excursion medical condition

• Patient Care & Health Information
• Diseases & Conditions
• Aortic valve disease

• Aortic valve stenosis

Aortic valve stenosis is a thickening and narrowing of the valve between the heart's main pumping chamber and the body's main artery, called the aorta. The narrowing creates a smaller opening for blood to pass through. This reduces or blocks blood flow from the heart to the rest of the body. Typically the aortic valve has three cusps, called a tricuspid aortic valve. But some people are born with an aortic valve that has two cusps, a condition called bicuspid aortic valve.

• Aortic valve regurgitation

In aortic valve regurgitation, the aortic valve doesn't close properly. This causes blood to flow backward from the body's main artery, called the aorta, into the lower left heart chamber, called the left ventricle.

Aortic valve disease is a type of heart valve disease. In this condition, the valve between the lower left heart chamber and the body's main artery doesn't work properly.

The aortic valve helps keep blood flowing in the correct direction through the heart. A damaged or diseased aortic valve can affect blood flow to the rest of the heart and body.

Aortic valve disease includes:

• Aortic valve stenosis. Each heart valve has flaps of tissue that open and close once per heartbeat. The flaps also are called cusps. Sometimes the aortic valve flaps become thick and stiff, or they connect together. These problems cause the valve opening to become narrow. The narrowed valve reduces or blocks blood flow from the heart to the rest of the body.
• Aortic valve regurgitation. The aortic valve doesn't close properly, causing blood to flow backward into the left lower heart chamber.

A person may be born with aortic valve disease. This is called a congenital heart defect. Sometimes aortic valve disease occurs later in life due to other health conditions.

Treatment for aortic valve disease depends on the type and severity of disease. Some people may need surgery to repair or replace the aortic valve.

Some people with aortic valve disease may not notice symptoms for many years. Symptoms of aortic valve disease may include:

• Chest pain or tightness.
• Fatigue after activity or having less ability to be active.
• Irregular heartbeat.
• Shortness of breath, particularly during vigorous activity or when lying down.
• Not eating enough. This is mainly seen in children with aortic valve stenosis.
• Not gaining enough weight. This is mainly seen in children with aortic valve stenosis.

When to see a doctor

If you're having sudden chest pain, call 911 or your local emergency number.

Make an appointment for a health checkup if you have symptoms of aortic valve disease, such as shortness of breath, fatigue after activity, or sensations of a pounding or an irregular heartbeat. Sometimes the first symptoms of aortic valve disease are related to heart failure. Get a health checkup if you have fatigue that doesn't get better with rest, shortness of breath, and swollen ankles and feet, which are common symptoms of heart failure.

Chambers and valves of the heart

A typical heart has two upper and two lower chambers. The upper chambers, the right and left atria, receive incoming blood. The lower chambers, the more muscular right and left ventricles, pump blood out of the heart. The heart valves, which keep blood flowing in the right direction, are gates at the chamber openings.

Aortic valve disease may be caused by a heart problem present at birth, called a congenital heart defect. Other causes of aortic valve disease later in life include:

• Age-related changes to the heart.
• Infections.
• High blood pressure.
• Injury to the heart.

To better understand the causes of aortic valve disease, it may be helpful to know how the heart valves typically work.

The heart has four valves that keep blood flowing in the correct direction. These valves are:

• Aortic valve.
• Mitral valve.
• Tricuspid valve.
• Pulmonary valve.

In aortic valve stenosis, the aortic valve opening is narrowed, as seen in the top image. The heart must work harder to pump blood across the smaller opening. This increases pressure within the heart. Eventually the strain reduces the heart's ability to pump blood to the body. This is like placing smaller and smaller nozzles on the end of a garden hose, as shown on the bottom image. The narrower the nozzle is, the slower the flow of water. This results in pressure buildup within the garden hose.

Each valve has flaps, also called cusps or leaflets, that open and close once during each heartbeat.

In aortic valve disease, the valve between the lower left heart chamber and the body's main artery doesn't work properly. The lower left heart chamber is called the left ventricle. The body's main artery is called the aorta.

The valve may become thick and stiff or the valve may not close properly.

Risk factors

Many things can raise the risk of aortic valve disease, including:

• Older age. Calcium can build up on the aortic valve as people age, causing the aortic valve to stiffen and become narrow.
• Heart valve problems present at birth, called congenital heart defects. Some people are born with a missing, extra or fused valve flap. This increases the risk of aortic valve regurgitation.
• Rheumatic fever. This complication of strep throat can cause aortic stenosis, a type of heart valve disease. If you have heart valve disease due to rheumatic fever, it's called rheumatic heart disease. If not, it's called nonrheumatic heart disease.
• Inflammation of the lining of the heart's chambers and valves, called endocarditis. This life-threatening condition is usually caused by infection. It can damage the aortic valve.
• History of radiation therapy to the chest. Some types of cancer are treated with radiation therapy. Symptoms of heart valve disease may not be noticed until many years after radiation therapy is received.
• Other health conditions. Chronic kidney disease, lupus and Marfan syndrome, a connective tissue disease, can increase the risk of aortic stenosis or regurgitation.

Complications

Potential complications of aortic valve disease may include:

• Blood clots.
• Heart failure.
• Heart rhythm problems, called arrhythmias.
• Death due to sudden cardiac arrest.

Proper diagnosis and treatment can help reduce the risk of complications.

Aortic valve disease care at Mayo Clinic

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• Bonow RO, et al., eds. Aortic valve disease. In: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 11th ed. Elsevier; 2019. https://www.clinicalkey.com. Accessed Aug. 7, 2021.
• Buji LM, et al., eds. Valvular heart disease. In: Cardiovascular Pathology. 4th ed. Elsevier; 2016. https://www.clinicalkey.com. Accessed Aug. 15, 2021.
• Crawford MH, ed. Aortic stenosis. In: Current Diagnosis & Treatment: Cardiology. 5th ed. McGraw-Hill; 2017. https://accessmedicine.mhmedical.com. Accessed Aug. 7, 2021.
• Crawford MH, ed. Aortic regurgitation. In: Current Diagnosis & Treatment: Cardiology. 5th ed. McGraw-Hill; 2017. https://accessmedicine.mhmedical.com. Accessed Aug. 7, 2021.
• Fuster V, et al., eds. Aortic valve disease. In: Hurst's the Heart. 14th ed. McGraw-Hill; 2017. https://accessmedicine.mhmedical.com. Accessed Aug. 7, 2021.
• Heart-healthy lifestyle changes. National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/health-topics/heart-healthy-lifestyle-changes. Accessed Aug. 15, 2021.
• Heart valve disease. National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/health-topics/heart-valve-disease. Accessed Aug. 8, 2021.
• Otto CM, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: Executive summary. Circulation. 2021; doi:10.1161/CIR.0000000000000932.
• Ami TR. Allscripts EPSi. Mayo Clinic. May 3, 2023.
• Otto CM, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Journal of the American College of Cardiology. 2021; doi:10.1016/j.jacc.2020.11.018.
• Phillips SD (expert opinion). Mayo Clinic. Sept. 30, 2021.

Associated Procedures

• Aortic valve repair and aortic valve replacement
• Heart valve surgery
• Transcatheter aortic valve replacement (TAVR)

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Specific Medical Conditions and Travel

• Heart Disease and Travel |
• Lung Disease and Travel |
• Diabetes and Travel |
• Pregnancy and Travel |
• Other Conditions |
• More Information |

People with certain medical conditions encounter special problems in transit.

Heart Disease and Travel

If people with angina , heart failure , or certain heart rhythm disturbances have symptoms during rest or with minimal exertion, they should not travel. If people recently have had a heart attack, they are advised to postpone travel for a variable period of time, depending on the severity of the heart attack. They should ask their doctor whether they need to wait and, if so, for how long. People with severe or worsening angina should avoid flying. Their symptoms may worsen because less oxygen is available in the cabin of airplanes traveling at high altitudes.

