Cruising With Disaster

I recently returned from a pleasure cruise to celebrate a milestone birthday. (I’m not telling you which one—but it did make me eligible for government health care!) Prior to embarking on this adventure, I had dreams of calm blue-green waters, endless plates of delectable food, sitting on the stateroom veranda drinking wine while watching the sunset, and exciting land and sea excursions.

However, I must admit that I also felt apprehensive. Just a year ago, one of my best friends lost his wife to severe influenza and necrotizing pneumonia while on a cruise. This disastrous event occurred very rapidly (what I call “from cough to death in less than 48 hours”) and in the same locale as my cruise. So, you can imagine my concern.

To prepare myself, I did a bit of research on the types of infectious diseases occurring aboard ship. The leading cause of human acute viral gastroenteritis on cruise ships is norovirus, outbreaks of which have increased significantly in recent years¹ and always garner significant media attention.

However, the most frequent con­sultation with a ship’s medical team on most cruises is for respiratory illness.² Outbreaks are not uncommon, particularly within flu season (October through May in the Northern hemisphere and April through September in the Southern hemisphere). Unfortunately, flu season is year round in the tropics and subtropics.³ There have also been occurrences of invasive meningococcal disease (four cases in the Mediterranean in October 2012, one of which was ultimately fatal)⁴ and cyclosporiasis (on two successive voyages embarking from Australia in 2010).⁵

Considering the detrimental consequences for passengers and the subsequent high costs for cruise companies, disease outbreaks on cruise ships represent a serious public health issue.⁶ Unfortunately, contagious disease on commercial ships tends to be poorly managed, as there is little capacity to confirm a case or isolate to curb transmission.⁷ (Personally, I was pleased—and relieved—to see that crew members stood outside every restaurant on the ship offering passengers hand disinfectant gel.)

I’m not trying to be alarmist. After all, I had a great cruise free of concerns. But I think anyone who sets sail should be aware of the circumstances should illness or injury occur. Here is some of what I learned through research and experience:

The cruise ship medical facility is not equivalent to your local hospital. Each ship in the fleet of a major cruise line contains a sick bay (to use a nautical term) with staff available 24 hours a day, but they are typically equipped to treat only minor, nonemergent conditions. I was told by the ship’s physician that he mostly sees upper respiratory infections, seasickness, and back pain. All ships have a physician on board who is trained in emergency medicine,⁸ and usually there are at least two RNs as well.

The medical facilities tend to resemble an infirmary or walk-in clinic rather than a “floating hospital.” There may be some simple equipment—a ventilator or a small x-ray machine—and the medical staff may be able to perform simple lab tests (eg, to check for infection or monitor glucose). But there is no capacity for advanced imaging, no ICU, and no store of blood in the event a transfusion is needed. Limited medications are available on board, but the inventories vary and are usually related to common conditions.

You should also know that there is no international body to regulate medical care on a passenger ship.⁹ The closest guidance comes from the American College of Emergency Physicians (ACEP), whose “Guidelines of Care for Cruise Ship Medical Facilities” was first published in 1996 (most recent revision, 2013).^10,11 They stipulate that shipboard infirmaries must have equipment to handle a range of diagnoses and treatments: wheelchairs, a stretcher and backboard for spine immobilization, lab capabilities, oxygen, ECG, two defibrillators, cardiac monitors, and vital sign monitoring. Cruise RNs are required to have a minimum of two years of recent hospital experience, particularly in cardiac care, trauma, and internal medicine.

ACEP’s guidelines have become an international reference for the practice of cruise medicine.¹² The proviso to their use is that they are based on member consensus rather than documented facts.

If there is an emergency on board, you are most likely on your own! You will be referred to a facility on land and disembarked to receive care—and the ship’s medical staff makes that call, not you. The “local” hospital may be at some distance from the port, necessitating transportation (which can be expensive), and in remote areas, the standards may not be what you are accustomed to in the United States. (There is the added difficulty that once you have recovered, you will have to make your own arrangements to get home.)

