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Abstract
Passengers and crew aboard cruise ships are at risk of acquiring certain communicable diseases associated with international travel and the cruise ship environment. Currently, an estimated 29.7 million passengers travel on cruise ships, with 15.4 million being North American travelers. Since 1975, the Vessel Sanitation Program (VSP) of the Centers for Disease Control and Prevention (CDC) has assisted the cruise industry in developing effective public health programs to manage the risks associated with communicable disease transmission aboard cruise ships. Additionally, under foreign quarantine regulations, the VSP is also charged with preventing the introduction, transmission, and spread of communicable disease pathogens into the United States from cruise ships carrying 13 or more passengers with foreign itineraries and making port calls in the United States. Cruise companies have recently built increasingly larger cruise ships capable of transporting over 9,000 passengers and crew. In addition to the larger transport capacities, a shift from disease risks of enteric pathogens linked to contaminated food and water in the 1970s to mid-1990s to viral pathogens associated with person-to-person transmission and environmental contamination has resulted in the threat of enhanced communicable disease transmission in the semi-enclosed, densely populated modern cruise ships. Moreover, viral enteric pathogens have increased pathogen transmission on cruise ships. Since 2002, the primary enteric pathogen associated with outbreaks of acute gastroenteritis on cruise ships is norovirus, which has been implicated in over 92 percent of cruise ship-associated AGE outbreaks. To address the surge in viral pathogen risks, new approaches to disease prevention and public health policy strategies are required to minimize the risks associated with viral enteric pathogens, protect the health of the passengers and crew aboard cruise ships, and the health of port communities in the United States. This dissertation evaluates the effectiveness of key VSP programs and policies in managing communicable disease risks associated with travel on passenger cruise ships.