title: A review of outbreaks of foodborne disease associated with passenger ships: evidence for risk management.
abstract: OBJECTIVE
  Foodborne disease outbreaks on ships are of concern because of their potentially serious health consequences for passengers and crew and high costs to the industry. The authors conducted a review of outbreaks of foodborne diseases associated with passenger ships in the framework of a World Health Organization project on setting guidelines for ship sanitation.
  
  
  METHODS
  The authors reviewed data on 50 outbreaks of foodborne disease associated with passenger ships. For each outbreak, data on pathogens/toxins, type of ship, factors contributing to outbreaks, mortality and morbidity, and food vehicles were collected.
  
  
  RESULTS
  The findings of this review show that the majority of reported outbreaks were associated with cruise ships and that almost 10,000 people were affected. Salmonella spp were most frequently associated with outbreaks. Foodborne outbreaks due to enterotoxigenic E. coli spp, Shigella spp, noroviruses (formally called Norwalk-like viruses), Vibrio spp, Staphylococcus aureus, Clostridium perfringens, Cyclospora sp, and Trichinella sp also occurred on ships. Factors associated with the outbreaks reviewed include inadequate temperature control, infected food handlers, contaminated raw ingredients, cross-contamination, inadequate heat treatment, and onshore excursions. Seafood was the most common food vehicle implicated in outbreaks.
  
  
  CONCLUSIONS
  Many ship-associated outbreaks could have been prevented if measures had been taken to ensure adequate temperature control, avoidance of cross-contamination, reliable food sources, adequate heat treatment, and exclusion of infected food handlers from work.
authors.affiliation: Water, Sanitation and Health Programme, Department of Protection of the Human Environment, World Health Organization, Geneva, Switzerland. rooneyr@who.int
authors.forename: Roisin M
authors.initials: RM
authors.lastname: Rooney
authors.forename: Elaine H
authors.initials: EH
authors.lastname: Cramer
authors.forename: Stacey
authors.initials: S
authors.lastname: Mantha
authors.forename: Gordon
authors.initials: G
authors.lastname: Nichols
authors.forename: Jamie K
authors.initials: JK
authors.lastname: Bartram
authors.forename: Jeffrey M
authors.initials: JM
authors.lastname: Farber
authors.forename: Peter K
authors.initials: PK
authors.lastname: Benembarek
mesh_terms: D003296:Cooking / Q000379:methods / Q000592:standards; D004196:Disease Outbreaks / Q000517:prevention & control / Q000706:statistics & numerical data; D019317:Evidence-Based Medicine; D005506:Food Contamination / Q000517:prevention & control / Q000706:statistics & numerical data; D005511:Food Handling / Q000379:methods / Q000592:standards; D005517:Foodborne Diseases / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D015994:Incidence; D017053:Infection Control / Q000379:methods / Q000592:standards; D009017:Morbidity; D009326:Naval Medicine / Q000379:methods / Q000592:standards; D020380:Needs Assessment; D016272:Occupational Health; D011159:Population Surveillance; D017410:Practice Guidelines as Topic; D012034:Refrigeration / Q000379:methods / Q000592:standards; D012307:Risk Factors; D012308:Risk Management / Q000379:methods / Q000592:standards; D012499:Sanitation / Q000379:methods / Q000592:standards; D012767:Ships / Q000706:statistics & numerical data*; D014944:World Health Organization