In the event of a serious emergency—a heart attack or stroke—the Coast Guard may step in to airlift you from the ship. But they aren’t obligated to risk a dangerous helicopter flight in bad weather, or if the ship is more than 250 miles from shore. Cruise ships do not commonly deviate course for evacuation purposes unless doing so will likely result in a markedly improved outcome.

On the next page: Will health insurance cover you? 

See also: Dr. Bukata's comment on this editorial

What about health insurance? Will it cover you? Most plans do not cover medical services on board, which means you will pay out-of-pocket for any costs incurred. The bill can range from a few hundred to several thousand dollars. If you receive treatment or medicine from the ship’s medical team, the cost will be charged to your personal account. You could then file a claim with your personal insurance carrier to recoup whatever is covered by your health policy.

Travel insurance, which usually costs between 5% and 8% of the total cost of the trip, could cover the rest. In addition to medical costs, you can buy insurance policies that cover a wide range of trip interruption and cancellation situations, as well as medical evacuation.

Travel health insurance is your best protection. Consumer Reports recommends avoiding commission-driven policies sold by tour operators, cruise-line representatives, and travel agents. Instead, check out an online broker (such as insuremytrip.com) that sells coverage from multiple companies and allows you to tailor a plan to your needs.⁸

Many employers purchase travel insurance for their employees, which covers both business and pleasure trips. This type of policy is particularly convenient if an expensive emergency procedure, such as evacuation from the ship and/or a hospital stay in a foreign port, is necessary.

Not all perils at sea are contagious. Norovirus and motion sickness aren’t the only health concerns onboard. Falls and cardiac problems are also quite common. The CDC estimates that injuries, typically from slips, trips, or falls, account for 12% to 18% of shipboard medical visits. Obviously, anyone can fall, but those with limited mobility or who require assistance (eg, cane, walker, or wheelchair) are particularly at risk from wet decks and rough waters. (Factor in a cocktail or two, and even the normally ambulatory will have trouble navigating!)

If you have a bad outcome, don’t expect to win a lawsuit against the cruise line. Be sure to actually read the lengthy form you sign before boarding the ship. Courts have ruled that a cruise line may not be held vicariously liable for the negligence of a ship’s physician. There is no medical malpractice for care rendered on board. Traditionally, the physician and nurses are private contractors.

Ultimately, I think pleasure cruises are worth the time and effort for the prepared cruiser. I intend to go again. And this editorial is not an indictment of the physicians and nurses who work hard and do a wonderful job on cruises to maintain the health of passengers and crew. I just don’t want anyone caught unaware if they set sail for an adventure and find more than they wanted.

I would love to hear about any experience, positive or negative, that you have had with cruise medicine. Contact me at PAEditor@frontlinemedcom.com.

REFERENCES

1. Diskin AL, Caro GM, Dahl E. Acute gastroenteritis and video camera surveillance: a cruise ship case report. Int Marit Health. 2014; 65(1):20-22.

2. Williams S, Dahl E. Briefing notes on emergency medical disembarks by helicopter at sea in North America. Int Marit Health. 2014;65(1):7-12.

3. Brown CM, Cetron MS. Crossing borders: one world, global health. Clin Infect Dis. 2012; 54(11):v-vi.

4. Stefanelli P, Fazio C, Neri A, et al. Cluster of invasive Neisseria meningitidis infections on a cruise ship, Italy, October 2012. Euro Surveill. 2012;17(50):pii20336. 

5. Gibbs RA, Nanyonjo R, Pingault NM, et al. An outbreak of Cyclospora infection on a cruise ship. Epidemiol Infect. 2013;141(3):508-516.

6. Bert F, Scaioli G, Gualano MR, et al. Norovirus outbreaks on commercial cruise ships: a systematic review and new targets for the public health agenda. Food Environ Virol. 2014; May 17. [Epub ahead of print.]

