac problems. Most ships have capabilities to communicate with backup experts on shore. This is useful for both medical and legal considerations. Infirmary beds are available for observation. Passengers are generally responsible for infirmary costs, and these can be significant. Medical insurance with evacuation coverage is strongly recommended. Prices for medications are usually higher when compared with home.
There is a good proportion of occupational medicine among the crew, especially overuse problems. If a crew member is very sick, the medical staff may recommend evacuation. For less urgent problems, consultation with portside consultants can be made while a ship is in port.
Common medical problems aboard ship
On board Medical Disorders: Most modern ship have well equipped medical facilities with excellent communication. Cruise ship medicine is becoming a specialty. However most medical crews are part timers. The physicians training varies. Emergency physicians are well suited for this type of work. To be a doctor or nurse on a large cruise ship during a long sea voyage is no vacation. The medical staff should expect a varied general practice with a higher consultation frequency rate than shore side, even higher in crew than in passengers. Respiratory and skin problems are common, but the medical staff must be particularly prepared to handle injuries and acute cardiopulmonary crises.
Crew illnesses is also a factor to be considered. Hepatitis – STD – Diarrhea diseases are some of the diseases that can be transmitted to the passengers by the crew.
Shore visit health risk:
Additionally, passengers disembark to sightsee place themselves at risk for diseases in the geographic areas they visit.
When assessing the risk of shore born disease one must consider:
General Health Risk :
Travel by cruise ship often congregates large groups of people from different parts of the world. Many of these travelers are also elderly, many with chronic illnesses. Modern ships have large capacities with thousands of passengers and crew traveling together. In such settings, diseases can spread from person-to-person contact :
• Infectious diseases (Hepatitis, Measles , Rubella)
• Legionnaire’s disease
• Cryptosporidium
• Acute respiratory illnesses (influenza, pneumonia)
• Gastrointestinal illnesses ( Staphylococcal, Shigella, and Norwalk-like virus)
• Motion sickness
• Skin disorders
• Cardiovascular events ( CHF-MI)
• Sudden Death
• Injuries among passengers and crew
• Tropical Diseases
Vaccination recommendations will depend on the above factors as well as vaccines required for entry into the country.
Passengers planning to go on a cruise should review their immunizations with a travel medicine specialist. Passengers and crew should be immune. Adults who come from equatorial countries are apt to be susceptible to chicken pox. Pregnant women should be immune to rubella since outbreaks have occurred aboard ship. Depending on the ports of call, cruise passengers may need immunizations against one or more of the following: tetanus, diphtheria, polio, hepatitis A, typhoid, influenza and, possibly, hepatitis B - for those who expose themselves to high risk situations.
Malaria chemoprophylaxis prescription decision is often difficult because of the mainly daytime coastal shore visits. However many will recommend chemoprophylaxis for high attack rate areas such as coastal Africa or for inland visits. Passengers embark on day trips to shore and are usually back before nightfall. They usually will not require antimalarial medications. They may be exposed to insect-borne diseases like yellow fever and dengue fever, for example Passengers should receive this type of advice during their pre-trip check up.
People planning cruise ship travel, especially anyone older than 65 years of age, anyone with acute or chronic illnesses or pregnant women should consult with a health care provider prior to travel for advice and possible preventive medication ( such as Amantidine against influenza)
Other measures to prevent the spread of infectious diseases on cruise ships include frequent hand washing, use of hand sanitizers and obtaining appropriate immunizations prior to travel.
It is also important to note, certain diseases can be transmitted before symptoms are apparent and that some people who become ill while on a cruise ship may have been infected prior to travel.
Disease Outbreak
Anyone who becomes ill while on a cruise ship should seek medical attention on board and see a health care provider upon returning home. Ill persons should limit contact with the general population on board as much as possible to reduce further spread of disease. Ship authorities report infectious diseases of public health significance to health officials.
Traveler's diarrhea. This condition can generally be averted by careful attention to what you eat, especially on shore. The recent outbreak of the Norwalk virus is a vivid example. The cruise doctor is responsible for doing a weekly "diarrhea log" of all affected passengers and crew. If the ship has an incidence of 0.5%, it is considered significant and, if the ship calls at a U.S. port, the outbreak must be reported to the U.S. Centers for Disease Control. They generally investigate large outbreaks. Observe food and water precautions, especially at ports of call in developing countries. Also, the ship’s food handlers come from developing countries and sanitation is not always optimal
Sea Sickness. It usually takes a few days to get your "sea legs". Avoiding excessive alcohol and sunburn, helps prevent dehydration. Medications such as Gravol, Transderm (Scopolamine) patches, Bonamine , and (phenothiazine), all help in controlling symptoms during the first few days. Injections of phenergan are available and are usually effective. Pregnant women may have prescriptions from their own doctors, diclectin (also known as Bendectin ) or may try ginger. Scopolamine may have some serious side-effects in the elderly such as blurred vision and confusion. To avoid seasickness, stay in the middle of the ship, near the center of gravity and where there is less sway. Avoid reading. If above deck, focus on far away objects.
