The news yesterday that Spain had shut its border with Gibraltar for the first time in two decades was the latest blow for the 1,800 British tourists on board the cruise ship Aurora, now bound for Southampton. They - or more properly, their gastrointestinal tracts - are at the centre of a row which has left them sailing around the Mediterranean "like unwanted refugees", as one official put it, after being refused permission to dock in Greece.
The passengers, one would imagine, are upset enough already without a diplomatic row to add to their complaints: 500 of them have so far fallen victim to the "Noro virus"- basically, a 24- to 48-hour stomach bug involving vomiting and diarrhoea. Spanish officials said this was a public health hazard and they didn't want them on Spanish land. A spokesman for Spain's ministry of health said the closure of the frontier was a "preventive measure until we know more about the nature and extent of the infection". But speaking to BBC radio, Gibraltar's chief minister, Peter Caruana, accused Spain of "an outrageous overreaction".
So were the Spaniards making a needless fuss, or was this ship a genuine threat to the nation's bowels? The Noro virus (often called the "Norwalk" virus) is "a small virus that is the cause of a highly infectious gastroenteritis" says Dr Jane Zuckerman, director of the World Health Organisation's collaborating centre in travel medicine at the Royal Free and University College Medical School in London. "It is an acute infection, but only life-threatening to people who are otherwise unwell." This is mainly because sickness and diarrhoea can lead to dehydration, which in weaker bodies can be dangerous.
A spokesperson for P&O Cruises, however, says that only six people are currently ill, with 50 confined on board the ship to avoid any chance of further infection. The other 1,750 passengers are, she says, alive and well, having a great holiday and "enjoying all the ship's facilities". Which include, as the brochure puts it "impressive and varied options for dining, entertainment and accommodation". Still, the Aurora's Cafe Bordeaux, "an enticing 24-hour bistro", may not hold quite the allure it once did to the no doubt increasingly paranoid passengers.
They are, however, not the first tourists to experience "misery on the Med". Indeed, over one particularly fragrant six-month period last year, around 1,400 tourists were struck down by nasty stomach viruses on 10 different cruises. Not since the Titanic has the passenger ship industry taken such a rap. So are cruise ships really little more than festering crucibles of disease? Or have such stories been blown out of proportion?
The main debate here centres on hygiene. Zuckerman explains that the exact source of the virus is unknown. Doctors do, however, know that the virus is spread through "the faecal-oral route". And that transmission can only be stopped by "high standards of hygiene". The Passenger Shipping Association (PSA), the UK industry body for cruising, has been - not surprisingly - quick to assert how safe and clean cruise ships are. "The [Noro] virus is passed from person to person," they say somewhat controversially, "and is not connected to hygiene standards on board ships." The prevalence of this virus certainly does not mean that cruise travel is unsafe because, in fact, "less than 1% of worldwide cruise passengers have been involved to date". Indeed, one reason such sick-bug stories are becoming more common is that now, more than ever (possibly because of September 11) we all love a good cruise. "More than 900,000 British holidaymakers take one each year," says the PSA, which is triple the volume of the early 90s.
Certainly, most cruise ships these days are extremely well-equipped. Though there have been scary stories of US cruise ships employing doctors with dubious medical qualifications, Zuckerman says: "In my experience medical officers working with British cruise companies are highly trained and work to exceptionally high standards". The Aurora itself has three doctors and five nurses on board. Most cruise liners have x-ray facilities, an intensive care unit, a mini-laboratory for blood biochemistry, a pharmacy, a treatment room which doubles up to be an operating theatre and several wards for patients.
Despite all this equipment, however, a medical team can do little to stop an infection like Noro from spreading. "There is no magic potion or lotion or treatment," says Zuckerman. "You can isolate infected people, but such viruses will spread very rapidly when people are in close quarters." This is because the bug can be passed on anything from cutlery and doorknobs, to the rails of staircases. It's not surprising, then, that it can ravage its way through the collective bowels of a ship. The only thing you, as a passenger, can do in this situation, says Zuckerman is "obsessively wash and dry your hands" while the ship's medical team does its best to "ensure people stay hydrated".
Clive Garner, head of the international travel litigation group at legal firm Irwin Mitchell, represents a number of clients who are suing for long-term health effects after contracting such lurgies as salmonella or the Norwalk virus on board ships. Long-term irritable bowel syndrome and chronic fatigue are two such claims, but he also has one appalling case where a four-year-old girl was left with permanent kidney damage after contracting E coli on a cruise. "We're seeing more and more claims of this type," says Garner, "when a ship's management or tour operators are at fault [because] kitchens have been found to be unacceptably dirty, with poor hygiene measures in food storage, preparation and handling". What's more, he says "there is often mismanagement of an outbreak, for example, when passengers are not adequately warned of a known problem, or where adequate steps are not taken to deep cleanse a ship, or to reasonably reduce the risk of infection".
Big companies such as P&O are, of course, scrupulous about hygiene, with policies and procedures for disinfecting ships, and there are excellent rules and protocols for dealing with such outbreaks. The Aurora, says Zuckerman, will be evacuated and fully decontaminated when it reaches UK port. "It will be put through an extremely thorough cleansing process."
But the main concern for doctors, when it comes to cruise ships, are respiratory illnesses such as influenza. The flu can be far more dangerous for older people, or those recuperating from illnesses (many of whom do go on cruise holidays). "We are currently trying to ensure that anyone going on a cruise at flu times of the year should be vaccinated against influenza," says Zuckerman.
So don't give up yet on your dreams of ballroom dancing between exotic ports. Just get a flu jab, and make sure you wash your hands a lot.
Some famous outbreaks
Ships have long been the source of horrible diseases and rank infections. In 1747, the naval surgeon James Lind, who was investigating scurvy among seamen, said: "The number of seamen in times of war who die of shipwreck, capture, famine, fire or sword, are but inconsiderable in respect of such as are destroyed by the ship diseases."
The mortality rate during the Middle Passage in the 18th century was high for slaves and crew alike, averaging between 13 and 33%. Dominican, Tomas de Mercado, recalled a Portuguese ship that lost 100 slaves out of 500 in one night. In April 1819, all 160 slaves and all but one of the 22 crew aboard the French ship Le Rodeur were blinded from an incurable disease. The one man spared steered the ship into port, but caught the bug three days later.
In the 1840s, during the potato famine in Ireland, around 9,000 Irish emigrants died at sea from the louse-borne infection typhus, or "ship fever".
A World Health Organisation literature review identified over 100 disease outbreaks associated with ships since 1970, although many more go undetected or unreported. One outbreak of viral gastroenteritis on a naval vessel in 1997 affected 1,807 (43%) crew members.
In 1994, 50 passengers, one of whom died, contracted Legionnaires' disease from a cruise ship over a period of nine cruises between April and July. The source of the outbreak appeared to be the whirlpool.