7. Bouricha M, Samad MA, Levy PY, et al. Point-of-care syndrome, rapid diagnosis of infections on commercial ships. J Travel Med. 2014;21(1):12-16.

8. Consumer Reports. 7 things you need to know about medical care on cruise ships. www.consumerreports.org/cro/news/ 2014/04/7-things-you-need-to-know-about-medical-care-on-cruise-ships/index.htm. Accessed July 17, 2014.

9. Dahl E. Cruise medicine: call for an international standard. Int Marit Health. 2001;52:24-26.

10. American College of Emergency Physicians. Guidelines of care for cruise ship medical facilities. Ann Emerg Med. 1996;27:846.

11. American College of Emergency Physicians. Health Care Guidelines for Cruise Ship Medical Facilities. www.acep.org/content.aspx?id=29500. Accessed July 16, 2014.

12. Cruise Lines International Association, Inc. Medical facilities. www.cruising.org/regula tory/policies/medical-facilities. Accessed July 16, 2014.

See also: Dr. Bukata's comment on this editorial
[Rick Bukata is the editor and founder of Emergency Medical Abstracts and has been studying the literature of emergency medicine in depth since 1977. Rick was awarded the Education Award of the American College of Emergency Physicians in 1993 and the College’s “Outstanding Speaker of the Year” award in 2000. He is a Clinical Professor of Emergency Medicine at the University of Southern California.]

I recently returned from a pleasure cruise to celebrate a milestone birthday. (I’m not telling you which one—but it did make me eligible for government health care!) Prior to embarking on this adventure, I had dreams of calm blue-green waters, endless plates of delectable food, sitting on the stateroom veranda drinking wine while watching the sunset, and exciting land and sea excursions.

However, I must admit that I also felt apprehensive. Just a year ago, one of my best friends lost his wife to severe influenza and necrotizing pneumonia while on a cruise. This disastrous event occurred very rapidly (what I call “from cough to death in less than 48 hours”) and in the same locale as my cruise. So, you can imagine my concern.

To prepare myself, I did a bit of research on the types of infectious diseases occurring aboard ship. The leading cause of human acute viral gastroenteritis on cruise ships is norovirus, outbreaks of which have increased significantly in recent years¹ and always garner significant media attention.

However, the most frequent con­sultation with a ship’s medical team on most cruises is for respiratory illness.² Outbreaks are not uncommon, particularly within flu season (October through May in the Northern hemisphere and April through September in the Southern hemisphere). Unfortunately, flu season is year round in the tropics and subtropics.³ There have also been occurrences of invasive meningococcal disease (four cases in the Mediterranean in October 2012, one of which was ultimately fatal)⁴ and cyclosporiasis (on two successive voyages embarking from Australia in 2010).⁵

Considering the detrimental consequences for passengers and the subsequent high costs for cruise companies, disease outbreaks on cruise ships represent a serious public health issue.⁶ Unfortunately, contagious disease on commercial ships tends to be poorly managed, as there is little capacity to confirm a case or isolate to curb transmission.⁷ (Personally, I was pleased—and relieved—to see that crew members stood outside every restaurant on the ship offering passengers hand disinfectant gel.)

I’m not trying to be alarmist. After all, I had a great cruise free of concerns. But I think anyone who sets sail should be aware of the circumstances should illness or injury occur. Here is some of what I learned through research and experience:

The cruise ship medical facility is not equivalent to your local hospital. Each ship in the fleet of a major cruise line contains a sick bay (to use a nautical term) with staff available 24 hours a day, but they are typically equipped to treat only minor, nonemergent conditions. I was told by the ship’s physician that he mostly sees upper respiratory infections, seasickness, and back pain. All ships have a physician on board who is trained in emergency medicine,⁸ and usually there are at least two RNs as well.

The medical facilities tend to resemble an infirmary or walk-in clinic rather than a “floating hospital.” There may be some simple equipment—a ventilator or a small x-ray machine—and the medical staff may be able to perform simple lab tests (eg, to check for infection or monitor glucose). But there is no capacity for advanced imaging, no ICU, and no store of blood in the event a transfusion is needed. Limited medications are available on board, but the inventories vary and are usually related to common conditions.

