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Gastrointestinal tract

Your digestive tract stretches from your mouth to your anus. It includes the organs necessary to digest food, absorb nutrients and process waste.

Traveler's diarrhea is a digestive tract disorder that commonly causes loose stools and stomach cramps. It's caused by eating contaminated food or drinking contaminated water. Fortunately, traveler's diarrhea usually isn't serious in most people — it's just unpleasant.

When you visit a place where the climate or sanitary practices are different from yours at home, you have an increased risk of developing traveler's diarrhea.

To reduce your risk of traveler's diarrhea, be careful about what you eat and drink while traveling. If you do develop traveler's diarrhea, chances are it will go away without treatment. However, it's a good idea to have doctor-approved medicines with you when you travel to high-risk areas. This way, you'll be prepared in case diarrhea gets severe or won't go away.

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Traveler's diarrhea may begin suddenly during your trip or shortly after you return home. Most people improve within 1 to 2 days without treatment and recover completely within a week. However, you can have multiple episodes of traveler's diarrhea during one trip.

The most common symptoms of traveler's diarrhea are:

• Suddenly passing three or more looser watery stools a day.
• An urgent need to pass stool.
• Stomach cramps.

Sometimes, people experience moderate to severe dehydration, ongoing vomiting, a high fever, bloody stools, or severe pain in the belly or rectum. If you or your child experiences any of these symptoms or if the diarrhea lasts longer than a few days, it's time to see a health care professional.

When to see a doctor

Traveler's diarrhea usually goes away on its own within several days. Symptoms may last longer and be more severe if it's caused by certain bacteria or parasites. In such cases, you may need prescription medicines to help you get better.

If you're an adult, see your doctor if:

• Your diarrhea lasts beyond two days.
• You become dehydrated.
• You have severe stomach or rectal pain.
• You have bloody or black stools.
• You have a fever above 102 F (39 C).

While traveling internationally, a local embassy or consulate may be able to help you find a well-regarded medical professional who speaks your language.

Be especially cautious with children because traveler's diarrhea can cause severe dehydration in a short time. Call a doctor if your child is sick and has any of the following symptoms:

• Ongoing vomiting.
• A fever of 102 F (39 C) or more.
• Bloody stools or severe diarrhea.
• Dry mouth or crying without tears.
• Signs of being unusually sleepy, drowsy or unresponsive.
• Decreased volume of urine, including fewer wet diapers in infants.

It's possible that traveler's diarrhea may stem from the stress of traveling or a change in diet. But usually infectious agents — such as bacteria, viruses or parasites — are to blame. You typically develop traveler's diarrhea after ingesting food or water contaminated with organisms from feces.

So why aren't natives of high-risk countries affected in the same way? Often their bodies have become used to the bacteria and have developed immunity to them.

Risk factors

Each year millions of international travelers experience traveler's diarrhea. High-risk destinations for traveler's diarrhea include areas of:

• Central America.
• South America.
• South Asia and Southeast Asia.

Traveling to Eastern Europe, South Africa, Central and East Asia, the Middle East, and a few Caribbean islands also poses some risk. However, your risk of traveler's diarrhea is generally low in Northern and Western Europe, Japan, Canada, Singapore, Australia, New Zealand, and the United States.

Your chances of getting traveler's diarrhea are mostly determined by your destination. But certain groups of people have a greater risk of developing the condition. These include:

• Young adults. The condition is slightly more common in young adult tourists. Though the reasons why aren't clear, it's possible that young adults lack acquired immunity. They may also be more adventurous than older people in their travels and dietary choices, or they may be less careful about avoiding contaminated foods.
• People with weakened immune systems. A weakened immune system due to an underlying illness or immune-suppressing medicines such as corticosteroids increases risk of infections.
• People with diabetes, inflammatory bowel disease, or severe kidney, liver or heart disease. These conditions can leave you more prone to infection or increase your risk of a more-severe infection.
• People who take acid blockers or antacids. Acid in the stomach tends to destroy organisms, so a reduction in stomach acid may leave more opportunity for bacterial survival.
• People who travel during certain seasons. The risk of traveler's diarrhea varies by season in certain parts of the world. For example, risk is highest in South Asia during the hot months just before the monsoons.

Complications

Because you lose vital fluids, salts and minerals during a bout with traveler's diarrhea, you may become dehydrated, especially during the summer months. Dehydration is especially dangerous for children, older adults and people with weakened immune systems.

Dehydration caused by diarrhea can cause serious complications, including organ damage, shock or coma. Symptoms of dehydration include a very dry mouth, intense thirst, little or no urination, dizziness, or extreme weakness.

Watch what you eat

The general rule of thumb when traveling to another country is this: Boil it, cook it, peel it or forget it. But it's still possible to get sick even if you follow these rules.

