Traveler's Diarrhea at Sea: Three Outbreaks of Waterborne Enterotoxigenic Escherichia coli on Cruise Ships

• Published in: The Journal of infectious diseases Vol. 181; no. 4; pp. 1491 - 1495
• Main Authors: Daniels, Nicholas A., Neimann, Jakob, Karpati, Adam, Parashar, Umesh D., Greene, Katherine D., Wells, Joy G., Srivastava, Anjali, Tauxe, Robert V., Mintz, Eric D., Quick, Robert
• Format: Journal Article
• Language: English
• Published: Chicago, IL The University of Chicago Press 01-04-2000; University of Chicago Press; Oxford University Press
• Subjects: Adult; Antimicrobials; Bacterial diseases; Bacterial diseases of the digestive system and abdomen; Bacterial Toxins; Biological and medical sciences; Concise Communications; Cruise ships; Cruises; Diarrhea; Diarrhea - epidemiology; Diarrhea - etiology; Disease Outbreaks; Diseases; Enterotoxins; Escherichia coli; Escherichia coli - classification; Escherichia coli Infections - epidemiology; Escherichia coli Infections - etiology; Escherichia coli Infections - transmission; Feces - chemistry; Feces - microbiology; Food Handling; Food Preservation; Gastroenteritis; Human bacterial diseases; Humans; Infectious diseases; Marine; Medical sciences; outbreaks; Passengers; Ships; Surveys and Questionnaires; Travel; Water consumption; Water Microbiology; Water Supply; water-borne diseases; Epidemic; Human; Drinking water; Colibacillosis; Escherichia coli; Gastroenteritis; Traveler disease; Infection; Characterization; Antibiotic; Sensitivity resistance; Bacteriosis; Digestive diseases; Bacteria; Intestinal disease; Antibacterial agent; Biological contamination; Enterobacteriaceae; Gastric disease
• ISSN: 0022-1899; 1537-6613
• DOI: 10.1086/315397

Enterotoxigenic Escherichia coli (ETEC) has become the leading bacterial cause of gastroenteritis outbreaks on cruise ships. Investigation of recent outbreaks of ETEC gastroenteritis on 3 cruise ships indicated that all were associated with consuming beverages with ice cubes on board the ship (relative risk [RR], 1.4, 95% confidence interval [CI], 1.0–1.9, P = .02; RR, 1.9, 95% CI, 1.3–2.9, P<.001; and RR, 1.3, 95% CI, 1.0–1.6, P< .01, and 2 were associated with drinking unbottled water (RR, 2.7, 95% CI, 1.8–4.1, P< .001; RR, 1.7, 95% CI, 1.3–2.3, P< .001). Multiple ETEC serotypes were detected in patients' stool specimens in each of the 3 outbreaks, and 12 (38%) of 32 isolates were resistant to ⩾3 antimicrobial agents. ETEC appears to be emerging as a waterborne pathogen on cruise ships. Water bunkered in overseas ports was the likely source of ETEC infection in these outbreaks. To ensure passenger safety, cruise ships that take on water in foreign ports must ensure that water treatment and monitoring systems function properly.