Cruises

Good preparation helps travellers planning a cruise have a safe and healthy trip

Key messages

• Cruise passengers should research their trip carefully and seek pre-travel health advice, ideally four to six weeks before they go.

• Comprehensive travel health insurance is recommended for all cruise passengers.

• Accidents, slips and trips can be a significant hazard.

• Cruise passengers may underestimate extremes of temperature and strength of the sun and need to be reminded of the importance of protecting themselves.

• Food and water spread illness can be transmitted very quickly in enclosed environments like cruise ships. Passengers should be advised to eat and drink sensibly and follow good food and water hygiene rules.

• Respiratory infections like COVID-19 and influenza can also spread rapidly on cruise ships.

Overview

Cruises are a popular holiday choice for all age groups and cruise ship itineraries visit increasingly exotic and/or remote destinations. Cruises bring together people from all over the world; passengers and crew, in crowded, semi-enclosed environments. Pre-travel advice and adequate preparation is essential to help reduce the risk of health problems. Being on-board can increase the spread of respiratory or food/water-borne illnesses. Trips ashore in tropical regions may expose passengers to different infections, including insect spread diseases [1].

COVID-19

See important guidance from the Foreign, Commonwealth & Development Office (FCDO) on international cruise ship travel about what to consider ahead of booking a cruise. Ensure you check the protocols of the cruise operator you are booking with. If your ship is affected by an outbreak of COVID-19 you may be required to quarantine on board or at a designated facility. If you do not follow the cruise operator protocols, you may be asked to disembark the ship.

Some people are at higher risk of severe infection from COVID-19. This mainly relates to age and any existing medical conditions and includes those prioritised for COVID-19 vaccination (see Table 2 and 3 in Immunisation against Infectious Disease).

All individuals should follow current UK recommendations to reduce their risk of infection and consider whether postponing travel would be appropriate.

Domestic cruises depart from and return to UK ports but may operate beyond UK waters. Domestic cruise operators will have a vaccination policy and require that all passengers present a negative COVID-19 test before boarding. Further guidance from the FCDO on cruise travel is available.

General guidance regarding risk assessment for travel and information about the COVID-19 vaccination programme is also available.

Pre-travel preparation

Cruise passenger advice should follow current destination recommendations for the countries detailed on the cruise itinerary, tailored to the individual traveller’s needs. Health professionals and passengers can use the TravelHealthPro Country Information to access current travel advice, vaccines and malaria guidance for specific destinations. For an effective risk assessment, health professionals need to check the cruise itinerary carefully, so it is helpful if passengers provide a clear itinerary, ideally a written/online copy of the official cruise company schedule.

Certain groups, such as pregnant women, older people and those with chronic health conditions or immunosuppression, require special consideration [1]. These individuals, and those with significant mobility problems, are advised to consult their doctor, nurse or a travel clinic prior to booking a cruise. This is to discuss any health concerns, consider the suitability of destinations, and helps them to make an informed decision about the appropriateness of a cruise.

Individuals with pre-existing health conditions should consider carrying a written summary of their medical history (including any appropriate results, allergy information, medication summaries and treatment details) from their doctor and/or hospital specialist [1].

Passengers should take good supplies of all regular medicines, including contraception. As trip delays can occur, more medication than required should be carried. Passengers who need specialist assistance or equipment such as wheelchairs or oxygen should inform their cruise company well before the departure date [1].

Emergency medical care and insurance

Medical care on cruises varies and most ships spend long periods of time at sea, remote from land. Treatment and medication aboard are not free and are not included in cruise packages.

Comprehensive travel insurance is essential for all cruise passengers. A full declaration of health conditions must be made, all destinations, equipment and planned activities should also be stated. Withholding details of medical history or trip details may mean travellers are not fully covered. Policies should be checked for coverage exclusions and must meet the costs of emergency medical treatment, including hospital charges, ambulance fees and medical evacuation from remote locations - evacuation by air ambulance can be very costly [2].

First aid kit

All passengers should carry a simple first aid kit, with basic equipment tailored to their needs and destinations, to help them deal with minor injuries and illnesses.