Other tips that may help decrease your risk of getting sick include:

• Don't consume food from street vendors.
• Don't consume unpasteurized milk and dairy products, including ice cream.
• Don't eat raw or undercooked meat, fish and shellfish.
• Don't eat moist food at room temperature, such as sauces and buffet offerings.
• Eat foods that are well cooked and served hot.
• Stick to fruits and vegetables that you can peel yourself, such as bananas, oranges and avocados. Stay away from salads and from fruits you can't peel, such as grapes and berries.
• Be aware that alcohol in a drink won't keep you safe from contaminated water or ice.

Don't drink the water

When visiting high-risk areas, keep the following tips in mind:

• Don't drink unsterilized water — from tap, well or stream. If you need to consume local water, boil it for three minutes. Let the water cool naturally and store it in a clean covered container.
• Don't use locally made ice cubes or drink mixed fruit juices made with tap water.
• Beware of sliced fruit that may have been washed in contaminated water.
• Use bottled or boiled water to mix baby formula.
• Order hot beverages, such as coffee or tea, and make sure they're steaming hot.
• Feel free to drink canned or bottled drinks in their original containers — including water, carbonated beverages, beer or wine — as long as you break the seals on the containers yourself. Wipe off any can or bottle before drinking or pouring.
• Use bottled water to brush your teeth.
• Don't swim in water that may be contaminated.
• Keep your mouth closed while showering.

If it's not possible to buy bottled water or boil your water, bring some means to purify water. Consider a water-filter pump with a microstrainer filter that can filter out small microorganisms.

You also can chemically disinfect water with iodine or chlorine. Iodine tends to be more effective, but is best reserved for short trips, as too much iodine can be harmful to your system. You can purchase water-disinfecting tablets containing chlorine, iodine tablets or crystals, or other disinfecting agents at camping stores and pharmacies. Be sure to follow the directions on the package.

Follow additional tips

Here are other ways to reduce your risk of traveler's diarrhea:

• Make sure dishes and utensils are clean and dry before using them.
• Wash your hands often and always before eating. If washing isn't possible, use an alcohol-based hand sanitizer with at least 60% alcohol to clean your hands before eating.
• Seek out food items that require little handling in preparation.
• Keep children from putting things — including their dirty hands — in their mouths. If possible, keep infants from crawling on dirty floors.
• Tie a colored ribbon around the bathroom faucet to remind you not to drink — or brush your teeth with — tap water.

Other preventive measures

Public health experts generally don't recommend taking antibiotics to prevent traveler's diarrhea, because doing so can contribute to the development of antibiotic-resistant bacteria.

Antibiotics provide no protection against viruses and parasites, but they can give travelers a false sense of security about the risks of consuming local foods and beverages. They also can cause unpleasant side effects, such as skin rashes, skin reactions to the sun and vaginal yeast infections.

As a preventive measure, some doctors suggest taking bismuth subsalicylate, which has been shown to decrease the likelihood of diarrhea. However, don't take this medicine for longer than three weeks, and don't take it at all if you're pregnant or allergic to aspirin. Talk to your doctor before taking bismuth subsalicylate if you're taking certain medicines, such as anticoagulants.

Common harmless side effects of bismuth subsalicylate include a black-colored tongue and dark stools. In some cases, it can cause constipation, nausea and, rarely, ringing in your ears, called tinnitus.

• Feldman M, et al., eds. Infectious enteritis and proctocolitis. In: Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, Management. 11th ed. Elsevier; 2021. https://www.clinicalkey.com. Accessed May 25, 2021.
• LaRocque R, et al. Travelers' diarrhea: Microbiology, epidemiology, and prevention. https://www.uptodate.com/contents/search. Accessed May 26, 2021.
• Ferri FF. Traveler diarrhea. In: Ferri's Clinical Advisor 2023. Elsevier; 2023. https://www.clinicalkey.com. Accessed April 28, 2023.
• Diarrhea. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/digestive-diseases/diarrhea. Accessed April 27, 2023.
• Travelers' diarrhea. Centers for Disease Control and Prevention. https://wwwnc.cdc.gov/travel/yellowbook/2020/preparing-international-travelers/travelers-diarrhea. Accessed April 28, 2023.
• LaRocque R, et al. Travelers' diarrhea: Clinical manifestations, diagnosis, and treatment. https://www.uptodate.com/contents/search. Accessed May 26, 2021.
• Khanna S (expert opinion). Mayo Clinic. May 29, 2021.
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What Is Travelers' Diarrhea?

A bout of diarrhea after traveling can increase the risk of dehydration and other complications.