All travelers with heart disease should carry a copy of a recent electrocardiogram (ECG). People with pacemakers, implantable defibrillators, or coronary stents should carry a card or doctor’s letter documenting the presence, type, location, and electronic characteristics of the implanted device. An implanted metal device may trigger an alarm as the person passes through electronic security. Electronic security devices do not generally affect implantable defibrillators, but travelers are advised to avoid standing in walk-through metal detectors for more than 15 seconds. Hand-held metal detectors are also safe for people with defibrillators, but prolonged contact, such as holding the detector over the defibrillator for more than 5 seconds, should be avoided.

If given notice in advance, most major airlines can provide low-sodium, low-fat meals on flights with regular meal service. If notified in advance, many cruise lines can also provide these meals.

Did You Know...

Lung disease and travel.

Travelers with lung cysts, severe emphysema , a large collection of fluid around the lungs ( pleural effusion ), recent lung collapse ( pneumothorax ), or who have had recent chest surgery can develop complications caused by airplane pressure changes. They should not fly without approval from their doctor.

Other travelers with lung disease may need supplemental oxygen while they are aboard an airplane. A doctor determines a person’s need for in-flight oxygen by measuring the level of oxygen in the blood. A low level of oxygen in the blood is called hypoxemia. Most airlines will provide in-flight oxygen if they are given a doctor’s prescription and advance notice. Travelers are not allowed to carry oxygen in any form aboard an airplane. Travelers who need oxygen during airport layovers must make their own arrangements, although most oxygen vendors will assist their regular customers without charge if they have services in the destination city. Other respiratory equipment, such as continuous positive airway pressure devices, can be accommodated on an airplane provided the equipment does not exceed the size allowed for carry-on luggage. However, travelers who need this equipment should allow extra time for security checks.

Ground travel at high altitudes may present special problems because less oxygen is available than at sea level ( see chapter Altitude Illness ). In general, people with mild or moderate lung problems do not have any difficulty at altitudes below 5,000 feet (1500 meters), but the higher the altitude, the greater the chance of problems. People with lung disease traveling in or through such areas should take the same precautions they would take if they were flying.

Bus, train, car, and ship travel is safe for people with lung disease but requires planning to ensure a supply of oxygen. Commercial services can coordinate oxygen deliveries for travelers anywhere in the world.

People with asthma , emphysema , or bronchitis may find that their symptoms worsen in cities where air pollution is significant. They may need additional treatment with their inhalers or additional drugs, such as corticosteroids, to control symptoms adequately. Smoking can make mild hypoxemia worse and should be avoided before flying. The effects of alcohol may be increased by hypoxia and fatigue, and therefore alcohol is best avoided while traveling.

Diabetes and Travel

Blood sugar levels are best managed in transit by frequent testing, with adjustments of food intake and drug doses as needed. Travelers with diabetes insulin , should consult with a doctor about how best to schedule their drugs. Insulin can be stored without refrigeration for many days but should be kept out of extreme heat.

If given 24 hours' notice, most major airlines provide special meals for people with diabetes. Measures to prevent dehydration while in flight are important.

Blood sugar levels should be monitored frequently on arrival because activities and diet often differ from those at home. Because controlling blood sugar levels precisely is more difficult while traveling, levels tend to vary more than usual. Trying to keep levels very close to normal thus increases the risk that levels may sometimes become too low ( hypoglycemia ). For this reason, target blood sugar levels should be somewhat higher than ideal while traveling. Diabetic travelers should adhere to established diets despite temptations to try new foods and to eat more frequently or off schedule. They should wear comfortable socks and shoes, check their feet daily, and avoid walking barefoot to prevent minor injuries that may become infected or be slow to heal.

Pregnancy and Travel

Pregnancy is generally not affected by flying on a jet. However, pregnant women who are close to their due date (over 36 weeks gestation) and those at risk of miscarriage , premature delivery , or placental abruption should avoid flying and traveling long distances. Most airlines have policies regarding travel for pregnant women, and these policies should be checked before tickets are purchased. For instance, an airline may require that a woman in her 9th month of pregnancy who wants to fly must have a doctor's written approval letter dated within 72 hours of departure that states her expected delivery date. Pregnant women traveling long distances should take precautions to reduce the risk of blood clots (such as getting up often when traveling by airplane and stopping to take short walks when traveling by car) and dehydration. Seat belts should be fastened below the abdomen and across the hips to prevent injury to the fetus.

Pregnant women should avoid live vaccines , including yellow fever, measles-mumps-rubella, varicella (chickenpox), and typhoid fever by mouth (see table Vaccines for International Travel ).

Pregnant women should avoid prolonged use of water purification tablets that contain iodine because iodine can affect development of the thyroid gland in the fetus.

Pregnant women who cannot postpone travel to regions of the world where malaria

Pregnant women are also at risk of contracting hepatitis E infection , a viral liver infection rare in the United States but common in Asia, the Middle East, North Africa, and Mexico. Miscarriage, liver failure, or death may result. There is no treatment, so postponing travel to regions where hepatitis E is common should be considered. Women who cannot postpone travel should be vigilant about hand washing and following safe food guidelines ( see Prevention ).

Pregnant women should not travel to areas with risk of Zika infection .

Other Conditions

Travel and transit also affect other medical conditions such as

Sickle cell disease

Human immunodeficiency virus (HIV) infection

The wearing of contact lenses

Mental health disorders

Physical disabilities

Jaw problems

Some travelers with sickle cell disease are at risk of having pain (sickle cell crisis) when exposed to the low humidity and low oxygen levels in airplane cabins. This risk can be minimized with adequate hydration and oxygen.

Drugs used to treat human immunodeficiency virus (HIV) infection or AIDS may interact with drugs frequently taken by international travelers to prevent malaria and traveler’s diarrhea . Therefore, affected travelers should discuss the risk of such interactions with their doctors and pharmacist.

People with a colostomy should wear a large bag or bring extra supplies because fecal output may increase with expansion of intestinal gas during flight. Because gas expands in flight, water should be substituted for air in devices secured by air-filled cuffs or balloons, such as feeding tubes and urinary catheters.

People who wear contact lenses may want to wear eyeglasses en route or wet their lenses frequently with artificial tears to compensate for low humidity in the airplane. Artificial tears may also be helpful for people with dry eyes. In general, bringing an extra set of eyeglasses or lenses or a prescription in case replacements are necessary is a good idea. Extra batteries for hearing aids may also be useful.

Travelers with serious mental health disorders, such as poorly controlled schizophrenia , may pose a risk to themselves or others and should be accompanied by a responsible attendant. Sedating drugs may be recommended also.

Most airlines provide disabled travelers with wheelchairs and stretchers on commercial flights. Some airlines accommodate travelers who need special equipment, such as intravenous lines or ventilators, as long as trained personnel accompany them and arrangements have been made in advance. If travelers cannot be accommodated on a commercial flight because of severe illness, air ambulance service is necessary.

People whose jaw is wired shut (as occurs after surgery on the jaw) should not fly unless they have a way to quickly open the jaw. If they vomit while the jaw is wired shut, they could choke or inhale vomit.

General advice about traveling with various medical conditions can be obtained from

The medical departments of major airlines

Online travel information sources

Local travel clinics

More Information

The following English-language resource may be useful. Please note that THE MANUAL is not responsible for the content of this resource.

Centers for Disease Control and Prevention : Travelers' Health

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Why Are Younger Adults Developing This Common Heart Condition?

New research suggests that A-fib may be more prevalent, and more dangerous, in people under 65 than previously thought.

By Dani Blum

Atrial fibrillation, a common cardiac condition that raises the risk of stroke, is increasingly affecting the health of people under the age of 65.

