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" An outbreak on a cruise liner in October 2008 was managed successfully by an international, multi-agency team that included the Lothian Health Protection Team "

For a common purpose

Health protection is one of the most obvious ways in which a mutual response to the practice of public health can be seen. Very often action is taken in relation to a specific event - an incident - which is aimed at providing a benefit not just for those who are immediately affected, but also for a wider community. This working for a common purpose is designed to reduce levels of avoidable harm from infectious diseases and contamination of water, air, land or people, now and in the future.


Norovirus is a common cause of viral gastroenteritis which can spread rapidly. Transmission is from person to person (via food or water) or by contact with the virus in a contaminated environment. Whilst norovirus can be contracted at any time of the year, some forms are more common during the winter months, hence the name: 'winter vomiting virus'.

Preventing the spread of norovirus

The first line of action in the prevention of norovirus is through good standards of personal and food hygiene. Simple measures such as hand washing after going to the toilet and before eating or preparing food are all that is usually necessary. However, outbreaks require more intensive action. Norovirus can spread rapidly amongst people living in close proximity. Here, social distancing and disinfection of public places may be required to reduce the spread of the virus. More information and advice about norovirus is available from the NHS website1.

[ Box 1 ] Preventing norovirus

Although it is not always possible to prevent contracting a norovirus, good hygiene can help to limit the spread of the infection. There are some practical steps that you can follow to help stop a norovirus spreading, some of which are outlined below.

  • Wash your hands frequently and thoroughly, particularly after using the toilet, and before preparing food.
  • Disinfect any surfaces or objects that could be contaminated with norovirus immediately. It is best to use a bleach-based household cleaner. Always follow the instructions on the cleaning product (so that you use the product safely and do not damage surfaces).
  • Avoid eating raw, unwashed produce.
  • Flush away any infected faeces or vomit in the toilet. You should also keep the surrounding toilet area clean and hygienic.
  • Wash any clothing, or linens, which could have become contaminated with norovirus. Washing with hot, soapy water will help to ensure that the virus is killed.

If you have symptoms of norovirus, you should avoid direct contact with other people, including going to work and preparing food for others, until at least 48 hours after your symptoms have gone. This is because you may still be infectious, even though you no longer have sickness or diarrhoea.

Avoid visiting hospitals if you have had the typical symptoms of norovirus in the past 48 hours. You may be asked to rearrange outpatient appointments if you have had recent symptoms. Norovirus infection is more serious and even more easily spread among people who are already ill.

A Cruise in October

In October 2008 the Health Protection Teams' (HPT) multidisciplinary, national and international relationships were tested. An outbreak of gastroenteritis was identified onboard a cruise ship which was to dock in the Port of Leith. Epidemiological investigations suggested norovirus infection, which was then confirmed microbiologically.

This was the first outbreak of norovirus related illness since the introduction of the new International Health Regulations2. It required coordinated action across several agencies. Representatives from Health Protection teams along the cruise liners route, including Liverpool, Belfast, Newcastle, Dover and Amsterdam, worked alongside the Lothian team. The local team also needed to integrate their response together with members of the City of Edinburgh Council's Environmental Health Department (who are the Port Health Authority for Leith), the Maritime and Coastguard Agency, local laboratory services and the UK Centre for Infections, part of the Health Protection Agency in London.

At the same time, the cruise ship operators worked with the team. Daily telephone conferences were held throughout the outbreak to ensure that all of the necessary tasks were undertaken by each agency and all interested parties were kept fully informed.

Managing health internationally - The International Health Regulations

The outbreak of norovirus on a cruise liner highlights the importance of international, mutual co-operation in meeting public health needs.

In 2005 the World Health Organisation (WHO) published an updated set of global 'rules' for health protection. Over 190 countries and states have agreed to abide by the International Health Regulations (IHR 2005)2. The IHR 2005 came into force on June 15 2007 and constitute a legally binding agreement. They provide a framework for coordinating the management of incidents/ events that may constitute an international public health emergency. The IHR 2005 also provide a framework by which countries can improve their capacity to detect, assess, notify and respond to public health threats such as international travel by land, air or sea.

Further implementation of the IHR 2005 includes completing and assessment of health surveillance and response capacities during 2009-10 and the development and implementation of action plans to assure standards for these core public health functions of surveillance and response by 2012. Work on this is already underway across Scotland and the UK.

It was possible to put in place learning from a similar incident affecting the Port of Leith in 2006.

Control measures included:

  • The cruise liner's routine cleaning schedule was enhanced, in accordance with the ships Outbreak Control Plan and in discussion with the Outbreak Control Team;
  • High risk onboard facilities, such as buffets, swimming pools and jacuzzis, were closed until the cruise was completed;
  • Passengers and crew who became ill whilst onboard were isolated in their cabins until they were symptom free; and
  • 'Deep cleaning' of the liner was arranged on completion of the cruise before the embarkation of new passengers.

The shared expertise enabled timely and effective management of the outbreak. The incident highlighted the necessity of good communication, within the team and with the public on board the ship. The ship operators and crew worked hard to implement the control measures and to manage their passengers effectively. The passengers themselves were exemplary in their understanding of the situation and complied with the restrictions placed on their movements on board the ship.

Key messages

  • A norovirus outbreak on a cruise liner is a threat to the health of the public
  • An outbreak on a cruise liner in October 2008 was managed successfully by an international, multi-agency team that included the Lothian Health Protection Team.
  • There are new International Health Regulations (2005) now in force that will improve and build our capacity to deal with such international threats to public health.
[ Figure 1 ] How to hand wash - step by step

How to hand wash