Kasandra Brabaw is a writer who focuses on health, sex/relationships, and stories for and about her communities including the LGBTQ+ and fat communities. Other than at Health, her work can be found at SELF, Women’s Health, VICE, and Refinery29.

• Travelers' Diarrhea Symptoms
• What Causes Travelers' Diarrhea?
• Is Travelers' Diarrhea Contagious?
• How Is Travelers' Diarrhea Diagnosed?
• Treatments for Travelers' Diarrhea
• How To Prevent Travelers' Diarrhea

Complications

• Coping With Travelers' Diarrhea

A Quick Review

Vacation is supposed to be a time of rest, but a case of travelers'  diarrhea  can make your trip a nightmare.

Travelers' diarrhea causes loose, watery stools, usually brought about by bacteria, viruses, or fungi. Generally, mild cases of travelers' diarrhea resolve with hydration, rest, and a bland diet. Still, travelers' diarrhea may lead to complications, such as dehydration and malabsorption.

Travelers' diarrhea is one of the most common travel-related illnesses, affecting anywhere from 30% to 70% of travelers. Though travelers' diarrhea can occur anywhere in the world, it is more common when traveling to parts of Asia, the Middle East, Africa, Mexico, and Central and South America.

Here, gastroenterologists explain what causes travelers' diarrhea, the symptoms, and how best to treat it so you can enjoy your vacation as much as possible.

Travelers' Diarrhea Symptoms

Travelers' diarrhea is a form of acute diarrhea that comes on while traveling. Acute diarrhea is sudden loose and watery stools . 

There are different levels of travelers' diarrhea (i.e., mild, acute, and severe). At varying severities, those levels can include symptoms like:

• Mild cramps
• Urgent loose stools
• Severe abdominal pain
• Bloody diarrhea

Symptoms can occur within a few hours to as long as a few weeks depending on the cause of the travelers' diarrhea. Bacterial travelers' diarrhea can last up to seven days. In contrast, viral travelers' diarrhea lasts about three days.

What Causes Travelers' Diarrhea?

Travelers' diarrhea spreads through fecal matter through contaminated food and water. Bacteria, viruses, and parasites cause travelers' diarrhea.

Bacteria account for about 80% to 90% of cases, while viruses make up about 5% to 15%. Less commonly, parasites, also known as protozoal pathogens, can cause travelers' diarrhea. Usually, those parasites are slower to manifest than bacteria and viruses.

Depending on the culprit, travelers' diarrhea may occur through non-inflammatory or inflammatory pathways. Non-inflammatory pathways reduce the ability of your intestines to absorb nutrients. As a result, your waste products increase. In contrast, inflammatory pathways damage your intestines, which increases bowel movements.

Risk Factors

Travelers' diarrhea is more likely to occur if you travel outside the country to a place with poor sanitation . A lack of clean water makes practicing proper hygiene and food preparation hard.

Other risk factors for travelers' diarrhea include:

• Warm climates
• A lack of refrigeration
• Inadequate food storage practices
• Proton pump inhibitor (PPI) and antibiotic use
• Unprotected sex
• Age (i.e., older adults and young children)
• Health conditions affecting the gastrointestinal (GI) system
• Weak immune system

Is Travelers' Diarrhea Contagious?

Depending on the culprit, travelers' diarrhea can be contagious . For example, cruise ships are a common culprit of travelers' diarrhea. 

"Cruise ships are known for two viruses specifically that spread like wildfire," Rabia De Latour, MD , a gastroenterologist and assistant professor in the department of medicine at the NYU Grossman School of Medicine, told  Health . 

Norovirus is a highly contagious virus that causes diarrhea and vomiting. Cruise ships help the virus spread because so many people stay in such proximity, and many people are not great at washing their hands before touching their faces or eating, noted Dr. De Latour.

In contrast, some cases of travelers' diarrhea are not spread between people. For instance, you may develop acute diarrhea because you are not used to the food or water in the place you are traveling.

"There may be different probiotic bacteria that live on lettuce or other foods there that you're just not accustomed to," explained Dr. De Latour. In that case, the diarrhea is about the change in environment, not an infection, and should clear up in a couple of days, added Dr. De Latour.

Traveling can be stressful, especially traveling internationally. For example, your body might respond with loose, watery stool if you are stressed and physically tired after a 12-hour flight. Diarrhea caused by stress isn't infectious and will get better quickly.

How Is Travelers' Diarrhea Diagnosed?

Healthcare providers can diagnose traveler's diarrhea by asking about your symptoms, recent travels outside the country, and what you ate. For example, having acute diarrhea three or more times within 24 hours or double the amount of regular bowel movements may signal travelers' diarrhea. 

A healthcare provider can palpate the stomach to check whether your abdomen is tender. Abdominal cramps, nausea , vomiting, and fever often accompany acute diarrhea.