For years, experts thought that A-fib, a type of irregular heartbeat, primarily occurred in people age 65 and older, and that younger people with the condition most likely wouldn’t develop other cardiac issues, said Dr. Aditya Bhonsale, a cardiac electrophysiologist at the University of Pittsburgh Medical Center. But in new research published Monday, Dr. Bhonsale and his colleagues examined data on more than 67,000 patients with A-fib who were treated at the center, nearly one-quarter of whom were under the age of 65. Those patients had an increased risk of death, compared to people without the condition. They also often had risk factors for A-fib like high blood pressure, obesity and sleep apnea, which could make cardiovascular health issues worse.

What is A-fib?

In A-fib, the upper and lower chambers of the heart are not coordinated as they should be, which makes the heart beat chaotically — sometimes too slow, sometimes too fast, often just irregularly. People with the condition can experience a fluttering heartbeat and palpitations.

Dr. Geoffrey Barnes, a cardiologist and vascular medicine specialist at University of Michigan Health, said that he frequently saw patients who say “I felt like my heart was racing away” or “I felt like it was skipping beats.” People with A-fib can also experience shortness of breath and chest discomfort. Some people have occasional episodes; others will continuously experience an irregular heartbeat. People often have no symptoms and don’t even realize they have the condition, Dr. Barnes said.

Increasingly, doctors said, patients are seeking care because their smart watches have detected an irregular heartbeat. That might help explain why more younger people are being diagnosed, said Dr. Hugh Calkins, a professor of cardiology at Johns Hopkins Medicine. “The more you screen, the more you’re going to find,” he said.

Doctors typically diagnose atrial fibrillation with an electrocardiogram while factoring in your medical and family history. They will sometimes give patients a portable monitor to wear for up to a month to look for an irregular heartbeat.

A-fib can cause clots to form in the heart that can travel to the brain and lead to strokes, even in younger patients, Dr. Bhonsale said. The condition may also raise the risk of cognitive decline and dementia , as well as heart failure. In the study, researchers found that people with A-fib under the age of 65 were at a significantly higher risk of hospitalization for heart failure, stroke and heart attack, compared to people without A-fib.

What’s driving the increase in younger adults?

Atrial fibrillation may also be increasing among younger adults because many of the risk factors for the condition — including pre-existing heart disease and diabetes — are on the rise in that age group, too, Dr. Bhonsale said.

Nearly one in five people in the study who had A-fib also had obstructive sleep apnea , which is a significant risk factor for the condition. People with sleep apnea stop and restart breathing in the night; they struggle to get sufficient rest. The condition, which often goes undiagnosed , is tied to a range of cardiovascular issues .

There is also a correlation between how much alcohol people consume and the likelihood they will develop A-fib, said Dr. Bradley Knight, the medical director of electrophysiology at the Northwestern Medicine Bluhm Cardiovascular Institute. Smoking cigarettes and vaping are also linked with a greater risk of A-fib, Dr. Barnes said.

While exercise in general is associated with a lower risk of cardiac conditions, extreme endurance exercise, like marathons and triathlons, are linked with a higher risk of A-fib, Dr. Calkins said.

How is A-fib treated?

Doctors work with patients to address factors that make A-fib more likely to occur, such as by making sure someone with sleep apnea is using a CPAP machine or by helping patients quit smoking. Sometimes, particularly for younger patients, physicians will recommend a procedure called catheter ablation , which doctors use to get rid of tissue in the heart that may be causing an irregular heartbeat.

Doctors may also prescribe blood thinners, to reduce stroke risk, as well as other medications to manage symptoms. These include drugs that can help regulate heart rate and rhythm , Dr. Knight said. While medications can help reduce the frequency and duration of A-fib episodes, “they rarely eliminate the A-fib,” he added. He tells patients that the disease is like high blood pressure: It must be continuously managed.

“If you are diagnosed with A-fib at any age, but in particular at a younger age, you have been given a great opportunity to now say, OK, what things can I do to help better manage my health and reduce the chance of having a problem later in life?” Dr. Barnes said. “I almost think of it like a wake-up call.”

Dani Blum is a health reporter for The Times. More about Dani Blum

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Looking for a more luxe experience? The right sheets can make a big difference. Here is a selection to choose from .

White noise machines have the power to mask yapping dogs, clanky radiators and late-night parties. Consider buying one .

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Policies & Medical

Guest Conduct Policy

The Guest Conduct Policy is intended to ensure that all guests enjoy their cruise experience whilst following our code of conduct throughout their holiday.

Related FAQs

Age Requirements for Travel

Note: These terms are effective at the time of boarding.

Travelling with Infants:

• At least six (6) months of age on the day of boarding
• At least twelve (12) months of age on the day of boarding if your cruise has 3 or more consecutive days at sea.

Travelling with Minors and Young Adults: Norwegian Cruise Line's policy dictates that a minor or young adult under the age of 21 must be accompanied in the same stateroom (or a connecting/adjoining stateroom) by a guest 21 years of age or older at the time of boarding.

• Minors – an individual under the age of 18 on the day of embarkation/boarding.
• Young Adult – an individual between the ages of 18 and 20.

Note: Two people under the age of 21 may travel together in the same stateroom if they are a married couple and provide proof of marriage to a Norwegian Cruise Line representative at the pier prior to boarding.

Travelling with Minors Unaccompanied by Parent or Legal Guardian*:

For passengers under the age of 18 travelling with an accompanying adult, who is not the minor's parent or legal guardian, a Parent/Guardian Consent Form that authorises the minor's travel and further authorises medical treatment in case of an emergency must be delivered to a Norwegian representative at the pier during check-in. Failure to produce this letter at embarkation may result in boarding being denied. Both living parents/legal guardians must sign and complete this form and attach a copy of his/her driver's license or other government issued identification. Minors of the same parent(s)/legal guardian(s) may be listed on the same form:

• 1) Download and Complete the  Parental Consent Release form  (PDF)

Minors or the same parent(s)/legal guardian(s) may be listed on the same form

• 2) Copy of both parents/legal guardians Driver’s License or other Government Issued ID

Adoptive parents, legal guardians or persons separated or divorced are advised to keep legal and other relevant documents available in order to clarify custody rights.

*If travelling to Canada, you’ll the following document in addition to items #1 and 2 (Alaska, Pacific Coastal, and Canada/New England Itineraries):

Canadian entry requirements stipulate that a child under the age of 18 travelling alone, or with person(s) other than both parents , should be in possession of a letter (preferably notarised) from the parents or legal guardian containing:

• Authorisation for the child to travel with another person and to be outside the country;
• The name and a 24-hour contact telephone number of the parents or guardian;
• The destination and length of stay in Canada.

ALCOHOL CONSUMPTION POLICY

Passengers must be 21 years of age or older to purchase or consume alcohol whilst in US sailings.

Parental consent is required for guests 18 to 20 to consume only beer and wine whilst vessels is in international waters. Authorisation will be given only when the accompanying parent completes the Young Adult Alcoholic Beverage Waiver form. This form can be obtained and completed at the Guest Services Desk upon embarkation of the vessel. In Alaska and Hawaii waters parental consent is NOT permitted for guests 18 to 20 years old.

Europe sailing permits young adults 18 to 20 to purchase and personally consume alcohol whilst onboard.

Please note that with the exception of Wine and Champagne, all guests are prohibited from bringing alcohol on board our ships. If you purchase any alcohol at one of our ports-of-call or in our onboard shops, we will safely store your purchase(s) and either on the final night of the cruise or the morning of debarkation it will be available for pick up in a designated area.

China/Asia: Do not serve or sell alcohol to guests under 21 years of age. Parental consent is NOT permitted for guests 18 to 20 whilst in China/ Asia waters.

Australia/New Zealand: Do not serve or sell alcohol to guests under 21 years of age. Parental consent is required for guests 18 to 20 to serve or sell only beer and wine whilst in international waters.

