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The gastrointestinal (GI) pathogen norovirus was the leading cause of infectious-disease outbreaks on cruise ships over the past 57 years, but respiratory pathogens such as influenza and SARS-CoV-2 also emerged as important contributors, reveals a meta-analysis published in eClinicalMedicine.

Peking University researchers in China led the analysis of 107 observational studies on 619 infectious-disease outbreaks among passengers and/or crew on 236 ships from 1969 to 2026.

While the risk of outbreaks and related deaths on cruise ships is relatively low overall, the 2026 Andes hantavirus outbreak on an expedition cruise ship, which sickened 13 and killed three, underscores the emerging risks tied to this type of travel, the authors said.

"Cruise ships represent unique, semiclosed and high-density environments where individuals from diverse geographical backgrounds live and dine in close proximity," they wrote. "These conditions, combined with shared facilities and repeated passenger turnover, facilitate the transmission of infectious agents through person-to-person contact, contaminated food and/or water, and environmental reservoirs, potentially leading to infectious disease outbreaks."

Before the mid-1990s, cruise ship outbreaks remained relatively uncommon and sporadic but rose markedly before peaking in the 2000s. After cases fell sharply in 2021 amid the COVID-19 pandemic, outbreaks became more common again. Although pathogen composition shifted over time, norovirus made up the largest percentage of outbreaks starting in 1995.

Among the 107 studies, the median total ship population was 1,715 (interquartile range [IQR], 924 to 2,904).

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