Healthcare providers do not usually require laboratory tests or imaging to diagnose travelers' diarrhea. In contrast, a healthcare provider may acquire a stool sample if you have blood in your stool or feel like you need to pass stool even if your bowels are empty. 

In severe cases, a healthcare provider may send for X-rays of the kidneys, ureters, and bladder and an abdominal CT scan.  

Treatments for Travelers' Diarrhea

Treatment for travelers' diarrhea depends on the severity of the case and may include the following:

• Fluid replenishment:  To avoid dehydration , increasing your water intake is essential. Sports drinks and electrolyte mixes can help, too. In contrast, milk and fruit juices can worsen diarrhea, increasing the risk of dehydration. You may require oral rehydration salt or intravenous (IV) fluids to replenish fluids for severe cases. 
• Anti-diarrheal medicines:  A healthcare provider may advise taking an anti-diarrheal like loperamide for mild cases. 
• Antibiotics:  In some cases, a healthcare provider may prescribe a round of antibiotics. Common antibiotics for travelers' diarrhea include ciprofloxacin, azithromycin, and rifaximin. The type of antibiotic may depend on your symptoms and where you are traveling. 

Mainly, mild to moderate cases of travelers' diarrhea involve supportive therapy. For many people with travelers' diarrhea, the illness simply runs its course. 

Try the following to make yourself as comfortable as possible:

• Hydrate to prevent dehydration .
• Get lots of rest.
• Eat small, gentle meals on your stomach , such as salty (e.g., pretzels, crackers, soup, sports drinks) and high-potassium (e.g., bananas, potatoes without the skin, fruit juices) foods.

How To Prevent Travelers' Diarrhea

Preventing travelers' diarrhea can be tricky, especially when traveling abroad. On a cruise ship , one of the best ways to avoid travelers' diarrhea is to watch where you put your hands, wash your hands frequently, and avoid touching your face, advised Dr. De Latour. Steer clear of buffet lines, where someone carrying norovirus could touch the food or serving utensils.

When traveling to underdeveloped countries, be careful what you eat and drink to prevent traveler's diarrhea. In the United States, many people are used to eating pasteurized foods partially sterilized through heat or irradiation. Sometimes, that is different in other countries.

"[G]etting that exposure to a digestive system that has never had an unpasteurized product, we would be very vulnerable," Christine Lee, MD , a gastroenterologist at the Cleveland Clinic, told Health . When traveling, be extra careful to check if something is pasteurized before you eat or drink it. You will want to avoid undercooked meats and seafood, too. 

"If you're traveling to an underdeveloped country, that might not be where you want to eat a rare steak," said Dr. Lee. The same goes for sushi made with raw fish or dishes like ceviche or tartare made with raw seafood and meat. Instead, cooked foods are your safest option while traveling anywhere you are unsure how safe the water is.

Fruit and vegetables are risky since they could have been washed in contaminated water. In that case, the fruit you can peel (e.g., bananas or oranges) may be the safest option.  

Finally, paying attention to what you drink is also vital in preventing travelers' diarrhea. Alcohol is considered safe because it can kill bacteria. Likewise, bottled drinks are safe if they have an unbroken seal. Boiled water is your next safest bet if those options are not available. 

Remember that contaminating water can get into your mouth in other ways, like showering and swimming . Try not to swallow during those times, brush your teeth with bottled water, and avoid ice in drinks, advised Dr. Lee.

Finally, a healthcare provider may advise taking precautions if traveling outside the country. For example, you might take two tabs of bismuth subsalicylate four times daily to decrease the risk of travelers' diarrhea. Usually, healthcare providers do not advise bismuth subsalicylate for pregnant people and children. 

A healthcare provider may recommend a round of antibiotics to prevent travelers' diarrhea if you are traveling to a high-risk area for a short period.

Most people with travelers' diarrhea make full recoveries. In rare, severe cases, complications can occur. For example, dehydration is one of the most common complications of travelers' diarrhea. Dehydration happens if you lose too many fluids through acute diarrhea, requiring immediate medical attention.

Other complications of travelers' diarrhea may include:

• Malabsorption:  This happens if the small intestine cannot absorb enough nutrients.
• Sepsis:  This is an infection that develops secondary to an existing one. Sepsis causes inflammation, which leads to organ damage and failure and, in some cases, death. 
• Hemolytic uremic syndrome:  This occurs if an infection damages the blood vessels in your kidneys.
• Reactive arthritides:  Some infections may cause painful and swollen joints.

Typically, those complications are more common in older adults and children younger than 4 than others.

Coping With Travelers' Diarrhea

To manage travelers' diarrhea, follow a healthcare provider's advice and treatment plan . Other steps to keep comfortable while your symptoms resolve include staying hydrated and practicing proper hygiene, such as handwashing. 

