Operational Guide · Registers & Logbooks

# Managing a Gastrointestinal Outbreak on Board

Not every case of gastroenteritis triggers the threshold: only when 3% or more of passengers or crew show symptoms must the ship formally declare an outbreak. In the first half of 2026 the number of recorded outbreaks fell 70% compared with the same period in 2025.

Vessel Sanitation Program norovirus AGE gastrointestinal outbreak

## Operational Explanation

The US CDC's Vessel Sanitation Program (VSP), together with equivalent programmes in other jurisdictions, sets precise thresholds for managing acute gastrointestinal illness (AGE, Acute Gastroenteritis) on board: the ship must report to the competent authorities when 2% or more of passengers or crew show symptoms consistent with AGE (typically defined as 3 or more episodes of unformed diarrhoea in a 24-hour period, beyond what is normal for that person); when the percentage reaches or exceeds 3%, the event is formally classified as an outbreak.

Once the outbreak is declared, the ship must apply isolation protocols for symptomatic cases, collect samples for pathogen identification (typically Norovirus or enterotoxigenic E. coli/ETEC), step up cleaning and disinfection procedures, and cooperate with an environmental inspection and epidemiological investigation by the competent health authorities. The first half of 2026 recorded 5 outbreaks (3 from Norovirus, 2 from E. coli), against 17 outbreaks in the same period of 2025 (12 of which from Norovirus): a fall of about 70%, attributed to strengthened prevention protocols.

## Regulatory Reference

Vessel Sanitation Program (VSP) of the CDC (for ships calling at US ports) and equivalent programmes in other jurisdictions: reporting threshold at 2% of symptomatic cases among passengers or crew, formal classification as an outbreak on reaching 3%, with isolation protocols, sampling, intensified cleaning/disinfection and cooperation with the health authorities' epidemiological investigation.

## Scope of Application

Every passenger ship, with particular relevance for cruise ships calling at ports subject to a health surveillance programme (such as the US VSP) and for the onboard medical staff responsible for syndromic surveillance.

## Procedure / How to Complete It

1. Maintain a syndromic surveillance system recording cases of gastrointestinal symptoms among passengers and crew, constantly calculating the percentage of the total on board.
2. Report to the competent authorities when the percentage of symptomatic cases reaches 2%, even before the formal outbreak threshold.
3. On reaching the 3% threshold, formally declare the outbreak and activate isolation protocols for symptomatic cases.
4. Collect clinical samples for pathogen identification and step up cleaning and disinfection procedures for high-touch surfaces.
5. Cooperate with the environmental inspection and epidemiological investigation of the competent health authorities during or at the end of the outbreak.

## Practical Example

Example: the onboard medical staff of a cruise ship detect an increase in gastroenteritis cases, report on reaching the 2% threshold, and formally declare the outbreak on exceeding 3%, isolating symptomatic cases, collecting samples and stepping up cleaning of high-touch surfaces per the VSP protocol.

## Real Cases

The roughly 70% fall in recorded gastrointestinal outbreaks in the first half of 2026 compared with the same period in 2025 (from 17 to 5 outbreaks) is attributed by industry operators to strengthened hygiene and syndromic surveillance protocols, demonstrating how rigorous management of the early reporting threshold (2%) helps contain progression toward full-blown outbreaks.

## Common Mistakes Mistake Library

Mistake | Consequence | How to avoid it
--- | --- | ---
Waiting until the 3% threshold is reached before stepping up cleaning and surveillance, instead of acting already at the 2% reporting threshold | Failure to prevent progression toward a formal outbreak that could have been contained earlier | Step up prevention measures already on reaching the 2% reporting threshold, without waiting for the formal 3% threshold
Syndromic surveillance not systematic or based only on spontaneous passenger reports | Underestimation of the actual percentage of symptomatic cases on board, with delayed detection of the threshold | Maintain an active, systematic syndromic surveillance system, not based solely on spontaneous reports

## PSC Observations

Although health management does not typically fall within the scope of standard PSC inspections, PSCOs may nonetheless check for documented protocols on managing gastrointestinal illness and consistency with any recent reports to port health authorities.

## Operational Tips

- Act already at the 2% reporting threshold, do not wait for the formal 3% outbreak threshold: the gap between the two thresholds is the operational space to prevent escalation.
- Maintain a systematic syndromic surveillance system, not based solely on spontaneous passenger reports.
- Always document cooperation with health authorities during the epidemiological investigation: it is part of proper outbreak management, not just a subsequent formality.

## Checklist

- Active syndromic surveillance system for passengers and crew
- Report made to the competent authorities on reaching the 2% threshold
- Outbreak formally declared on reaching the 3% threshold, with isolation protocols activated
- Clinical samples collected for pathogen identification
- Cleaning and disinfection procedures intensified and documented

## FAQ

What is the reporting threshold for gastrointestinal illness on board according to the VSP?
2% of passengers or crew with symptoms consistent with AGE; on reaching or exceeding 3% the event is formally classified as an outbreak.
How is a case of AGE (Acute Gastroenteritis) defined?
Typically 3 or more episodes of unformed diarrhoea within a 24-hour period, beyond what is normal for that person, per the case definition used by onboard medical staff.
What are the most common pathogens in gastrointestinal outbreaks on cruise ships?
Norovirus is the most common, followed by enterotoxigenic E. coli (ETEC); in the first half of 2026, of 5 recorded outbreaks, 3 were from Norovirus and 2 from E. coli.
🎬 Additional photos, videos and interactive diagrams for this topic will be available in a future version of the platform.

## Related Topics

SAR Cooperation Plan on Passenger Ships Persons with Reduced Mobility: Accessibility on Board

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