Wine & Champagne Policy

Guests may bring bottles of wine and champagne on board. When bottles are brought on board and served or consumed in any restaurant, public room area or in their stateroom, a corkage fee will be charged according to bottle sizes noted below. 750 ml Bottle: $15.00 USD 1,500 ml Magnum: $30.00 USD

Wine or champagne sent directly to the ship by travel agents, friends, family, etc. or from another retail source, are subject to the same fees. Box wines are not allowed on board.

Guests who purchase a beverage package, or who have a beverage package as part of the Free At Sea promotion, will not be charged a corkage fee.

* Norwegian encourages the responsible use of alcohol and accordingly reserves the right to permanently or temporarily revoke the drinking privileges of any guest who violates Norwegian's Guest Code of Conduct or who is deemed a danger to himself, herself or others by vessel management. Continued abuse of alcohol whilst sailing and/or violation of Norwegian's alcohol policy may result in immediate disembarkation.

For more information read our FAQ about "Can I bring water or soda on board?"

Passengers should not bring the following items onboard any Norwegian Cruise Line ship:

• Drones (Game Flying Device) Guests are not permitted to bring drones onboard for safety of other guests, as well as the welfare of the vessel.
• Samsung Galaxy Note7 In light of recent safety issues with the Samsung Galaxy Note7, we are asking our guests who own this model to please avoid travelling with this mobile device. The Federal Aviation Administration has banned the Samsung Galaxy Note7 from all air travel, and until further notice, this device will be restricted from all Norwegian Cruise Line ships. Fire is one of the greatest threats at sea and due to the safety concerns these devices present, if one is found in a guest's possession or unattended in a stateroom onboard, our policy instructs the crew to confiscate the device for safekeeping. The device will remain in our possession, in a safe, monitored location, for the duration of the cruise. Guests can reclaim their device at the conclusion of the cruise from the reception desk.
• Alcoholic or non-alcoholic beverages of any kind including water, soda and juices* For more information read our FAQ about "Can I bring water or soda on board?".
• Unsealed food items will not be allowed onboard.
• Firearms, weapons of any kind , ammunition, explosive substances or any goods of a dangerous nature
• Irons / Ironing Boards and Steamers Guests are not permitted to bring and use their own irons or steamers onboard. Norwegian Cruise Line carries a limited number of irons and ironing boards which can be loaned to guests for a few hours at a time. They can be requested through housekeeping or Guest Services Desk. Irons and steamers would both be taken from guests at embarkation and returned at the end of the sailing.
• Animals of any kind , except service or guide animals, provided the passenger notifies Carrier prior to the cruise of his intention to bring such animal and agrees to take sole responsibility for any expense, damage, injuries or losses associated with or caused by such animal.
• Large Batteries, Emergency Position Indicating Radio Beacons (EPIRB), ham radios, satellite phones, transformers, lasers and laser pointers are not allowed onboard.

For a full list of items that are prohibited onboard, please CLICK HERE

A physician and nurse are on each ship to provide medical care and services at customary charges. Commonly used medications are kept on board and may be prescribed by the ship's doctor.

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Shore Excursion FAQs

Who can book?

• Guests must order directly through Carnival.com.
• We will not accept Pre-Sail orders by telephone, fax, email or mail.
• Fully deposited cruise booking
• Cabin level booking number
• Internet access/email account
• Registered with Carnival.com
• For a list of acceptable forms of payment, click  here .

When can I book shore excursions? Shore excursions may be booked online prior to sailing up until the Pre-Sail cut-off time, 11:59pm ET, the evening prior to the cruise departure. After the online Pre-Sail, the remaining inventory will be available on the departure day on board the ship. Due to availability, it is strongly suggested that guests take advantage of ordering their shore excursions in advance, online, in order to avoid disappointment once on board. To browse our shore excursions, click here .

How do I book?

• Pre-Sail shore excursion orders must be booked online at www.carnival.com/shore-excursions ; the guest's cruise booking must be fully deposited. 
• The guest must be registered with the site.
• Only shore excursions relevant to the specific itinerary booked will be shown.
• Desired selections can be booked and placed in ‘My Shopping Cart’ for review.
• Full payment is due upon completion of the order process at ‘Check Out’. For a list of acceptable forms of payment, click  here . 
• Note: If shore excursions are booked online, they must be paid for immediately; if the shore excursions are purchased onboard the ship, then they are billed to the guest’s Sail & Sign® account.
• A confirmation page with order number will be available online in a print friendly format.

What happens after I place my order? Guests will be able to view and print:

• A shore excursion confirmation with an order number.
• A full itinerary/schedule of all shore excursions booked for all guests on the booking.
• Orders can be cancelled online, without cancellation charges, up until the Pre-Sail cut-off time, 11:59pm ET, two days prior to the cruise departure.  
• Shore excursion charges and corresponding payment will be posted to the designated responsible guest's Sail & Sign folio account.
• Shore excursion tickets are delivered to the guest's stateroom prior to embarkation.

How can I cancel a shore excursion online? In order to cancel a shore excursion order, please follow these steps:

• Login or access your booking by going to https://secure.carnival.com/BookedGuest
• Once in My CRUISE MANAGER , select VIEW DETAILS to view specific information about your cruise vacation.
• Click on the MY ACTIVITIES tab which will display the excursion purchased.
• Then click on the VIEW ORDER link on the right hand side.
• User will be directed to the MODIFY ORDER page.
• Select the guest(s) that wish to be removed by checking their respective boxes on the right hand side.
• Complete the contact information located below.
• Click on CONFIRM CHANGES to remove guest or to cancel excursion.

Can I purchase a shore excursion for the day I debark the ship? Yes, in many ports of call, shore excursions have been designed for guests with late flights. You will see these listed under your debarkation port name. Please verify your flight time prior to booking this type of shore tour.   Do I have to book a shore excursion through Carnival or can I go off on my own? You are not obligated to book shore excursions through Carnival in order to leave the ship. Public transportation is available at each port. We suggest you visit your local library, bookstore or a pertinent website to determine where you would like to go. Carnival does not offer any alternatives from the established shore excursion program. All shore excursions sold through Carnival are coordinated with reputable tour operators and include all of the most popular sites of interest. One of the many benefits of booking excursions through Carnival is a guarantee that the ship will remain in port until all guests are back onboard. Carnival will not be aware of shore excursions that are booked independently. Also, keep in mind that some ports have visa requirements that may prevent you from venturing off on your own. How do I make changes to shore excursion orders after the Pre-Sail cut-off time? Unfortunately, we no longer have access to any shore excursion orders after the cut-off time (11:59pm ET, two days prior to the cruise departure). Keep in mind that you will have up until this time, unless otherwise noted in the excursion description, to cancel all or part of existing shore excursion orders or change the designated contact person. In order to make any change to your shore excursion orders after the cut-off time, you will need to see the Shore Excursion Manager once you are onboard the ship. In the event of a cruise booking cancellation within the cut-off window, a full refund will automatically be posted to the form of payment used to pay for the order. 

What if the shore excursion I am interested in is sold out? Check back often. Unfortunately, it does happen that some of the more popular shore excursions will sell out. However, cancellations may occur from time to time. We recommend that you book all shore excursions as early as possible after booking your cruise and meeting all deposit requirements for each of the guests you are booking shore excursions for. If an excursion is not available, you may want to search for alternate excursions within the same activity type or see the Shore Excursion Manager onboard to check for last minute cancellations. The option to waitlist an excursion is not available at this time. When will I receive my pre-paid shore excursion tickets? Pre-paid shore excursion tickets will be delivered to your stateroom after sailing on the first evening of your cruise. Which shore excursions are recommended for physically challenged guests? It depends on the type and degree of the disability. In general, if guests are able to walk on their own, we recommend those excursions that are designated as easy or moderate activity. See specific excursion activity levels.