Mostly, people with travelers' diarrhea only require emergency medical attention if they are dehydrated. Consult a healthcare provider if your symptoms do not subside after 10 days.

Travelers' diarrhea causes acute diarrhea that comes on while traveling . You can avoid travelers' diarrhea as much as possible by watching what you eat and drink while traveling outside the country. To treat mild cases, staying hydrated is essential. 

Although you are at risk for diarrhea when traveling, it should not be scary. South America, Central America, Mexico, Africa, the Middle East, and Asia offer unique, enriching experiences worth the risk.

Connor BA. Travelers' diarrhea . In:  Travelers' Health . Centers for Disease Control and Prevention; 2020.

Dunn N, Okafor CN. Travelers diarrhea . In:  StatPearls . StatPearls Publishing; 2023.

MedlinePlus. Traveler's diarrhea diet .

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Norovirus Cases Are Rising on Cruises. Here’s How You Can Stay Safe

Keep hands clean as stomach bug cases rise.

Larry Bleiberg,

Just as travel has begun to bounce back after the pandemic, cruise ship passengers are facing another threat to their vacation: norovirus .

Thirteen ships so far this year have reported outbreaks of the highly contagious stomach bug, the most since 2012, according to the  U.S. Centers for Disease Control and Prevention (CDC) . Nearly 1,700 passengers have come down with the virus, which causes vomiting, nausea, diarrhea and stomach pain. Not only does it take the joy out of vacation, keeping passengers confined to their stateroom, but for older travelers, there’s a concern of dehydration, doctors say.

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The  bug thrives in crowded conditions  and is spread through food and by touching contaminated surfaces. The easiest way to avoid the ailment is to wash your hands with soap and water after using the bathroom, before eating and after touching surfaces touched by others.

Samuel Mathis, M.D., an assistant professor in the University of Texas Medical Branch Department of Family Medicine, says the resilient virus can live for days and there are plenty of places for it to linger on cruise ships: “Door handles, stairway banisters, tongs for food at the buffet, things that a lot of people touch that aren’t cleaned between each use.”

And washing your own hands isn’t enough. Mathis says older passengers and others traveling with family face a risk from others in their party. For example, if grandchildren aren’t careful hand-washers, they can easily infect their grandparents and others.

Mathis, who works in Galveston, Texas, a cruise port, has seen passengers with norovirus. He says that while the virus itself is uncomfortable, it isn’t typically dangerous. “The biggest risk for almost everyone — but especially for seniors — is actually the risk of dehydration: losing all that fluid through nausea, vomiting and diarrhea.”

Symptoms of dehydration  include extreme thirst, lack of urination and dizziness when standing, Mathis says.

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If passengers come down with a stomach bug, they should contact the ship’s medical clinic, which will monitor for dehydration. In addition, they should stay in their cabin away from people until they are symptom-free for at least 24 hours, Mathis says. “That can be really rough because you’re missing your cruise.”

The most recent norovirus outbreak was reported on the  Viking Neptune  cruise ship. During its June 6 to June 20 voyage, 110 of the ship’s 838 passengers, or 13.1 percent, were infected. In addition, nine of the 455 crew members were infected.

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“We believe the gastrointestinal illness originated from a shoreside restaurant in Iceland where a group of guests dined during their free time,” the cruise line said in a statement. After docking in New York, the ship was thoroughly cleaned and disinfected, and continued its scheduled sailings.

The CDC regularly inspects cruise ships and monitors the number of outbreaks. This year, norovirus also has been reported on cruises operated by Royal Caribbean International, Celebrity Cruises, Princess Cruises, Holland America and P&O Cruises. The worst year for norovirus was 2006, when 32 ships reported infections, according to the CDC.

Cruise experts say several factors may be contributing to the rise in cases. For one, cruising has soared this year, with the number of passengers expected to surpass the total that sailed in 2019, according to the Cruise Lines International Association.

Letting down their guard

Ashley Kosciolek, senior cruise writer at The Points Guy, a consumer travel website, says that after years of COVID-related precautions, passengers may have let their guard down. 

“People are just so happy to be back, but they’ve gotten a little lax with hygiene. I personally have seen lots of people using the women’s room and not washing their hands. I don’t know if it’s subconscious rebellion or if they don’t realize what could happen.”

Kosciolek says she has made it a practice to wash her hands before going to the buffet, and then washing them again before she eats, since buffet implements aren’t sanitized after each passenger touches them.

Mathis says it might even make sense for passengers to avoid the buffet and dine only at their ship’s sit-down restaurants.