Deep vein thrombosis

Passengers may join their ship after a long haul flight [3] and need to be reminded to seek urgent medical advice for any symptoms that could indicate deep vein thrombosis (DVT) including calf/thigh pain, swelling, warmth and red or darkened skin. See here for current NHS DVT prevention advice for travellers.

Motion sickness

Seasickness is a common complaint, affecting up a quarter of passengers [1]. Even individuals who do not normally get motion sickness may experience it on a cruise. All travellers planning a cruise should get advice from a pharmacist about anti-sickness medication before travel. Further information on motion sickness is available here.

Security

Passengers should check the Foreign, Commonwealth & Development Office for country specific foreign travel safety and security advice.

Respiratory infections including influenza (flu)

Coughs, colds and respiratory infections, including flu, can spread quickly on cruises. Passengers should follow good personal hygiene rules and avoid close contact with anyone with symptoms. In some situations, cruise ships may impose restrictions, such as isolating ill passengers [1].

Flu occurs worldwide: in northern hemisphere countries like the UK most flu activity is from late autumn to early spring (usually December to March in the UK). In the southern hemisphere, flu activity occurs between April and September. In the tropics, flu viruses can circulate all year round. Flu risk during travel depends on time of year, type of travel, destination and duration. However, cruise passengers may be at risk in the summer, especially if the cruise ship is large, includes passengers from parts of the world where flu viruses are circulating and/or is visiting tropical destinations.

All travellers should take the following precautions to reduce risk of exposure to respiratory infections, including flu:

• Avoid close contact with anyone with symptoms
• Avoid crowded conditions where possible
• Avoid travel if unwell with influenza-like symptoms
• Frequent hand washing
• Practise cough hygiene: sneeze or cough into a tissue and dispose of it promptly and hygienically

See our Influenza factsheet here for more information.

Vaccination

As well as making sure they have all recommended country specific travel vaccines, cruise passengers should check they are in date for routine United Kingdom (UK) vaccines including the Mumps, Measles and Rubella (MMR) vaccine and COVID-19 vaccination if eligible.

Flu outbreaks can occur at any time of the year on cruise ships passengers [4, 5]. All passengers should consider having a flu vaccine before they travel. In the UK, pregnant women, young children, anyone aged 50 years or older, and anyone with underlying long-term health conditions like heart disease, respiratory conditions or immunosuppression are offered flu vaccine routinely [6]. For cruise passengers not entitled to an NHS flu vaccine, during the flu season, flu vaccine is available from travel clinics and high street chemists for a fee.

Due to the changing nature of flu, the World Health Organization monitors flu viruses worldwide and each year they recommend flu vaccine strains for the winter ahead for the northern and southern hemispheres [7]. This is why a different flu vaccine is offered every year [6].

Yellow fever

The cruise itinerary should be carefully checked to establish if there is a yellow fever risk. If the ship is visiting yellow fever risk areas, passengers need to get advice from a specialist yellow fever vaccination clinic (this vaccine can only be given at these centres) as they may need vaccination for personal protection.

If yellow fever vaccine cannot be given because of a medical contraindication, a medical letter of exemption can be provided. This facilitates entry to countries requiring a certificate. However, the passenger needs to be made aware of their risk of yellow fever.

In some instances, even if passengers are not at risk of yellow fever, some countries may require proof of yellow fever vaccine.

Specialist yellow fever clinics can advise on all these issues.

Food and water risks

Outbreaks of diarrhoea and gastrointestinal infections, including Campylobacter jejuni, E. coli, norovirus and Shigella sonnei have been reported on cruise ships [8]. Close contact with the crew and other passengers means infections can spread more easily [1].

Passengers can reduce their risk by following food, water and personal hygiene precautions carefully both while on the ship and ashore. This includes hand washing and using alcohol-based hand sanitisers (when hand washing facilities are unavailable). Good hand hygiene is particularly important during and after shore visits.

Excessive food and alcohol consumption should be avoided and drinks should never be left unattended. Passengers should take the same care ashore as on-board the boat and remember alcohol strength varies worldwide and local measures may be very generous.

Vector-borne risks

Passengers should pack and use insect repellents: see Mosquito bite avoidance for travellers for more detailed information. Insect bite avoidance is particularly important if the cruise ship is visiting or stopping in regions where malaria is present [9]. Other insect spread illnesses like dengue, yellow fever and Zika may also be a risk in tropical and sub-tropical destinations.

