Cruise ships: High-risk passengers and the global spread of new influenza viruses

In 1997, passengers on North American cruises developed acute respiratory illnesses (ARIs); influenza was suspected. We reviewed 1 ship's medical records for 3 cruises: cruise 1 (31 August to 10 September 1997), cruise 2 (11-20 September 1997), and cruise 3 (20-30 September 1997), Medically attended ARI was defined as any 2 of the following symptoms: fever (temperature, greater than or equal to 37.8 degrees C) or feverishness, sore throat, cough, nasal congestion, chills, myalgia, and arthralgia, During cruise 2, we collected nasopharyngeal swabs for viral culture from people with ARI and surveyed passengers for self-reported ARI (defined as above except feverishness was substituted for fever). The outbreak probably began among Australian passengers on cruise 1 (relative risk, 3.3; 95% confidence interval, 1.89-5.77). Of 1284 passengers on cruise 2, 215 (17%) reported ARI, 994 (77%) were a;:ed greater than or equal to 65 years, and 336 (26%) had other risk factors for respiratory complications. An influenza strain not previously identified in North America was isolated. We concluded that an off-season influenza outbreak occurred among international travelers and crew on board this cruise ship.