That said, the chances of catching the bug on a cruise ship aren’t particularly high. According to the  Cruise Lines Industry Association , the risk each year of getting laboratory-confirmed norovirus during a ship outbreak is about 1 in 5,500. The most common settings for norovirus aren’t even at sea. Over half of all cases originate in long-term health care facilities, according to the CDC, while less than 1 percent of all norovirus cases come from cruise ships.

Kosciolek notes that while cruise ships are required to report outbreaks, many land-based cases go unreported. “It is easy for someone who has never cruised to see these news reports and say, ‘Oh my goodness, I’m never going to cruise because I’m going to get sick.’ ”

Likewise, Mathis says vacationers shouldn’t let the fear of norovirus keep them from taking a vacation.

“I do not suggest that people don’t go on cruises. When proper safety precautions are taken, cruises are fantastic opportunities for individuals to relax, to spend time with friends or family and meet new people. It really just comes down to recognizing there are risks.”

Virginia native Larry Bleiberg is president of the Society of American Travel Writers, a frequent contributor to  BBC Travel  and the creator of  CivilRightsTravel.com .​​

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Cruises are back — and so are stomach viruses, diarrhea, and vomiting onboard

• 11 sick bug outbreaks have been reported on cruises so far this year. 
• That's the same as the number reported in the whole of 2018. 
• The cruise industry is back in full swing after shutting down during the COVID pandemic.

Cruises are back up to pre-pandemic levels — and so are onboard stomach bug outbreaks . 

Holland America's the Nieuw Amsterdam, which set sail on May 6, is among a string of 11 cruise ships to report gastrointestinal illness onboard this year, according to the Centers for Disease Control and Prevention . 213, or over 10%, of passengers and 35, or 4%, of crew on the Nieuw Amsterdam have been reported sick during the voyage that lasts until May 21, mostly with diarrhea and vomiting.

The same number of sick bug outbreaks on cruise ships have been reported so far this year than in the entirety of both 2017 and 2018, when there were 11 in total. 10 outbreaks were reported in 2019 and 13 in 2016.

Related stories

Of the 11 outbreaks this year, four were caused by highly contagious  norovirus . Holland America told Insider in a statement that it suspects that's the cause of its outbreak, too.

"The cases have been mostly mild and quickly resolving," the statement read.

Like other affected cruise ships, Holland America told the CDC it has increased cleaning and disinfection procedures to deal with the outbreak and has sent stool samples to a lab to determine the cause.

The cruise industry shut down during the pandemic , and as such there were no outbreaks of gastrointestinal illness reported in 2020, and one in 2021 as trips started up again.

In 2022 there were still only four outbreaks, which the CDC told The Washington Post was likely due to fewer passengers on ships during that time, as well as an increase in cleaning, disinfection, and the number of hand sanitizer stations, along with crew-served buffets, and physical distancing — all as a result of the pandemic.

In a statement to The Washington Post, the Cruise Lines International Association said that gastrointestinal illness outbreaks on cruise ships are "quite rare" compared to those on land.

It added that alongside the crew, passengers should be doing all they can to keep themselves, their families, and fellow travelers healthy.

To stay healthy while cruising, the CDC recommends : washing your hands often to prevent the spread of germs, getting plenty of rest, drinking enough water. If you see someone who is sick with vomiting or diarrhea, leave the area and report it to staff.

Insider has contacted the CDC for comment.

• Main content

Traveler's diarrhea at sea: three outbreaks of waterborne enterotoxigenic Escherichia coli on cruise ships

Affiliation.

• 1 Foodborne and Diarrheal Diseases Branch, Division of Bacterial and Mycotic Diseases, Atlanta, GA 30333, USA.
• PMID: 10762583
• DOI: 10.1086/315397

Enterotoxigenic Escherichia coli (ETEC) has become the leading bacterial cause of gastroenteritis outbreaks on cruise ships. Investigation of recent outbreaks of ETEC gastroenteritis on 3 cruise ships indicated that all were associated with consuming beverages with ice cubes on board the ship (relative risk [RR], 1.4, 95% confidence interval [CI], 1.0-1.9, P=.02; RR, 1.9, 95% CI, 1.3-2. 9, P<.001; and RR, 1.3, 95% CI, 1.0-1.6, P<.01), and 2 were associated with drinking unbottled water (RR, 2.7, 95% CI, 1.8-4.1, P<.001; RR, 1.7, 95% CI, 1.3-2.3, P<.001). Multiple ETEC serotypes were detected in patients' stool specimens in each of the 3 outbreaks, and 12 (38%) of 32 isolates were resistant to > or =3 antimicrobial agents. ETEC appears to be emerging as a waterborne pathogen on cruise ships. Water bunkered in overseas ports was the likely source of ETEC infection in these outbreaks. To ensure passenger safety, cruise ships that take on water in foreign ports must ensure that water treatment and monitoring systems function properly.

