Pii: s0196-0644(99)70419-

Descriptive Epidemiology of Injury and IllnessAmong Cruise Ship Passengers From the Division of Emergency Dwight Edward Peake, MD*
Study objective: To provide information, which can be used
Medicine, Department of Surgery,* Charles Lanford Gray, MPH*
in the formation of guidelines concerning medical facilities and University of Texas Medical Branch Melissa Renee Ludwig, MD‡
at Galveston, Galveston, TX, the staff on cruise ships, on the descriptive epidemiology of the Carter Degen Hill, MD§
Department of Emergency Medicine,‡ medical conditions encountered by cruise ship physicians.
University of Texas Medical School atHouston, Houston, TX, and the Methods: A retrospective descriptive epidemiologic study design
Medical Department,§ Holland was used to evaluate patient physician encounters on cruises America Line Westours, Seattle, WA. originating in a calendar-year period for the 4 ships of a major Received for publication cruise ship line with cruises originating in the United States.
October 17, 1997. Revision received July 28, 1998. Accepted Demographic data regarding sex and age of the passengers on for publication August 7, 1998. these ships were available for each cruise. We collected infor- Supported by a Section Grant to the mation on patient age, sex, chief complaint, diagnoses, treat- Section on Cruise Ship and Maritime ment, and patient disposition recorded in the patients' medical Medicine from the American Collegeof Emergency Physicians. records in the ships' medical logs.
Address for reprints: Dwight E
Results: Seven thousand one hundred forty-seven new patient
Peake, MD, 30 Lebrun Court, visits occurred in a population of 196,171 passengers and 1,537,298 Galveston, TX 77551; E mail [email protected]. passenger days; 56.7% of passengers were female, and 60.7% ofpatients were female; 43.3% of passengers and 39.6% of patients Copyright 1999 by the AmericanCollege of Emergency Physicians. were male. Visits to the ship infirmaries were made for the fol- 0196-0644/99/$8.00 + 0 lowing reasons: 18.2% of visits were related to injuries, 69.3% were related to medical conditions, and 12.5% were unspecifiedor other conditions. The most common diagnosis was respiratorytract infection (29.1%); 11% of patients had a serious or poten-tially life-threatening diagnosis. The most common group of pre-scription medications prescribed was antibiotics.
Conclusion: Many different injuries and illnesses occur on
board cruise ships. The spectrum is similar in many respects to
the patients presenting to emergency departments. Cruise lines
must prepare for the initial treatment and stabilization of patients
with serious illnesses or injuries with appropriately qualified and
equipped medical personnel and establish procedures for dis-
embarkation of patients to facilities capable of handling such
conditions.
[Peake DE, Gray CL, Ludwig MR, Hill CD: Descriptive epidemiologyof injury and illness among cruise ship passengers. Ann EmergMed January 1999;33:67-72.] Peake et al sionmaking process for cruise ship medical service guide- Although shipboard epidemics of gastroenteritis and, more lines and standards.
recently, respiratory illnesses are well described in themedical literature,1-8 apparently only DiGiovanna et al9have published a study on the nonepidemic illnesses among passengers encountered on cruise ships. Very little pub- The patient population is a subset of the passengers who lished information is therefore available to the cruise-line traveled on 4 Holland America Westours Line ships—the industry and other interested parties on which to base MS Nieuw Amsterdam, the MS Noordam, the SS Rotterdam, standards for medical equipment, supplies, and personnel.
and the MS Westerdam—on cruises originating in 1991.
However, in 1994 alone, approximately 4.8 million US The cruise destinations were determined from the Holland citizens took cruises, and the number of such passengers America Westours ship schedule for 1991. The medical log has been increasing about 10% per year.10 This study was for Voyage 373 of the MS Nieuw Amsterdam was not avail- undertaken to increase the knowledge base regarding the able for inspection. This study was approved by the insti- epidemiology of cruise ship illnesses to support the deci- tutional review board of the institution of the first 2 authors.
Distribution of study ships' passengers and infirmary patients by age, by sex and age, and by ship. By age (y)*:
<15
By sex and age (y)*:
Sexes combined
By ship*:
MS Westerdam
MS Nieuw Amsterdam *Totals differ between age totals and totals of sex and age because of some missing data regarding the age and sex of passengers. The percent numbers refer to percent of passengers or patients forwhom age or sex is recorded for the respective category.