You should also know that there is no international body to regulate medical care on a passenger ship.⁹ The closest guidance comes from the American College of Emergency Physicians (ACEP), whose “Guidelines of Care for Cruise Ship Medical Facilities” was first published in 1996 (most recent revision, 2013).^10,11 They stipulate that shipboard infirmaries must have equipment to handle a range of diagnoses and treatments: wheelchairs, a stretcher and backboard for spine immobilization, lab capabilities, oxygen, ECG, two defibrillators, cardiac monitors, and vital sign monitoring. Cruise RNs are required to have a minimum of two years of recent hospital experience, particularly in cardiac care, trauma, and internal medicine.

ACEP’s guidelines have become an international reference for the practice of cruise medicine.¹² The proviso to their use is that they are based on member consensus rather than documented facts.

If there is an emergency on board, you are most likely on your own! You will be referred to a facility on land and disembarked to receive care—and the ship’s medical staff makes that call, not you. The “local” hospital may be at some distance from the port, necessitating transportation (which can be expensive), and in remote areas, the standards may not be what you are accustomed to in the United States. (There is the added difficulty that once you have recovered, you will have to make your own arrangements to get home.)

In the event of a serious emergency—a heart attack or stroke—the Coast Guard may step in to airlift you from the ship. But they aren’t obligated to risk a dangerous helicopter flight in bad weather, or if the ship is more than 250 miles from shore. Cruise ships do not commonly deviate course for evacuation purposes unless doing so will likely result in a markedly improved outcome.

On the next page: Will health insurance cover you? 

See also: Dr. Bukata's comment on this editorial

What about health insurance? Will it cover you? Most plans do not cover medical services on board, which means you will pay out-of-pocket for any costs incurred. The bill can range from a few hundred to several thousand dollars. If you receive treatment or medicine from the ship’s medical team, the cost will be charged to your personal account. You could then file a claim with your personal insurance carrier to recoup whatever is covered by your health policy.

Travel insurance, which usually costs between 5% and 8% of the total cost of the trip, could cover the rest. In addition to medical costs, you can buy insurance policies that cover a wide range of trip interruption and cancellation situations, as well as medical evacuation.

Travel health insurance is your best protection. Consumer Reports recommends avoiding commission-driven policies sold by tour operators, cruise-line representatives, and travel agents. Instead, check out an online broker (such as insuremytrip.com) that sells coverage from multiple companies and allows you to tailor a plan to your needs.⁸

Many employers purchase travel insurance for their employees, which covers both business and pleasure trips. This type of policy is particularly convenient if an expensive emergency procedure, such as evacuation from the ship and/or a hospital stay in a foreign port, is necessary.

Not all perils at sea are contagious. Norovirus and motion sickness aren’t the only health concerns onboard. Falls and cardiac problems are also quite common. The CDC estimates that injuries, typically from slips, trips, or falls, account for 12% to 18% of shipboard medical visits. Obviously, anyone can fall, but those with limited mobility or who require assistance (eg, cane, walker, or wheelchair) are particularly at risk from wet decks and rough waters. (Factor in a cocktail or two, and even the normally ambulatory will have trouble navigating!)

If you have a bad outcome, don’t expect to win a lawsuit against the cruise line. Be sure to actually read the lengthy form you sign before boarding the ship. Courts have ruled that a cruise line may not be held vicariously liable for the negligence of a ship’s physician. There is no medical malpractice for care rendered on board. Traditionally, the physician and nurses are private contractors.

Ultimately, I think pleasure cruises are worth the time and effort for the prepared cruiser. I intend to go again. And this editorial is not an indictment of the physicians and nurses who work hard and do a wonderful job on cruises to maintain the health of passengers and crew. I just don’t want anyone caught unaware if they set sail for an adventure and find more than they wanted.