If guests are non-ambulatory, we generally recommend independent transportation for their comfort and convenience. Our shore excursion staff can provide them with excursion suggestions. We also recommend that non-ambulatory guests be accompanied by someone who is able to assist them throughout the duration of the excursion. Some ports of call require tenders to go ashore and that may preclude non-ambulatory guests from leaving the vessel. Will I miss meals if I go on shore excursions? When the ship is in port, the meal times are sometimes adjusted to accommodate the departure and return times of shore excursions booked through Carnival. On most ships, alternative dining is available so guests participating in shore excursions can dine at their convenience. When booking a morning excursion and an afternoon excursion together, you should allow a minimum of one hour, rather than the suggested 30 minutes, in between excursions to enjoy a quick buffet lunch onboard. If the port requires tendering, you will need additional time for the transfer to and from shore side. Does Carnival own the tour companies in the ports and is it responsible for what happens on the shore excursions? No. All of the shore excursions, including any related transportation, are operated by local independent companies and they are solely responsible for their products, excursions and any related transportation. We try to choose the most reputable companies available to provide your excursions. Carnival is not responsible for any losses, damage, death, injuries or claims whatsoever arising from, connected with, or related to any activities engaged in by guests while off of Carnival’s ships or tenders in any port of call.  This includes all shore excursions, whether sold onboard or by third parties ashore. You will engage in all such activities off of the ship at your own risk. Carnival neither supervises nor controls tour operators actions, nor makes any representation either expressed or implied as to their suitability. Carnival sells tickets for all excursions as a convenience to guests only. Tour operators, transportation providers, and their employees are neither agents nor employees of Carnival, not withstanding their use of any signage or clothing which may contain the name “Carnival” or other related trade names or logos. Are there any children's prices for shore excursions? Yes. Children between the ages of 4 to 12 years and teens between the ages of 13 to 18 years will be charged full adult price, or special child/teen prices when applicable and noted. Infants ages 3 and younger sitting on a parent’s lap and therefore not occupying a seat, are not charged for most shore excursions. These excursions are indicated with the 'Infants Free' advisory. There are also some shore excursions that require that each guest purchase a ticket, regardless of age. This will be noted in the specific shore excursion’s description. If a parent would like their infant to occupy a seat, where it is not required, then the parent must purchase an excursion ticket for the infant at the published excursion price or child price, where available. Parents are also responsible for bringing a safety seat for their child if required.

Guests under 18 years of age must be accompanied by an adult (18 years or older) to participate in shore excursions. Some excursions require a minimum age to participate and will be noted accordingly. Are there any special requirements to participate in a Beginner's Scuba Diving or Snuba excursion? Yes. There are certain medical conditions that may prevent your participation in a Beginner’s Scuba Diving or a Snuba excursion. You must complete the medical history form and the liability waiver/release form that will be provided either onboard, or by the tour operator at the beginning of the excursion. There are several medical conditions that may prevent you from safely participating in a Beginner’s Scuba Diving excursion. Having any of the following conditions would require that you are examined by a qualified physician and obtain written permission from that physician to participate in the excursion:  Heart disease or previous heart attack, diabetes, epilepsy or seizures, high blood pressure or taking medicine to control blood pressure, presently taking prescription medicines (with the exception of birth control), pregnancy, asthma or any form of lung disease, recent surgery, blackouts, sinus problems, fear of closed spaces, recurring migraine headaches, recurrent ear problems, and severe motion sickness. Keep in mind that this is not a comprehensive list. For more information you should consult your physician. What is the Tour Operator's Diving Policy? Due to the nature and level of physical exertion involved in diving excursions, certain excursions may not be appropriate for individuals with certain medical conditions such as asthma, heart conditions, high blood pressure or serious diabetes. This applies to scuba diving, Snuba, power snorkel, underwater scooter, and sea trek excursions.  Tour Operators require that all guests be able to participate safely in the excursions. You will be required to sign a Medical Waiver/Liability Release form on board prior to your shore excursion.  If you have any medical conditions that may affect your ability to participate safely in the diving excursion, please contact the Shore Excursion Department at  [email protected] prior to booking your excursion. What is the cancellation and refund policy for shore excursions in the event of bad weather or unexpected circumstances? Certain excursions have minimum guest participation requirements and shore excursions may be cancelled or modified depending on the number of guests participating. In the event of cancellation or modification of a tour, best efforts will be made to provide advance notice. Shore excursions may be cancelled by Carnival or the Tour Operator due to inclement weather conditions, or any other reason whatsoever. Full refunds will be made to guests who purchased excursions which get cancelled. If the shore excursions are cancelled prior to the sailing, you will receive a refund directly to the form of payment used to pay for the shore excursion order. If the shore excursions are cancelled while onboard, the amount of the refund will be credited to your shipboard account. What if I do not have a cruise booking number? You can always browse shore excursions online at www.carnival.com/shore-excursions . This will help you decide which of our exciting destinations you would like to visit.  However, to make a shore excursion booking, you must first book a cruise and meet all deposit requirements for each of the guests for which you are booking shore excursions. At this point, you should receive your cruise booking number. If you have done so and still do not have a cruise booking number, please contact your Travel Agent or whoever assisted you with your cruise booking. Will my shore excursion orders change automatically, if I change my cruise booking to a different ship and/or sailing date? If you have existing shore excursion orders and you change either ship or sail date, all shore excursion orders for your cancelled cruise booking will automatically cancel and any payments will be refunded to the form of payment used to pay for the shore excursion order. You will need to re-book shore excursions for your new ship and/or sail date by repeating the order process using your new cruise booking number. Keep in mind that new shore excursion bookings cannot be made online after the cut-off date for the new sailing. If you are within the cut-off window for the new sailing, you must purchase shore excursions once onboard. You will find a detailed listing of all available excursions for your cruise, along with a shore excursion order form and instructions on how to book excursions onboard. Some of our ships offer an interactive television system, which allows you to book your excursions from the convenience of your stateroom. Should I tip the tour guide? Tipping is a discretionary matter. However, it is customary around the world, if you are pleased with the excursion, to tip the tour guide. A general rule of thumb is one dollar per person for a half-day excursion and two dollars per person for a full-day excursion. What type of clothing should I wear on an excursion in a port? It depends on the climate of the port. Given the warm climate and the more rustic conditions in the Caribbean and Central America, we strongly suggest that you wear light, casual clothing and comfortable, low-heeled walking shoes or sneakers. For any brief tropical showers you may encounter, you might want to bring a fold-up umbrella and a light jacket. We have placed a symbol next to the water-related excursion descriptions, for which we suggest you wear your bathing suit, cover-up and hat.  Also, remember to bring sunscreen, a towel and a camera and to leave your valuables onboard, in your staterooms. For all golf excursions, collared shirts and either long pants or Bermuda-style shorts (no cut-offs, bathing suits, etc.) are required. Given the fluctuating climate in Alaska, Canada, and New England, we strongly suggest you dress in layers – a shirt, sweater and light raincoat will do. This allows you to add or remove layers as needed. Wear comfortable, low-heeled walking shoes or sneakers, or sturdier shoes for activities such as hiking. You might want to bring a fold-up umbrella and a light jacket in your carry on. Note: Cancellations due to weather are the determination of the tour operator only. See specific questions related to shore excursion cancellations. Can I take more than one shore excursion in each port of call? Yes, depending on the length of each applicable shore tour relative to the amount of time the ships stay in port. Make sure that you allow at least 30 minutes between each tour. Why are some of the shore excursions I saw while browsing unavailable for me to purchase? While browsing the site, you are able to view details for all shore excursions within a destination and port regardless of ship or itinerary. You are only able to purchase shore excursions that are offered for the specific itinerary you have booked. How can I receive technical support if I am having trouble with this website? For assistance with this website, or to report an issue of a technical nature, please contact our Online Support Desk. They are available Monday through Sunday, 9:00am to 9:00pm ET. You may contact them by calling 1-800-845-2599 or by email at [email protected] . Where can I address questions regarding the operation of an excursion? If you have an operational question about an excursion or you need additional information, please send an e-mail to [email protected] . Every effort will be made to provide you with feedback within 48-72 hours, with those queries requiring additional specific research possibly taking longer. Please be sure to include your ship and sail date in the subject line. And be sure to include any other specific information such as port name and exact excursion name in all correspondence. Are there any special requirements to participate in a helicopter excursion? The Federal Aviation Administration requires guests’ weights and names for weight and balance calculations as well as flight manifesting. Any guest whose weight is 250 pounds or more will be required to purchase a seat and a half. You must purchase the specific helicopter excursion for guests over 250 pounds or you will be refused service. Once onboard, you may see the Shore Excursion Manager for assistance. Is it possible to go shopping and participate in an excursion while in port? Yes. Many of our excursions are only a few hours in duration, leaving you with plenty of time in most ports for shopping, sightseeing or even participating in another tour. Also, many of our longer excursions include a shopping stop. What type of ground transportation is used for shore excursions? Standards of transportation vary considerably throughout the world. Air-conditioned equipment is requested, but is not always available. In some cases, the transportation used will be open-air safari buses, minivans, taxis or otherwise noted. Guests wishing to travel with friends should all leave the ship together, as this will help the shore excursion staff allocate sufficient space in the same vehicle wherever possible. Please note that motor coaches and other forms of transportation may require guests to climb 2 to 3 steps. Most, but not all motor coaches, can accommodate collapsible wheelchairs. Staff is not obligated to lift guests into or out of vehicles. Tendering may prevent guests in wheelchairs from going ashore at certain ports of call. For further information about specific excursions’ transportation accessibility, please look for the accessibility advisories online, represented by a blue wheelchair icon or see the Shore Excursion Manager onboard. Will I miss the ship if I go on shore excursions? One of the major advantages of participating in shore excursions sold through Carnival is that we closely monitor the excursion departures and returns. Therefore, we can assure you that even if there are unexpected delays on an excursion, your ship will be there when you return. Please be aware that if you make your own arrangements, or leave an organized excursion, you will be on your own and it will be up to you to make sure you return to your ship on time. What happens if I don't want to participate in the snorkel portion of the tour? For those excursions that include snorkel portions, participation is strictly optional. However, there is no discount taken off the price for the tour. Can I book my excursions over the phone? At this time, shore excursions can only be purchased online prior to your cruise or once on board. If you need assistance with how to book your shore excursions online, please contact our Online Support Desk. They are available Monday through Sunday, 9:00am to 9:00pm ET. You may contact them by calling 1-800-845-2599 or by email at [email protected] . Note: Promotional codes (when available) can only be redeemed online. Can I cancel or add to my shore tour order? Online: Orders must be cancelled online and no cancellation charges will be assessed if done prior to the pre-sail cut-off time (11:59pm ET,  two days prior to the cruise departure), as noted in the table below. In the event of pre-sailing online cancellations, a full refund will automatically be posted to the form of payment used to secure the order.