Peake et al The Holland America Line Westours medical personnel low-up visits for the same condition were recorded as a for each cruise on these ships consisted of a physician and continuation of the original medical record and these visits 3 registered nurses. Although a few doctors practiced in the were not counted as new patient encounters, but visits by infirmaries on more than 1 voyage, a variety of physicians patients who presented with a different complaint on a staffed the cruises. All personnel were licensed in the subsequent visit were counted separately.
United States or Canada. Scheduled infirmary hours were The official Holland America Westours Lines database from 8 to 11 AM and from 4 to 6 PM each day, but care was maintained by MANUS Direct was queried for the age, sex, available on an emergency basis 24 hours a day. On each cabin number, ship, and sailing date (no names were ship, some passengers presented to the infirmary to pur- obtained) of each passenger, and this information was chase over-the-counter medications and did not require a used for determination of overall age and sex demographics.
physician's involvement, and the only record of their The database records passenger ages as 2-digit numbers presence in the infirmary was their name and request in the and the precise number of passengers older than 99 years visit log of the infirmary; these persons were not included of age is not available since the study used cruises from in the study. Roles of the physician and nurses were similar 1991 and persons with birthdays before 1892 cannot be on each ship. All visits to these ships' infirmaries that separated from passengers born in the 20th century. A involved a patient-physician relationship that generated greater number of persons with a birth year listed as 91 an individual medical report were included in this inves- occurred compared with 90 or 92; it was assumed for analysis purposes that persons with the birth year 91 were The medical records include information regarding the 100 years old if the cruise occurred in the first half of 1991 voyage dates of the cruise and each patient's date of visit, and were born in 1991 if the cruise fell in the second half of age, sex, chief complaint, history and physical, treatment, and disposition. Information for each patient extracted Descriptive statistics and frequencies were calculated from the records consisted of ship's name, voyage, sailing with SAS software (SAS 6.0, SAS Institute, Cary, NC).
dates, length of voyage, geographic area of the voyage,patient sex and age, time seen (clinic or nonclinic hours),cruise day seen, cabin number, chief complaint, diagnoses,treatment, prescriptions, prior history of the problem, need for follow-up visit, number of days lost from the cruise, visit Study ships' infirmary visits by principal diagnosis. type (emergency or nonemergency), whether or not anaccident report was made, disposition, and need for a Visits to Ships'
shore consultation. If a category of information was not recorded in the medical record, the space on the data sheetwas left blank or noted to be missing, and is listed under All patient visits the unspecified categories in the results. Scheduled fol- Endocrine and immune diseases Nervous system and sense organ diseases Circulatory system diseases Respiratory system diseases Digestive system diseases Genitourinary system diseases Disposition of study ships' infirmary patients. Skin and subcutaneous tissue diseases Musculoskeletal and connective tissue diseases Symptoms and signs Remained on board Disembarked before completion of cruise Superficial wounds Medical consult obtained ashore, returned to ship Medical consult on shore, disposition not recorded Unspecified disposition Disembarked before sailing Unspecified injury Other or unspecified conditions
Peake et al passengers in general, patients showed similar composi- The 4 ships in this study had a total of 196,171 passengers tion by gender but tended to be older (Table 1) with 82.2% on 172 cruises with their embarkation date in 1991 giving of patients 45 years old or older. A majority of the patients a total of 1,537,298 passenger-days during the study period.
(50.9%) were older than age 64, but only 38.6% of the The average length of a cruise was 7.8 days (range 1 to 35 overall passengers were within that age group. The aver- days) with a mean of 1,143 passengers per cruise. Cruise age age of the patients was 61.0 years.
destinations included Alaska; the Caribbean; trans–Panama Although most patients were treated on board the ships Canal from Fort Lauderdale, Florida, to Los Angeles, without ending their cruise, the disposition of patients who California, and Los Angeles, California, to Fort Lauderdale, remained on board included 91 consultations with physi- Florida; the Mexican Riviera; Hawaii; Polynesia; and Canada.
cians onshore and 587 referrals for immediate follow-up Table 1 shows the demographics by age and gender and when the patient returned home. Several patients disem- ship for the passengers and patients during the study period.
barked before sailing for medical causes, and numerous Most passengers were middle-aged and older adults. The patients disembarked for medical reasons after sailing average age of the passengers was 55.7 years; 73.9% of the (Table 2). Fifteen deaths were pronounced on board the passengers were older than 44 years of age. More passen- ships during the study period, and 2 cardiac arrest victims gers were female than male.
were successfully resuscitated and disembarked.