I would love to hear about any experience, positive or negative, that you have had with cruise medicine. Contact me at PAEditor@frontlinemedcom.com.

REFERENCES

1. Diskin AL, Caro GM, Dahl E. Acute gastroenteritis and video camera surveillance: a cruise ship case report. Int Marit Health. 2014; 65(1):20-22.

2. Williams S, Dahl E. Briefing notes on emergency medical disembarks by helicopter at sea in North America. Int Marit Health. 2014;65(1):7-12.

3. Brown CM, Cetron MS. Crossing borders: one world, global health. Clin Infect Dis. 2012; 54(11):v-vi.

4. Stefanelli P, Fazio C, Neri A, et al. Cluster of invasive Neisseria meningitidis infections on a cruise ship, Italy, October 2012. Euro Surveill. 2012;17(50):pii20336. 

5. Gibbs RA, Nanyonjo R, Pingault NM, et al. An outbreak of Cyclospora infection on a cruise ship. Epidemiol Infect. 2013;141(3):508-516.

6. Bert F, Scaioli G, Gualano MR, et al. Norovirus outbreaks on commercial cruise ships: a systematic review and new targets for the public health agenda. Food Environ Virol. 2014; May 17. [Epub ahead of print.]

7. Bouricha M, Samad MA, Levy PY, et al. Point-of-care syndrome, rapid diagnosis of infections on commercial ships. J Travel Med. 2014;21(1):12-16.

8. Consumer Reports. 7 things you need to know about medical care on cruise ships. www.consumerreports.org/cro/news/ 2014/04/7-things-you-need-to-know-about-medical-care-on-cruise-ships/index.htm. Accessed July 17, 2014.

9. Dahl E. Cruise medicine: call for an international standard. Int Marit Health. 2001;52:24-26.

10. American College of Emergency Physicians. Guidelines of care for cruise ship medical facilities. Ann Emerg Med. 1996;27:846.

11. American College of Emergency Physicians. Health Care Guidelines for Cruise Ship Medical Facilities. www.acep.org/content.aspx?id=29500. Accessed July 16, 2014.

12. Cruise Lines International Association, Inc. Medical facilities. www.cruising.org/regula tory/policies/medical-facilities. Accessed July 16, 2014.

See also: Dr. Bukata's comment on this editorial
[Rick Bukata is the editor and founder of Emergency Medical Abstracts and has been studying the literature of emergency medicine in depth since 1977. Rick was awarded the Education Award of the American College of Emergency Physicians in 1993 and the College’s “Outstanding Speaker of the Year” award in 2000. He is a Clinical Professor of Emergency Medicine at the University of Southern California.]

I recently returned from a pleasure cruise to celebrate a milestone birthday. (I’m not telling you which one—but it did make me eligible for government health care!) Prior to embarking on this adventure, I had dreams of calm blue-green waters, endless plates of delectable food, sitting on the stateroom veranda drinking wine while watching the sunset, and exciting land and sea excursions.

However, I must admit that I also felt apprehensive. Just a year ago, one of my best friends lost his wife to severe influenza and necrotizing pneumonia while on a cruise. This disastrous event occurred very rapidly (what I call “from cough to death in less than 48 hours”) and in the same locale as my cruise. So, you can imagine my concern.

To prepare myself, I did a bit of research on the types of infectious diseases occurring aboard ship. The leading cause of human acute viral gastroenteritis on cruise ships is norovirus, outbreaks of which have increased significantly in recent years¹ and always garner significant media attention.