Any cancellations that need to be done after the pre-sail cut off time (11:59pm ET, two days prior to the cruise departure) must be done on board and will be subject to the following:

• 25% charge once on board
• 100% charge if cancellation within 24 hours of arrival in port
• Refunds less cancellation charges will be applied in the form of a credit to the guest's Sail & Sign account.
• Sail & Sign credit balances will be paid to the guest in the form of a Carnival check at the end of the voyage.

Can we book group excursions? In order for us to pre-arrange a group shore excursion, your group must have 12 or more guests booked under a common group booking number.  We would be glad to help you book shore excursions that are perfect for everyone in your party. The perfect occasion for enjoying fun activities during a Carnival cruise… is any occasion you’ve got! Whether you’re celebrating a birthday, anniversary, wedding, reunion, retreat, corporate meeting/incentive — or simply looking for an excuse to get away with extended family and friends — you’ll know that our experts are ready to help you plan something unforgettable. For more information please visit our Group Shore Excursion Page .

What are the guidelines for writing tour reviews? We want to publish your review, so please:

• Keep your review focused on the shore excursion
• Refrain from mentioning competitors, prices, promotions or time sensitive details
• Do not include any personally identifiable information, such as full names
• Avoid writing about customer service; contact us instead if you have issues requiring immediate attention
• Reviews should be written by the guest who took the shore excursion.
• Please do not submit a review if you have not taken the shore excursion.

What is the Shore Excursion Best Price Guarantee?       Guests sailing on a Carnival cruise who book a shore excursion through us can be completely confident they are getting the best price and best value with the introduction of our Shore Excursion Best Price Guarantee. The only guarantee of its kind in the cruise industry, the program is now available fleetwide for all Carnival Cruise Lines shore excursions on ships sailing from North America. Under the best price guarantee, guests who find the same tour offered by another operator at a lower price than their booked excursion either before or during their cruise will be eligible to receive 110% of the difference in the form of a shipboard credit. The best price guarantee is applicable to shore excursion matches on the same date as the tour purchased from Carnival. For details about the Shore Excursion Best Price Guarantee, click here .  

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• Guided tour

Moscow: City Sightseeing by Car/Bus

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Visiting a new city is akin to going on a first date, it is something you will never forget. Many people imagine Moscow as just a bunch of sporadic landmarks: Red Square, the Kremlin, Lenin’s Mausoleum and GUM. There is so much more to this wonderful city than that and even though we only have a few hours, we will do all we can to show you everything we know and love about our capital in one fell swoop. We will take you on a journey through the ages, from centuries ago, right up to the modern day, soaking in the sights of this vast and bustling metropolis. Bright, luxurious and both ancient and modern at the same time, Moscow invites you on a date you’ll never forget!

On our sightseeing bus tour of the city, you will see:

• The wonderfully historic city centre and its unique museums, magnificent cathedrals, the exquisite Chambers of the Romanov Boyars and of course, the famous towering red brick walls of the Kremlin, The charming beauty of the Alexander Garden awaits the capital's guests - a lush green oasis in the midst of the glass and concrete clad metropolis, basking in the etherial aura emanating from the whitewashed stone walls of the restored Cathedral of Christ the Saviour, the world- renowned fairytale onion domes of St. Basil's Cathedral and other impressive monumental buildings such as the library built in Lenin's honour - the Russian State Library - and the State Duma.
• The Lubyanka KGB headquarters is notorious to members of older generations and although nowadays, the face of the secret police has changed dramatically, the looming enigmatic building on the waterfront maintains its aura of mystery, shrouded in a variety of murky rumours and dark myths. Then, there’s another of Moscow's main attractions - the marvellous Bolshoi Theatre, yew simply cant leave Moscow without taking in its breathtaking architecture. Engrained in the fabric of Russia's cultural heritage, virtuoso performers such as prima ballerina Galina Ulanova, opera singer Feodor Chaliapin and pianist, composer and conductor Sergei Rachmaninoff once stood centre stage of this vaunted institution.
• The memorial complex on Poklonnaya Hill was constructed in the glory and honour of our heroes who defended our nation in the many crucial battles of the Great Patriotic War (WWII). This is a place that embodies a particularly acute and inextricable link between older ancf younger generations. Moving on to the Moscow International Business Centre, not dubbed ‘Moscow City' for nothing, a true glimpse of the future in the present. This incredible, rather jaw-dropping project in the capital has shown that Moscow has come to accept the age of the skyscraper. Finally, the stunning views from the observation deck at Sparrow Hills will leave professional and amateur photographers alike itching to capture them. How could one resist?

The most beautiful of all the world's cities - lady Moscow invites you out on a date!