During the study period, 7,147 passengers were evalu- The patients' diagnoses covered a broad range of condi- ated by the ships' physicians. The utilization of the infirmary tions (Table 3). Diseases of the respiratory system and by passengers undergoing a physician evaluation was 5.0 injury-related problems accounted for nearly 50% of the patients per day (3.6% of the total passenger population).
patient presentations. Potentially life-threatening conditions Because Holland America Line Westours calculates that 60% or conditions requiring immediate care including cardiac of the physician visits are by members of the crew (statis- arrest, myocardial infarction, transient ischemic attack or tics provided by Holland America Line Westours medical cerebrovascular accident, pneumothorax, altered mental department), a ship's physician could expect to see an average status, bowel obstruction, deep venous thrombosis, hip frac- of 12.5 patients, including crew, per day. Compared with the ture, and others accounted for 11% of the patients (Table 4).
The most common individual diagnoses were upper respi-ratory tract infections and acute bronchitis, enteritis and gastroenteritis, sprains, contusions, superficial wounds, Study ships' infirmary patients and percent of total study ships' seasickness, and medications refill.
infirmary patients by potentially serious or life-threatening illness. Gastroenteritis did not affect 3% or more of the passen- gers on any single cruise, and thus none of the study cruises Visits to Ships'
were subject to review by the Centers for Disease Control of Patients
Location of occurrence of accidental injuries aboard study ships. Congestive heart failure Chronic obstructive pulmonary disease No. of Injuries
Cerebral ischemic event Myocardial infarction Other or not specified Venous thrombosis Deck (including stairs) Mental status change Passenger's own cabin Ashore, including tours Bowel obstruction Heat-related illness Peake et al and Prevention for gastroenteritis epidemics. Accidental ably did not present to the ships' infirmaries, the number injuries occurred in a variety of places during the cruises of respiratory infections acquired during a cruise is prob- (Table 5). Of the injuries where the location of occurrence ably higher than the numbers observed in this study.
was noted, 62% occurred on the deck and stairs areas, in Although most medical conditions encountered among the passenger's own cabin, or ashore during port calls.
ships' passengers in this study were handled onboard ship, One hundred fifteen different medications were admin- the substantial number of patients with serious or even istered or prescribed to the ships' infirmary patients. The life-threatening conditions demonstrates the need for top 15 prescription medications used are listed in Table 6.
adequately skilled medical care providers and appropriate Antibiotics accounted for more than 32% of the medica- equipment. On an average cruise in this study, a ship's physi- tions prescribed; antihistamines, antitussives, and decon- cian could expect to encounter a potentially serious illness gestants for 26%; nonsteroidal anti-inflammatory drugs or injury 4 times and to have to have a patient disembark and topical antibiotics for 5% each; and narcotic pain for medical reasons once. The increasing numbers of cruise medications for 4%.
ship passengers suggest a need to ensure that the medicalcare available to passengers on these ships is adequate tomanage the medical problems encountered on voyages that may take passengers many hours or even days from the near- The American College of Emergency Physicians has pub- est shore-based medical facilities. Many cruises are taken lished a policy statement, "Guidelines of Care for Cruise into areas that may not have medical care available at the Ship Medical Facilities."11 The purpose of this policy is same level of standards as is expected in the United States.
"…to provide assistance to the cruise industry in develop- Because this study is based on 1 cruise line, it may not be ing their own standards for medical services"12 because no indicative of the entire cruise line industry. The findings, how- industry-wide standards have otherwise existed. The ever, parallel those of the smaller study by DiGiovanna et al.9 International Council of Cruise Lines has prepared its own Some cruise lines have a passenger population apparently set of guidelines.13 A resolution has been passed by the younger than that of Holland America Line,10 and the age American Medical Association asking for federal or interna- differences may produce differences in patient populations.
tional law regulating cruise ship medical care. Furthermore, Similar differences may exist for gender composition of the US Senate Commerce Committee has initiated an inves- the passenger population. Another limitation of this study tigation into what medical care is provided by cruise shipsthat call on US ports.14 Young15 has suggested "…an emergency physician is ideally suited for the duties of a cruise ship physician." The Top 15 oral prescription medications prescribed for study ships' distributions of illnesses and injuries described in this study support his opinion. Therefore physicians who are engagedin working on cruise ships should at least be experienced Percent of All
in caring for all ages of patients, in management of wounds, fractures, and other trauma, and in management of a wide range of medical conditions. Because at least for this cruiseline, passengers and patients tended to be middle-aged or older, a cruise ship physician should be particularly skilled in the care of older patients.