However, the most frequent con­sultation with a ship’s medical team on most cruises is for respiratory illness.² Outbreaks are not uncommon, particularly within flu season (October through May in the Northern hemisphere and April through September in the Southern hemisphere). Unfortunately, flu season is year round in the tropics and subtropics.³ There have also been occurrences of invasive meningococcal disease (four cases in the Mediterranean in October 2012, one of which was ultimately fatal)⁴ and cyclosporiasis (on two successive voyages embarking from Australia in 2010).⁵

Considering the detrimental consequences for passengers and the subsequent high costs for cruise companies, disease outbreaks on cruise ships represent a serious public health issue.⁶ Unfortunately, contagious disease on commercial ships tends to be poorly managed, as there is little capacity to confirm a case or isolate to curb transmission.⁷ (Personally, I was pleased—and relieved—to see that crew members stood outside every restaurant on the ship offering passengers hand disinfectant gel.)

I’m not trying to be alarmist. After all, I had a great cruise free of concerns. But I think anyone who sets sail should be aware of the circumstances should illness or injury occur. Here is some of what I learned through research and experience:

The cruise ship medical facility is not equivalent to your local hospital. Each ship in the fleet of a major cruise line contains a sick bay (to use a nautical term) with staff available 24 hours a day, but they are typically equipped to treat only minor, nonemergent conditions. I was told by the ship’s physician that he mostly sees upper respiratory infections, seasickness, and back pain. All ships have a physician on board who is trained in emergency medicine,⁸ and usually there are at least two RNs as well.

The medical facilities tend to resemble an infirmary or walk-in clinic rather than a “floating hospital.” There may be some simple equipment—a ventilator or a small x-ray machine—and the medical staff may be able to perform simple lab tests (eg, to check for infection or monitor glucose). But there is no capacity for advanced imaging, no ICU, and no store of blood in the event a transfusion is needed. Limited medications are available on board, but the inventories vary and are usually related to common conditions.

You should also know that there is no international body to regulate medical care on a passenger ship.⁹ The closest guidance comes from the American College of Emergency Physicians (ACEP), whose “Guidelines of Care for Cruise Ship Medical Facilities” was first published in 1996 (most recent revision, 2013).^10,11 They stipulate that shipboard infirmaries must have equipment to handle a range of diagnoses and treatments: wheelchairs, a stretcher and backboard for spine immobilization, lab capabilities, oxygen, ECG, two defibrillators, cardiac monitors, and vital sign monitoring. Cruise RNs are required to have a minimum of two years of recent hospital experience, particularly in cardiac care, trauma, and internal medicine.

ACEP’s guidelines have become an international reference for the practice of cruise medicine.¹² The proviso to their use is that they are based on member consensus rather than documented facts.

If there is an emergency on board, you are most likely on your own! You will be referred to a facility on land and disembarked to receive care—and the ship’s medical staff makes that call, not you. The “local” hospital may be at some distance from the port, necessitating transportation (which can be expensive), and in remote areas, the standards may not be what you are accustomed to in the United States. (There is the added difficulty that once you have recovered, you will have to make your own arrangements to get home.)

In the event of a serious emergency—a heart attack or stroke—the Coast Guard may step in to airlift you from the ship. But they aren’t obligated to risk a dangerous helicopter flight in bad weather, or if the ship is more than 250 miles from shore. Cruise ships do not commonly deviate course for evacuation purposes unless doing so will likely result in a markedly improved outcome.

On the next page: Will health insurance cover you? 

See also: Dr. Bukata's comment on this editorial

What about health insurance? Will it cover you? Most plans do not cover medical services on board, which means you will pay out-of-pocket for any costs incurred. The bill can range from a few hundred to several thousand dollars. If you receive treatment or medicine from the ship’s medical team, the cost will be charged to your personal account. You could then file a claim with your personal insurance carrier to recoup whatever is covered by your health policy.

Travel insurance, which usually costs between 5% and 8% of the total cost of the trip, could cover the rest. In addition to medical costs, you can buy insurance policies that cover a wide range of trip interruption and cancellation situations, as well as medical evacuation.

Travel health insurance is your best protection. Consumer Reports recommends avoiding commission-driven policies sold by tour operators, cruise-line representatives, and travel agents. Instead, check out an online broker (such as insuremytrip.com) that sells coverage from multiple companies and allows you to tailor a plan to your needs.⁸

Many employers purchase travel insurance for their employees, which covers both business and pleasure trips. This type of policy is particularly convenient if an expensive emergency procedure, such as evacuation from the ship and/or a hospital stay in a foreign port, is necessary.

