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Meta-Analysis
. 2024 Mar;29(10):2300345.
doi: 10.2807/1560-7917.ES.2024.29.10.2300345.

Systematic literature review and meta-analysis on preventing and controlling norovirus outbreaks on cruise ships, 1990 to 2020: calling for behaviour change strategies of travellers

Varvara A Mouchtouri  1   2   3 , Evangelia Simou  1 , Soteris Soteriades  1 , Xanthoula Rousou  1 , Katerina Maria Kontouli  1   3 , Dimitra Kafetsouli  1 , Leonidas Kourentis  1   2   3 , Lemonia Anagnostopoulos  1   3 , Christos Hadjichristodoulou  1   2   3
Affiliations
Meta-Analysis

Systematic literature review and meta-analysis on preventing and controlling norovirus outbreaks on cruise ships, 1990 to 2020: calling for behaviour change strategies of travellers

Varvara A Mouchtouri et al. Euro Surveill. 2024 Mar.

Abstract

BackgroundOutbreaks of norovirus gastroenteritis aboard cruise ships may affect a large number of people, debilitate vulnerable travellers, disrupt vacations and cause economic losses to the cruise ship industry.AimWe aimed to identify risk factors for norovirus outbreaks on cruise ships and assess the effectiveness of prevention and control measures.MethodsWe conducted a systematic literature review searching PubMed and Scopus databases as well as grey literature for articles and reports describing norovirus outbreaks on cruise ships between 1990 and 2020. We also performed a meta-analysis of norovirus prevalence in passengers and crew members.ResultsData from 45 outbreaks on 26 cruise ships from 1990 to 2020 were identified in 13 articles and five reports, with a weighted average of prevalence (attack rate) for passengers of 7% (95% confidence interval (CI): 5.00-9.00) and for crew of 2% (95% CI: 0.00-3.00). Person-to-person was the most frequent mode of transmission in 35 of the 45 outbreaks (in 14 the only mode and in 21 as part of multiple transmission routes). Having an ill cabin mate (OR = 38.70; 95% CI: 13.51-110.86) was the most common risk factor. Six outbreak investigations reported poor hygiene, while four reported satisfactory hygiene in the cruise setting. Behavioural risk factors among travellers were investigated in three of the 13 studies.ConclusionsThe findings indicate a need for behavioural interventions to improve personal hygiene, symptom reporting and compliance with isolation measures, and for reconsidering current isolation policies where symptomatic and healthy individuals are isolated in the same cabin.

Keywords: Norovirus; cruise; gastroenteritis; infectious disease; isolation; maritime; prevention; ship; travel.

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Conflict of interest statement

Conflict of interest: None declared.

Figures

Figure 1
Figure 1
PRISMA flow diagram of the study selection process based on inclusion and exclusion criteria, systematic review on preventing and controlling norovirus outbreaks on cruise ships, 1990–2020 (n = 181)
Figure 2
Figure 2
Forest plot of passenger attack rates with 95% confidence intervals, norovirus outbreaks on cruise ships, 1990–2020 (n = 42)
Figure 3
Figure 3
Funnel plot of passenger attack rates, norovirus outbreaks on cruise ships, 1990–2020 (n = 42)
See this image and copyright information in PMC

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