Cruise ships have become floating hotels with entertainment, but still must meet the health and safety standards established for all ships at sea. The ship design, equipment, training of personnel, housing, and provision for a large number of different services from food to housekeeping have to be evaluated on each ship to make sure that there is compliance with existing regulations and that the passengers as well as the crew will return to the port in a healthy and safe manner. This may be very difficult to accomplish in this floating city unless there is strict adherence to appropriate supervision and management techniques and all procedures needed to prevent illness and injury are understood by crew and passengers and are followed closely.

The North American cruise industry of over 200 ships carrying about 15 million people annually is the largest in the world. Cruise ships vary in size. Some of them may carry thousands of people including passengers and staff. Passengers tend to be older and therefore are already subject to the numerous health and physical conditions that have been described in other parts of this book. Most passengers come from the United States or Canada, however they may be coming from all parts of the world and bringing with them the microorganisms which are common in their own homelands. Crew members tend to be from an international group and also may be contributing microorganisms from many areas. The cruise ship environment is such that it is crowded with people who may be perfectly healthy, have subclinical symptoms of various diseases, or sick and their microorganisms can be transmitted from person to person or from contaminated food, water, or surfaces. The stress of travel can reduce resistance to disease especially among the elderly, children, individuals with underlying health conditions, and pregnant women who are more susceptible to various levels of contamination. The elderly have also had immunological changes resulting in loss of certain antibodies, a decrease in immunity, and chronic diseases. Drugs that reduce gastric acidity can make the individuals more susceptible to gastrointestinal pathogens. Diuretics, frequently used by heart patients, can increase the severity of the disease because a typically mild diarrhea could cause severe dehydration. (See endnote 1.) Repeated outbreaks especially of noroviruses on the same ship on different cruises with different passengers indicates that the disease is easily transmitted from person to person in a closed environment and that the problem may be with infected members of the crew and/or contaminated surfaces on the ship.

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