Publication types

• Research Support, Non-U.S. Gov't
• Research Support, U.S. Gov't, Non-P.H.S.
• Bacterial Toxins
• Diarrhea / epidemiology*
• Diarrhea / etiology
• Disease Outbreaks*
• Enterotoxins
• Escherichia coli / classification
• Escherichia coli Infections / epidemiology*
• Escherichia coli Infections / etiology
• Escherichia coli Infections / transmission
• Feces / chemistry
• Feces / microbiology
• Food Handling
• Food Preservation
• Surveys and Questionnaires
• Water Microbiology
• Water Supply

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Cruise Ship Travel

CDC Respiratory Virus Guidance has been updated. The content of this page will be updated soon.

While cruising is a popular way to travel, there are some health concerns to be aware of. Find out more about health issues on cruises and steps you can take to stay safe and healthy during your trip.

If you are feeling sick before your voyage, do not travel and ask your cruise line about rescheduling or reimbursement options. If you feel sick during your voyage, report your symptoms to the ship’s medical center and follow their recommendations.

Common Health Concerns During Cruise Travel and what You Can Do to Prevent Illness

• Respiratory illnesses like influenza , COVID-19 , and the common cold. Get your annual flu shot and get up to date on your COVID-19 vaccines . Check directly with your cruise line about their COVID-19 testing or vaccination protocols before travel. If you have a weakened immune system , talk with your healthcare provider about your cruise travel plans. Wash your hands frequently or use hand sanitizer . When you cough or sneeze, cover your nose and mouth with a tissue to prevent spreading germs. Consider wearing a mask in crowded or poorly ventilated indoor areas.
• Norovirus. Symptoms of vomiting and diarrhea, primarily caused by outbreaks of norovirus, have been reported. To prevent norovirus , wash your hands with soap and water before eating and after using the bathroom, changing diapers, or touching things that other people have touched, such as stair railings. Avoid touching your face. For more information, visit CDC’s  Vessel Sanitation Program  website.
• Seasickness. Cruise ship passengers may experience seasickness or motion sickness. If you know you get seasick or think you may be likely to get seasick, talk to your healthcare provider about medicine to reduce your symptoms. Some common medications, including some antidepressants, painkillers, and birth control pills, can make seasickness worse.
• Sunburns. Apply sunscreen with SPF 15 or higher when traveling. Protecting yourself from the sun isn’t just for tropical beaches—you can get a sunburn even if it’s cloudy or cold.
• Bug bites. On your trip, use insect repellent and take other steps to avoid bug bites. Bugs, including mosquitoes and ticks, can spread diseases such as malaria, yellow fever, Zika, dengue, chikungunya, and Lyme. Many ships visit ports where these diseases are a concern.

Before Your Trip

Check CDC’s destination pages for travel health information . Check CDC’s webpage for your destination to see what vaccines or medicines you may need and what diseases or health risks are a concern at your destination.

Make sure you are up to date with all of your routine vaccines . Routine vaccinations protect you from infectious diseases  that can spread quickly in groups of people. Outbreaks of chickenpox, influenza, and COVID-19 have been reported on cruise ships.

Many diseases prevented by routine vaccination are not common in the United States but are still common in other countries. Crew members and fellow travelers often board a cruise ship from destinations where some diseases are more common than in the United States or where vaccination is not routine.

Make an appointment with your healthcare provider or a travel health specialist  that takes place at least one month before you leave. They can help you get destination-specific vaccines, medicines, and information. Discussing your health concerns, itinerary, and planned activities with your provider allows them to give more specific advice and recommendations.

Plan for the Unexpected

Prepare for any unexpected issues during your cruise ship travels with the following steps:

Prepare a  travel health kit  with items you may need, especially those items that may be difficult to find at your destination. Include your prescriptions and over-the-counter medicines in your travel health kit and take enough to last your entire trip, plus extra in case of travel delays. Depending on your destination you may also want to pack a mask ,  insect repellent , sunscreen (SPF15 or higher), aloe, alcohol-based hand sanitizer, water disinfection tablets, and your health insurance card.

Get travel insurance.  Find out if your health insurance covers medical care abroad. Travelers are usually responsible for paying hospital and other medical expenses out of pocket at most destinations. Make sure you have a plan to  get care overseas , in case you need it. Consider buying  additional insurance  that covers health care and emergency evacuation, especially if you will be traveling to remote areas.

If you need medical care abroad, see Getting Health Care During Travel .

After Travel

If you traveled and feel sick, particularly if you have a fever, talk to a healthcare provider and tell them about your travel. Avoid contact with other people while you are sick.