Bite avoidance

Many of these insect-spread diseases such as chikungunya, dengue and Zika cannot be prevented by drugs or vaccines, so careful insect bite avoidance is the only way passengers can protect themselves.

Malaria

Many cruises only stop on land during the daylight hours, when malaria mosquitoes rarely bite, so most cruise passengers do not require antimalarials. However, if the cruise itinerary indicates overnight stops in malarial areas or passengers are ashore overnight in risk regions, antimalarials may be recommended [9]. Passengers should take any recommended tablets as directed, finish the course, be meticulous about insect bite avoidance and get urgent medical attention for any symptoms.

Other health risks

Legionnaires’ disease

Outbreaks of Legionnaires’ disease (a type of pneumonia caused by inhaling fine water sprays contaminated with bacteria) have been reported on cruise ships [1, 10, 11] and are usually linked to whirlpools, hot tubs and spas [1, 11]. Passengers with any concerns about upkeep of on-board facilities should avoid using them and report their concerns to cruise ship staff.

Rabies

In some destinations, there may be a risk of rabies. Any cruise passengers bitten, scratched, licked on open skin or spat at by any animal, either or on-board or ashore, must get urgent medical attention from the ship’s medical facilities.

Safety

Falls, slips and trips are a hazard and can cause serious injury [12, 13]. Decks and stairs easily become wet and slippery. Sturdy footwear is recommended. Passengers should take extra care, particularly in rough and stormy weather, and when getting on and off the ship. They should never sit on balcony or deck railings.

Care should be taken when swimming or taking part in poolside activities [13]. Passengers should be strongly advised never to swim at night or after drinking alcohol/taking drugs.

Injuries can also occur while passengers are on excursions [12]. During trips ashore, passengers should be respectful of cultural sensitivities and mindful of their personal safety.

Sexual health

Alcohol and the novelty of being on holiday may lower inhibitions and increase the possibility of casual sex. Passengers should be reminded of the risks of unplanned, casual sex. Reliable condoms should be carried and used to reduce the risks. Further information is available here.

Sun, changing environments and extreme temperatures

Cruises can involve extremes of weather and temperature. Passengers may underestimate their risk of sun damage, especially in colder destinations. Snow and ice can increase sun exposure by reflecting UV rays. Cruise passengers should try to limit time they spend in the sun, covering up with clothes, gloves, a hat and sunglasses.

High factor sunscreen (SPF 30 or above with a 4 or 5 star UVA rating) is also recommended. Limiting sun exposure and regularly applying a broad spectrum, high protection sunscreen helps protect against skin damage, with the associated risk of skin cancer: see further information here.

Illness abroad

All passengers should make sure they are aware of the location of the ship’s medical facilities and are familiar with all emergency evacuation procedures as soon as they arrive on-board. Any passengers with pre-existing health problems should introduce themselves to the ship’s doctor and/or nurse, informing them of their medical history and any medication.

Passengers should report any symptoms or illnesses, especially diarrhoea and vomiting, promptly to the ship’s medical team and crew.

Cruise passengers should be reminded that if they have been prescribed antimalarial tablets, they must complete the course at home, even if they are well.

Returned cruise passengers with any symptoms, including a lasting cough, fever, flu-like illness, or persistent diarrhoea, must get medical advice, remembering to inform their doctor that they travelled on a cruise. If they have visited malaria risk areas the possibility of malaria must be considered and, an urgent malaria blood test must be arranged. This is important even if the traveller completed an antimalarial course and has been home for some time.

Resources

• Cancer Research: Ways to enjoy the sun safely
• Foreign, Commonwealth & Development Office: Foreign travel advice
• Foreign, Commonwealth & Development Office: International cruise ship travel
• Global Dialysis: Planning your trip
• Malaria in brief
• Medicines and travel
• National Kidney Federation: Holiday Tips and Guidelines
• NHS: Can I take my medicine abroad
• NHS: Motion sickness
• Older travellers
• UK Health Security Agency: Malaria – information for people travelling overseas
• UK Health Security Agency: Zika virus: country specific risk
• Venous thromboembolism
• Yellow fever in brief
• Yellow Fever Zone: International Certificate of Vaccination or Prophylaxis