Although many recent reports have been published Bactrim DS (Septra DS) Acetaminophen with codeine regarding respiratory epidemics on cruise ships,3-8 no epidemics of respiratory illness were noted in this study, but, nevertheless, respiratory-related complaints were the most commonly encountered medical problem. The frequency of these conditions in this study (29.1% of diag- noses) is similar to that noted in the study by DiGiovanna et al9 (27%). Considering that a cruise duration may be less than the incubation period for some respiratory infec- tions and considering that some infected passengers prob- Peake et al 12. Wheeler R: From the chair. Cruise Ship and Maritime Medicine: Membership Section is its retrospective design. For example, patient diagnoses Newsletter from the American College of Emergency Physicians 1996;3:1.
recorded in the medical chart were used, and for some ill- 13. International Council of Cruise Lines: International Council of Cruise Lines medical facilities nesses such as upper respiratory tract infections and bron- guidelines: Policy statement [draft]. Washington DC: International Council of Cruise Lines, chitis, the illnesses were combined for study purposes September 1996.
because these entities would have been difficult to consis- 14. Wheeler R: From the chair. Cruise Ship and Maritime Medicine: Membership SectionNewsletter from the American College of Emergency Physicians, 1996;3:1.
tently separate using the medical records alone. Unfortunately, 15. Young W: New horizons: Emergency medicine at sea. Ann Emerg Med 1992;21:1463.
this study also did not include the injuries and illnesses of thecrew members of the ships since the crews' medical recordswere not available at the time of this study.
The findings of this study, however, highlight the need for cruise lines to prepare for emergency medical situationson a routine basis. Cruise lines should have plans in placeto allow evacuation, during any part of a given cruise, ofseriously ill patients to facilities with medical treatmentcapabilities consistent with passengers' expectations. Toallow passengers to develop realistic expectations in theevent of a medical emergency, cruise ship passengers andtravel agents who provide information to prospectivepassengers should have information available regardingship-based medical capabilities and the cruise line's plansfor medical evacuations. Physicians who are planning towork as ships' physicians on cruise ships should be preparedto treat a variety of illnesses and injuries including manylife-threatening conditions and should expect frequentdisembarkation of patients for medical conditions.
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2. Dannenberg AL, Yashuk JC, Feldman RA: Gastrointestinal illness on passenger cruise ships, 1975–1978. Am J Public Health 1982;72:484-488.
3. Jernigan DB, Hofmann J, Cetron MS, et al: Outbreak of Legionnaires' disease among cruise ship passengers exposed to a contaminated whirlpool spa. Childhood and Respiratory DiseasesBranch, National Center for Infectious Diseases, Centers for Disease Control and Prevention,Atlanta, Georgia, USA. Lancet 1996;347:494-499.
4. Update: Outbreak of Legionnaires' disease associated with a cruise ship, 1994. MMWR Morb Mortal Wkly Rep 1994;43(31):574-575.
5. Outbreak of pneumonia associated with a cruise ship, 1994. MMWR Morb Mortal Wkly Rep 6. Acute respiratory illness among cruise-ship passengers—Asia. MMWR Morb Mortal Wkly 7. Christenson B, Lidin-Janson G, Kallings I: Outbreak of respiratory illness on board a ship cruising to ports in southern Europe and northern Africa. J Infect 1987;3:247-254.
8. Berntsson E, Hogevik H, Lidin-Janson G, et al: Infections among cruise passengers (a Legionella-like organism?) [letter]. Infection 1986;14:93.
9. DiGiovanna T, Rosen T, Forsett R, et al: Shipboard medicine: A new niche for emergency medicine. Ann Emerg Med 1992;21:1476-1479.
10. Perrin W: Cruise ships medical care: Why it's not always smooth sailing at sea. Conde NastTraveler 1994;Dec:37-45. 11. American College of Emergency Physicians: Guidelines of care for cruise ship medical facili-ties [policy statement]. Ann Emerg Med 1996;27:846.

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