The cost of an excursion with a personal guide for 1 person

Meeting point We'll pick you up at your hotel

St. Basil's Cathedral

House on the Embankment

Cathedral of Christ the Saviour

Vorobyovy Hills

Poklonnaya Hill Poklonnaya Gora

Moscow-City

Alexander garden

Russian State Library

Bolshoi Theatre

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• Excursion Moscow: City Sightseeing by Car/Bus
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Supporting the Mental Health of Employees of Color

• Angela Neal-Barnett

Advice for both individuals and decision-makers.

Mental health isn’t the same for everyone; disparities exist between people of color and their white counterparts in the prevalence, incidence, symptoms, and treatment of mental health conditions. You can take steps to acknowledge and address these disparities in the workplace. If you’re a person of color, you can address the mental health struggles you face at work by understanding racism and its impact and assessing the state of your mental health, even deciding whether your company is a place you can thrive. If you’re a leader, make it a priority to find out more about how your employees of color really feel at work and how you can better support them. Doing so is a win for the employees and the business alike.

Too often, we mistakenly assume that mental health is the same for everyone, and that race and ethnicity are not factors. But disparities exist between people of color and their white counterparts in the prevalence, incidence, symptoms, and treatment of mental health conditions. The Covid-19 pandemic and the wider recognition of racism as a public health crisis have highlighted these disparities, along with the need to acknowledge and address them in the workplace.

• AN Angela Neal-Barnett , Ph.D. is a professor of Psychological Sciences at Kent State University. The first Black woman promoted to Full Professor in the College of Arts and Sciences, she directs the Program for Research on Anxiety Disorders among African Americans. Follow her on Twitter @dranjela or Linked In: Dr. Angela Neal-Barnett .

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The CDC says maternal mortality rates in the U.S. got better, after a pandemic spike

Selena Simmons-Duffin

After an alarming spike in 2021, maternal mortality numbers the next year went back down, according to a report released Thursday. CDC Director Mandy Cohen says the rates are still too high. Rich Legg/Getty Images hide caption

After an alarming spike in 2021, maternal mortality numbers the next year went back down, according to a report released Thursday. CDC Director Mandy Cohen says the rates are still too high.

After spiking in 2021, the maternal mortality rate in the U.S. improved significantly the following year, according to a new report from the Centers for Disease Control and Prevention.

The data shows that 817 women died of maternal causes in the U.S. in 2022, compared to 1,205 in 2021. These are deaths that take place during pregnancy or within 42 days following delivery, according to the World Health Organization , "from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes."

"I think that the bump [in 2021] reflects the pandemic and we're returning to pre-pandemic levels," says study author Donna Hoyert, who a health scientist at the CDC's National Center for Health Statistics.

The maternal mortality rate in 2022 was 22.3 deaths per 100,000 live births. That's a significant decrease from the 2021 rate of 32.9, but it's still much higher than the rate in other wealthy countries.

There continue to be enormous racial disparities in the U.S. maternal mortality rate as well – the rate for Black women was 49.5 deaths per 100,000 births in 2022, compared to a rate of 19 deaths for white women. Research shows the vast majority of these deaths are preventable .

Dr. Veronica Gillispie-Bell is an OB-GYN in New Orleans who was not involved in the CDC report. She agrees that COVID-19 was likely the reason for the major spike in maternal mortality.

"I really think that 2021 was actually an outlier because of the circumstances," Gillispie-Bell says. "We know that because of COVID-19, there were disruptions to care that obviously impacted our ability to care for pregnant individuals, plus there were pregnant individuals who were dying from COVID." It's hard to know for certain since the CDC report did not include cause of death, she adds.

She's encouraged that the 2022 numbers are slightly lower than 2020 – 817 in 2022 versus 861 in 2020. "It could mean that we're moving in the right direction – I think we need more years of data to know," she says.

CDC's newest data comes several weeks after an academic study cast doubt on the agency's methodology, suggesting that a pregnancy checkbox on death certificates was causing the numbers to be much higher than they are in reality. CDC strongly rejected the study's findings.

Hoyert also defends CDC's methodology. "There was plenty of literature before we made the changes that we were underestimating [maternal deaths] without a checkbox, and so we did add the checkbox," she says, explaining that they have continued to do evaluations and issue guidance to ensure it's being used correctly.

"I think CDC is doing great work in collecting the data and sharing that back," CDC Director Mandy Cohen told NPR last month. "We disagree with how that study was looking at it, and think it's unacceptable for moms to be dying at that rate here in the United States."

The stakes for getting these numbers right are high in a post- Roe America. Reproductive health advocates warn that abortion bans threaten women's lives, and if CDC's data is not viewed as reliable by the public, that could make it hard to evaluate the impact of these restrictions.

In a statement about CDC's latest report, Dr. Verda Hicks, president of the American College of Obstetricians and Gynecologists, connected the maternal mortality figures to "the worsening state of reproductive health care since the Dobbs decision."

"When treating pregnancy complications, abortion care can be lifesaving, and withholding that care unquestionably compromises patient lives and outcomes," Hicks wrote.

Despite the challenges with the data, Dr. Gillispie-Bell says the public should still put a "great bit of stock" into CDC's analysis. She also pointed to the work of state maternal mortality review committees around the country – she is the medical director of the committee in Louisiana. They are supported and funded by CDC.

"The first step for our maternal mortality review committee – once we get the death certificate with that pregnancy checkbox – is to then start extracting data to confirm ... so our numbers are very accurate," she says.

Not all states have these committees validating maternal deaths and making recommendations to reduce their numbers. CDC Director Cohen pointed out the agency now has funding available for each state. She also pointed out that CDC's data has already led to policy changes to reduce maternal deaths, including allowing Medicaid coverage to continue for a year postpartum .

"I think we're making strides, which is great," Cohen added. "We have more work to do."

• Centers for Disease Control and Prevention
• reproductive health
• maternal mortality

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• Moscow Tours

Our 20 Best Moscow Tours of 2022

Join us on an unforgettable tour to Moscow, the capital of Russia. Imagine visiting Red Square, St. Basil’s the Kremlin and more. Moscow is one of Europe’s most vibrant cities and one of Russia’s most historical. All of our tours to Moscow are fully customizable and can be adjusted to fit any budget. Our most popular tours are listed below. Please click on the tour details to learn more or contact us for more information about our Moscow tours using the form at the side of the page. You can also schedule a call with one of our Russian travel specialists to learn more.

Classic Moscow

This is our most popular Moscow tour that includes all the most prominent sights. You will become acquainted with ancient Russia in the Kremlin, admire Russian art in the Tretyakov Gallery, listen to street musicians as you stroll along the Old Arbat street, and learn about Soviet times on the Moscow Metro tour.

Accommodation

PRIVATE TOUR

A Week in Moscow

This tour is a perfect choice for those who wish to get to know Moscow in depth. One of the highlights of this package is the KGB history tour which gives an interesting perspective on the Cold War. You will also have time for exploring the city on your own or doing extra sightseeing.

Weekend in Moscow

This tour is a great way to get acquainted with the capital of Russia if you are short of time. You will see all the main attractions of the city, the most important of which is the Kremlin - the heart of Russia. The tour starts on Friday and can be combined with a business trip.

Group Tour Moscow Break by Intourist

Russia's capital has so much to offer, from the Kremlin and the Metro to the Old Arbat street and the Tretyakov Gallery. Besides these sites, you will also visit a fascinating country estate which today is quite off the beaten path, Gorky Estate, where the Soviet leader Lenin spent the last months of his life.

Kolomenskoye Tour with transport

The history of Kolomenskoye stretches back for centuries. In 1380, Dmitri Donskoi’s army passed through Kolomenskoye on their way to the Kulikovo battlefield, and it was...

Tours by car

Kremlin, Red Sq., Cathedrals & Armory Tour

The Kremlin is truly a fascinating structure, at the same time it is an ancient tower, the city’s former military fortification, a palace, an armory, the sovereign treasury...