Not all perils at sea are contagious. Norovirus and motion sickness aren’t the only health concerns onboard. Falls and cardiac problems are also quite common. The CDC estimates that injuries, typically from slips, trips, or falls, account for 12% to 18% of shipboard medical visits. Obviously, anyone can fall, but those with limited mobility or who require assistance (eg, cane, walker, or wheelchair) are particularly at risk from wet decks and rough waters. (Factor in a cocktail or two, and even the normally ambulatory will have trouble navigating!)

If you have a bad outcome, don’t expect to win a lawsuit against the cruise line. Be sure to actually read the lengthy form you sign before boarding the ship. Courts have ruled that a cruise line may not be held vicariously liable for the negligence of a ship’s physician. There is no medical malpractice for care rendered on board. Traditionally, the physician and nurses are private contractors.

Ultimately, I think pleasure cruises are worth the time and effort for the prepared cruiser. I intend to go again. And this editorial is not an indictment of the physicians and nurses who work hard and do a wonderful job on cruises to maintain the health of passengers and crew. I just don’t want anyone caught unaware if they set sail for an adventure and find more than they wanted.

I would love to hear about any experience, positive or negative, that you have had with cruise medicine. Contact me at PAEditor@frontlinemedcom.com.

REFERENCES

1. Diskin AL, Caro GM, Dahl E. Acute gastroenteritis and video camera surveillance: a cruise ship case report. Int Marit Health. 2014; 65(1):20-22.

2. Williams S, Dahl E. Briefing notes on emergency medical disembarks by helicopter at sea in North America. Int Marit Health. 2014;65(1):7-12.

3. Brown CM, Cetron MS. Crossing borders: one world, global health. Clin Infect Dis. 2012; 54(11):v-vi.

4. Stefanelli P, Fazio C, Neri A, et al. Cluster of invasive Neisseria meningitidis infections on a cruise ship, Italy, October 2012. Euro Surveill. 2012;17(50):pii20336. 

5. Gibbs RA, Nanyonjo R, Pingault NM, et al. An outbreak of Cyclospora infection on a cruise ship. Epidemiol Infect. 2013;141(3):508-516.

6. Bert F, Scaioli G, Gualano MR, et al. Norovirus outbreaks on commercial cruise ships: a systematic review and new targets for the public health agenda. Food Environ Virol. 2014; May 17. [Epub ahead of print.]

7. Bouricha M, Samad MA, Levy PY, et al. Point-of-care syndrome, rapid diagnosis of infections on commercial ships. J Travel Med. 2014;21(1):12-16.

8. Consumer Reports. 7 things you need to know about medical care on cruise ships. www.consumerreports.org/cro/news/ 2014/04/7-things-you-need-to-know-about-medical-care-on-cruise-ships/index.htm. Accessed July 17, 2014.

9. Dahl E. Cruise medicine: call for an international standard. Int Marit Health. 2001;52:24-26.

10. American College of Emergency Physicians. Guidelines of care for cruise ship medical facilities. Ann Emerg Med. 1996;27:846.

11. American College of Emergency Physicians. Health Care Guidelines for Cruise Ship Medical Facilities. www.acep.org/content.aspx?id=29500. Accessed July 16, 2014.

12. Cruise Lines International Association, Inc. Medical facilities. www.cruising.org/regula tory/policies/medical-facilities. Accessed July 16, 2014.

See also: Dr. Bukata's comment on this editorial
[Rick Bukata is the editor and founder of Emergency Medical Abstracts and has been studying the literature of emergency medicine in depth since 1977. Rick was awarded the Education Award of the American College of Emergency Physicians in 1993 and the College’s “Outstanding Speaker of the Year” award in 2000. He is a Clinical Professor of Emergency Medicine at the University of Southern California.]