More Information

• Cruise Ship Travel in CDC Yellow Book
• Information for Cruise Ship Travelers
• Maritime Guidance

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Nearly 200 people sick in norovirus outbreaks on Princess, Royal Caribbean ships

Nearly 200 people got sick in norovirus outbreaks on Princess Cruises and Royal Caribbean International ships.

The Centers for Disease Control and Prevention said 94 of the 2,532 guests on Sapphire Princess reported being ill during its April 5 cruise, along with 20 crew members. The round-trip cruise, which left from Los Angeles with stops in Hawaii and the South Pacific, will end on May 7, according to CruiseMapper .

On Royal Caribbean’s Radiance of the Seas, 67 of its 1,993 guests reported being ill in addition to two crew members during a cruise that ended April 22, according to the CDC . The two-week voyage sailed from Tampa, Florida to Los Angeles with stops in countries like Colombia and Panama, according to CruiseMapper .

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In both outbreaks, the guests and crew members’ main symptoms were diarrhea and vomiting.

Princess, Royal Caribbean and the ships’ crews implemented heightened cleaning and disinfection measures and isolated those who were sick, among other steps, the health agency said.

"At the first sign of an increase in the numbers of passengers reporting to the medical center with gastrointestinal illness, we immediately initiated additional enhanced sanitation procedures to interrupt the person-to-person spread of this virus," a Princess spokesperson told USA TODAY in an emailed statement. "Our sanitation program, developed in coordination with the CDC, includes disinfection measures, isolation of ill passengers and communication to passengers about steps they can take to stay well while onboard."

Royal Caribbean did not immediately respond to a request for comment.

The CDC has logged six outbreaks of gastrointestinal illness on cruise ships that met its threshold for public notification since the beginning of the year. Norovirus was listed as the causative agent in five, while one was unknown.

The illness is often associated with cruise ships but outbreaks occur in communities on land as well, according to Dr. Sarah E. Hochman, a hospital epidemiologist and the section chief of infectious diseases at NYU Langone Health’s Tisch Hospital.

“There's not something special or unique about cruise ships,” she said. “It's really any type of congregate setting, but it's also happening out in the community on a much smaller scale among households and household contacts. It just doesn't come to the attention of public health as much as it does for larger congregate settings.”

Hochman said the virus is “incredibly infectious” and congregate settings tend to have many shared surfaces, such as handrails in cruise ship stairwells or elevators. “And so, if you just have one person who's shedding the virus and touches the surface and then someone else touches it and then touches their mouth, that's how it can spread in those types of settings.”

Cruise ship medical facilities: What happens if you get sick or injured (or bitten by a monkey)

Alcohol-based hand sanitizer isn't as effective against norovirus, and Hochman emphasized that washing hands with soap and water “will do a lot to prevent the spread.”

The news comes after more than two dozen Silversea Cruises guests got sick in a gastrointestinal illness outbreak on the luxury line’s Silver Nova ship during a sailing that began in late March.

Nathan Diller is a consumer travel reporter for USA TODAY based in Nashville. You can reach him at [email protected].

This article originally appeared on USA TODAY: Nearly 200 people sick in norovirus outbreaks on Princess, Royal Caribbean ships

Investigation Update on the Radiance of the Seas

Cruise Line : Royal Caribbean International

Cruise Ship : Radiance of the Seas

Voyage Dates : April 8–April 22, 2024

Voyage number: 20095

Number of passengers who reported being ill during the voyage out of total number of passengers onboard : 67 of 1,993 (3.36%)

Number of crew who reported being ill during the voyage out of total number of crew onboard : 2 of 924 (0.22%)

Predominant symptom : diarrhea and vomiting

Causative agent : norovirus

Actions : In response to the outbreak, Royal Caribbean Cruises and the crew aboard the ship reported the following actions:

• Collected stool specimens from gastrointestinal illness cases for testing.
• Isolated ill passengers and crew.
• Increased cleaning and disinfection procedures according to the ship’s outbreak prevention and response plan.

VSP conducted an environmental assessment and outbreak investigation to assist the ship in controlling the outbreak.

Note : The gastrointestinal illness cases reported are totals for the entire voyage and do not represent the number of active (symptomatic) gastrointestinal cases at any given port of call or at disembarkation.

Learn how passengers can protect themselves with these  tips for healthy cruising .

• Inspection Reports
• About Inspections
• Cruise Ship Outbreak Updates
• About Noroviruses on Cruise Ships
• VSP Operations Manual   [PDF – 5 MB]
• VSP Construction Guidelines   [PDF – 4 MB]
• Illness Prevention Information
• Publications

Exit Notification / Disclaimer Policy

• The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website.
• Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website.
• You will be subject to the destination website's privacy policy when you follow the link.
• CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website.