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Effective Hand Hygiene Strategy for Passenger Cruise Ships

Patrick Boshell
June 14, 2016




Modern passenger cruise ships are effectively “mini cities” at sea, with populations of several thousand and hence with all the complexity in hygiene provision of a typical urban infrastructure, with the added complication of isolation for long periods of time (no-one leaving or entering the environment).

This article considers the requirements for hand hygiene and specifically the role of waterless hand sanitizers within the cruise ship eco-system. This is only one part of a holistic hygiene or hand hygiene strategy.

We consider the scenarios and responsibilities of individuals for hand hygiene within the cruise ship ecosystem, and the role waterless hand sanitizer plays within this.


Washroom Hand Hygiene


Hygiene in washrooms (either public or in passenger/staff quarters) is a vital element of any holistic infection prevention strategy. Washrooms present an infection risk via two main pathways; infection from feces (either an infected individual or an asymptomatic carrier) and infection following contamination of on-board water supply (e.g. Legionella). The role for thorough surface cleansing and disinfection in washrooms, and for effective water quality control, is clear and will not be covered here.

Regarding hand hygiene and the selection of the most appropriate solution, two factors are important in washrooms:

1. Water for rinsing is commonly (and should be) available
2. Physical cleansing in addition to hand sanitizing is required

Passenger and Public Washrooms

Given the above, the primary hand hygiene solution for passenger and public washroom should be a high quality non-soap hand cleanser designed for frequent use and with mild, skin-friendly properties.

Additional considerations for Healthcare and Food Handlers

Staff involved in healthcare and food handling have an additional duty of care and risk profile following any visit to the washroom. For this reason, it is strongly recommended that either a suitable broadspectrum antimicrobial cleanser is adopted in place or a general washroom cleanser for the specific washrooms used by staff in these departments. When this is not possible, a regime of washing with a non-soap cleanser followed by sanitizing with a suitable waterless hand sanitizer should be adopted.


Opportunities for adoption of the former strategy would include instances where washrooms are used uniquely by such employees (e.g. in kitchen areas). Opportunities for adoption of the latter strategy would include instances where such employees use public washrooms in the course of their duties (e.g. a doctor visiting a passenger room). In this case, both washroom hand cleanser and waterless hand sanitizer should be provided, and instructions for use given to key staff.

Food Storage and Food Preparation Areas

In these environments, two main pathways for contamination and infection can occur; food contamination from an infected individual and food contamination from other contaminated food. In addressing these risks, the role for robust surface cleansing is clear, as is the role for effective food management (storage, separation and control) and personnel management. 


Food contamination can take a number of forms; bacterial, fungal or viral. Of key concern are bacterial contaminations such as Listeria and Salmonella, and viral contaminations such as Norovirus. It is important to note a key distinction in that bacterial colonies can grow and multiply on or inside contaminated food, while viral contaminants typically lay dormant awaiting transport to a human host.



The safest and most effective means to ensure good hygiene is to wash hands thoroughly according to established best practice. Washing with an appropriate hand cleanser and water ensures the physical removal of greasy soiling as well as any microbiological contamination. Given the high duty of care for such situations, a high level of sanitizing (>99.99% reduction) is desired. As noted above, this can be achieved either through combination of standard non-soap hand cleanser and waterless hand sanitizer or by using a suitable antimicrobial hand cleanser.

The latter strategy should be strongly encouraged for food handlers as it provides a more convenient solution unless a suitable product is not available. When cleanser and sanitizer are used, it is important that hands are both physically clean and dry before the sanitizer is applied. It is not considered that frequent requirements for hand hygiene away from the provision of running water is likely or desired for food handling environments. 


Healthcare Areas


Within on-board healthcare areas, we consider that individuals can be healthcare professionals, passengers (as patients or visitors) and other non-associated staff members (also as patients or visitors). In terms of the key duty of care for hand hygiene, we will focus on healthcare professionals, with comments as to suitable provision for the other groups.

Within healthcare areas, control of infection is vital. Typical pathways for contamination leading to infection include transmission of pathogens from one patient directly to another, or via surfaces touched by both or by healthcare workers engaged in the treatment of both. Specific opportunities for infection include feeding of patients and particularly treatment of open wounds or execution of aseptic procedures. In addition to the requirement for effective surface cleansing not covered here, there is a very clear and effective strategy for hand hygiene outlined in the World Health Organization (WHO) 5 moments for Hand Hygiene.


In terms of the key concerns for healthcare workers, clearly prevention of transmission of all pathogens is important however paramount is prevention of transmission of multi-drug-resistance-organisms (MDROs) such as MRSA and VRE which are endemic in healthcare settings due to regular contact with antibiotic drugs. Additional activity against key infection strains such as C. difficile and norovirus is also highly desirable.

For healthcare staff, very frequent hand hygiene may be required in order to fully comply with the risk based approach of the 5 Moments. In many cases, hand hygiene at the point of care (away from the provision of running water) is needed. For these reasons it is strongly recommended that a suitable waterless hand sanitizer is adopted as the primary strategy for hand hygiene for healthcare staff, supplemented by either a standard or an antimicrobial hand cleanser when necessary. Only when hands are physically dirty, or following key risk indicators such as Moment 3 (after body fluid exposure risk) should hands be washed with cleanser and water. In most other cases, better disinfection and better skin care is achieved by using a suitable waterless hand sanitizer designed for frequent use.

Non-healthcare workers (either passengers or non-involved staff) should be encouraged to sanitize with a waterless hand sanitizer on entry to and exit from the healthcare area, or following clear risk indicators such as touching a patient.

General Public Areas

Beyond washrooms, main pathways for infection in public areas will be touching contaminated surfaces and airborne pathogens. Robust surface cleansing strategies clearly must play a role. In addition, sensible hand hygiene practices can effectively mitigate spread of non-airborne pathogens and can assist in the control of airborne (aerosol) pathogens.

Provision of waterless hand sanitizer at key locations such as entry/exit to open spaces and along thoroughfares is a very effective means to tackle such infection risks, which will be dominated typically by control of “herd” contagions, including Norovirus, and E. coli. 


Elements for Selection

The primary criterion for selection of a waterless hand sanitizer must be antimicrobial efficacy, but this is not the only aspect. Other key selection criteria for a successful outcome include skin compatibility, likely build-up of microbial resistance and user preference in use. The latter is especially important in driving compliance either when very frequent use is required (e.g. Healthcare) or when professional responsibility cannot be assumed (e.g. public areas).


Alongside robust water treatment, food handling and management and surface cleansing procedures, and supplemented where appropriate by water rinsed hand cleansers, waterless hand sanitizers can play a vital role within hygiene and hand hygiene strategy for infection prevention aboard modern cruise ships.



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The Role of Waterless Hand Sanitizer as part of an Effective Hand Hygiene Strategy for Passenger Cruise Ships, and Selection of Suitable Products - Dr J. D. Hines, B.Sc, D.Phil., MRSC, FIM, Global Research and Development Director, Deb Group


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