Sexual Transmitted Diseases (STDs). Many of the crew, especially officers, can be openly promiscuous with passengers. The crew may have little knowledge of STD prevention, which is very worrisome considering the prevalence of HIV in many parts of the world. The crew is not regularly tested for STDs.. Occasionally there are charges of rape or other forms of assaults against crew or other passengers.
Accidents. Incidences, whether on or off the ship do occur. Many passengers try to get a free cruise by pressing claims when they report to the infirmary with an injury.
Jellyfish envenomation are also seen and the medical staff should be trained to deal with them.( See outline in this topic) Hazards like marine animal encounters and SCUBA- related problems are possible since many vacationers also embark on a variety of activities at port.
Pregnancy. Some cruise lines have policies that if their female employees get pregnant, they are sent home. Further, the employee’s superior must report the pregnancy to the company, or lose their job as well.. Although cruise lines have guidelines for accepting passengers with advanced pregnancy or serious severe medical problems, one can encounter several people who “pushed the envelope” of what was acceptable safe travel.
Disabilities. Cabins specifically designated for people with disabilities are not always available. They should be booked ahead. Although the cabin was designated as “handicap accessible,” it must be properly maintained by the stewards.
Evacuations
Evacuation is indicated for patients that are very ill, badly injured or in need of immediate testing. But evacuation is not always practical, and is always very expensive. The Captain and Chief Medical Officer will make arrangements to evacuate patients to the nearest appropriate hospital. The ship’s doctor can only recommend evacuations, not order them, but no reasonable captain would go against their doctor's medical opinion. Some of the medical emergencies encountered included myocardial infarcts, strokes, deep vein thrombosis, and open fractures.
The U.S. Coast Guard will evacuate passengers from ships that are within 100 miles of the U.S. coast. Many cruises obviously travel much further than that. And there are watershed areas where there is about one to one and a half days between ports. When passing through these watersheds, evacuation becomes logistically difficult. Also, many sick or injured passengers are reluctant to leave the ship. And changing course angers lots of other passengers. Sometimes the ship is reversed to the last port or sped up past its cruising speed. Although in the Caribbean the arrival time between islands is usually given as a day, it can usually be accomplished in a few hours. This is not widely done, in part because the company benefits more from keeping the passengers in international waters longer so they can gamble more in the casinos.
Man Overboard
Passengers will do crazy things such as standing on the upper rails, urinating while intoxicated, and even fall into the sea. This will lead to cruise ships and other rescue crafts diverting to the area and delay for many passengers.
People do go overboard and it is important to know the proper way to respond to emergencies. Passengers are shown the proper safety measures and responses when boarding and while participating in lifeboat drills. For “man overboard” situations, witnesses should point at the spot where the person was last seen while someone runs to stop the boat. By maintaining a bearing it becomes easier to find the lost person.
Working with Shore Doctors in Foreign Countries
Ships try to maintain list of doctors at ports of call who seem to provide reasonable treatment. But sometimes patients chose their own doctors, with variable results. When interacting with shore doctors, it’s best to work with people you know. Often the local Canadian or US Embassy can provide a list of practitioners in the area and, while they may not specifically endorse any, they can tell you about recent complaints. This also is true for recent problems at local businesses like hotels and restaurants.
Security
Security forces aboard ship exist more to police employees rather than protect passengers. If there is an altercation aboard ship, one should not become involved unless absolutely necessary. Notify security. Brawls among crew members are usually over unattended women Generally, the ships’ security unit adopts a passive approach to surveillance since there is “no place to run.” If caught, they will be processed, and if necessary, confined to an empty pantry, which also doubles as the morgue. Spousal abuse, especially among newlyweds, is not unknown on cruise ships.
Interacting with the Crew
The crew consists of individuals of many nationalities and different backgrounds. Theft is rare but if suspected should be reported to security. Most crewmembers, despite coming from poor backgrounds, are hardworking and honest. The deck hands may work more than 12 hours a day and are often treated poorly by other staff and passengers. They often depend on tips from customers, and with the tips, do very well relative to their native countries. Speaking with the crew is a good way to learn about their countries.
Travelers should be prepared and not expect the full level of medical resources we have to manage problems at home.
Every vessel that has a foreign itinerary, carries 13 or more passengers,
and calls on a U.S. Port is subject to un-announced twice-yearly inspections
and, when necessary, to re-inspection by VSP staff.
The ships must meet the
criteria established by VSP in the "Vessel Sanitation Program Operations
Manual". The ship is given a score based on a 100 point scale. To pass the
inspection, a ship must score 86 or above. If the ship fails an inspection, it
will be re-inspected, usually within 30 to 45 days. The inspection may take from
5 to 8 hours to complete, depending on the size and complexity of the vessel.
The inspection focuses on the following:
Inspection scores tables and reports are published on the following websites www.hc-sc.gc.ca and www2.cdc.gov/nceh/vsp/vspmain.asp. In addition, scores are published every month in the Summary of Sanitation Inspections of International Cruise Ships, commonly referred to as the green sheet. This sheet is distributed to more than 3,000 travel-related services around the world.
Dr. Podolsky's web site is www.skylarkmedicalclinic.com
REF: Gary Podolsky MD