Walking tours

Kremlin, Red Sq., Cathedrals, Armory, Diamond Fund Tour

Old Arbat walking tour

You will be told of the street’s interesting history and view the street’s artisan culture. You will also have the opportunity to view and purchase souvenirs from the...

Tour to Sergiev Posad with transport

Considered by some to be the Russian Vatican, Sergiev Posad is the temporary residence of the Patriarch of the Russian Orthodox Church. The Trinity St. Sergius Monastery (Lavra)...

Tour to Kuskovo with transport

The Kuskovo Estate often called the Moscow Versailles due to its perfectly preserved French park, is an example of an 18th century, luxurious Moscow summer residence. Its history...

Tour to Tsaritsyno with transport

The Tsaritsyno Estate is located in the southern part of Moscow. The estate was constructed for Catherine the Great by the Russian architects Bazhenov and Kazakov in a romantic...

Moscow Metro and Old Arbat Tour

The Moscow Metro is one of the largest and most grandly built metro systems in the world. It was meant to be a showcase of the Soviet Union’s achievements for both the Russians...

Vodka Museum Tour with transport (excursion and vodka tasting)

Vodka is an important component of Russian life, an element of national identity and everyday culture. We invite you to visit the Vodka Museum and feel the atmosphere of long-gone...

Mikhail Bulgakov Apartment Museum

This apartment museum located close to Patriarch Ponds became the prototype of the "bad apartment" described in the novel "The Master and Margarita." Currently the museum's...

Kremlin, Red Sq., Cathedrals & Diamond Fund Tour

The State Museum of Lev Tolstoy Tour

Take this opportunity to learn more about the Russian writer Lev Tolstoy. During the visit to the museum you will see part of a vast collection of exhibits connected to Tolstoy...

Novodevichy Convent Tour with transport

Tour of the Novodevichy Monastery. Founded in 1524 by Grand Prince VasiliIoanovich, the original convent was enclosed by fortified walls and contained 12 towers. The structure...

City Tour with Visit to St. Basils & Red Sq. with transport

Panoramic City Tour. This Moscow tour is a great start to your trip and the best way to get acquainted with many of the city’s major highlights. Our professional guide will...

City Tour of Moscow

Head to the heart of Moscow with a professional guide on a 4-hour private walk through the city center. See Tverskaya and Old Arbat streets, Theatre Square with the world-famous...

Moscow Metro walking tour

Kremlin, Red Square and Cathedrals Tour

KGB Tour with transport

This is a very interesting and insightful tour. You will visit places connected with Stalin’s terror - a time of great repression and fear. You will be shown monuments to...

Soviet and Post-Soviet Moscow Tour

The tour begins with a drive or walk down Tverskaya Street – a Soviet masterpiece. In the years of Soviet power, Tverskaya began to undergo a transformation: it was widened...

Tretyakov State Gallery Tour

This world-famous gallery contains masterpieces of Russian art beginning in the 10th century up until today. You will view exquisite Russian icons and paintings from the 18th and...

Jewish Heritage of Moscow Tour

This tour offers a detailed look into the history and present-day life of the Jewish community of Moscow. On the tour, you will visit sites connected with the cultural and religious...

Vodka Museum Tour with transport (excursion only)

Lena, our guide in Moscow was excellent. She was very knowledgable and could answer any question we had for her. We liked that she could pick up on our interests and take us places we might not have thought of to go. When we realized that one of the places we had chosen to see would probably not be that interesting to us, she was able to arrange entry to the Diamond Fund and the Armoury for us. Riding the Metro with Lena was a real adventure and a lot of fun. In Saint Petersburg we found Anna well versed in the history of the Tsars and in the Hermitage collection. Arkady in Veliky Novgorod was a very good guide and answered all of our questions with ease. Novgorod was perhaps a long way to go for a day trip, but we did enjoy it. Vasily was a great driver to have and kept us safe with good humour and skill. We enjoyed ourselves so much, my daughter says she is already planning to return. We would both have no hesistation to recommend ExpresstoRussia to anyone we know.

Just wanted to let you know that My grandson Bruno and I couldn´t have been more pleased with our week in Moscow (6/15 - 6/21). We were absolutely enchanted with the whole experience, including getting lost a couple of times in the Metro during our free time. Although both our guides (both Eleanas) were excellent, I would particularly commend the first one (she took us to the Tatiakov, the KGB tour, and to that beautiful cemetery where so many great Russian artists, authors, composers, musicians, militarists, and politicians are buried). Her knowledge is encyclopedic; and her understanding of today´s Russia as a product of its past was, for us, truly enlightening. I will be taking another tour in Russia, with my wife, within the next two or three years. I will be in touch with you when the time comes. Meanwhile, I will refer you to other potential visitors to Russia as I meet them.

Tours to Moscow

Our Moscow tours are land only meaning that you arrange your own air travel to Russia and our expert staff meets you at the airport and handles everything else from there. Our online Airline Ticket booking system offers some of the most competitive rates to Russia available on the web so if you need tickets, please visit our Russian air ticket center . Rest assured that you will be taken great care of on one of our Moscow tours. Express to Russia has a fully staffed office in Moscow that will help to make your visit fun, informative and unforgettable. Please remember that of all these tours are private and can be adjusted to your taste. You can add, replace or skip some sights; you can add more days to the package or cut the tour short. Our specialists will be glad to help you create the tour of your dreams!

Moscow, a City Like No Other

Moscow is Russia’s largest city with a population of between 12 and 13 million. It is also Europe’s largest city and when you visit Moscow, you can feel it. The layout and architecture of the city is eclectic, ranging from crooked, ancient streets and alleyways to wide, bustling boulevards, from medieval churches to Stalin skyscrapers and to modern, glass buildings towering over everything and of course in the center of it all is the Kremlin and the magnificent Red Square. Moscow is also home to a fantastic, efficient and very beautiful metro system – each station having its own special design. In fact, Express to Russia’s Moscow metro tours and excursions are some of our most popular attractions that we offer. On our Moscow tours, you will see this and more.

Moscow Tours centering on Russian History

Moscow has a long and interesting history and has been the capital of Russia in many of its different iterations – capital of the Grand Duchy of Moscow , the Russian Empire and of course the Soviet Union (who could ever forget the Soviet Union?). Moscow, was founded in the 12th century by Prince Yuri Dolgaruki (Yuri of the long arms – he really did have long arms!). From that time on, it was home to the Russian Tsars until Peter the Great moved the capital to St. Petersburg in 1703. The city has survived invasions and sieges from the Mongols, the Tartars, the Poles, Lithuanians and Napoleon but has always persevered. Our Moscow tours will enlighten you on this great history and give you insights into Muscovites and their unique culture. Our Moscow tours show you what the city is like today but also brings to life the past. Moscow never seems to sleep and is bursting with energy. A Moscow tour with Express to Russia is truly the best way of getting to know Russia’s largest and most vibrant city.

Frequently Asked Questions From Our Travelers

What is the best time to visit moscow.

Any time of year is fine depending on what you plan to do. Summertime is pleasantly warm, ideal for exploring the city and its vibrant atmosphere, but Moscow will be much busier and accommodation is more expensive. Winter can be quite cold but beautiful nonetheless, and this is unproblematic if you intend to spend most of your trip in museums and galleries. There are also various festivals and events organised throughout the year. For more information about the best time to visit, read our guide

How many days are enough in Moscow?

If you plan your itinerary strategically and aren’t averse to a packed schedule, you can cover Moscow’s main sights over a long weekend. Most popular attractions are in the city centre, and the Moscow Metro allows you to cover much ground in a small amount of time. Ensure that your accommodation is fairly central and book tickets in advance, so that you can make the most of your days. For an informative and well-organised day out, check out our Moscow day tours with options to suit all interests.

Do they speak English in Moscow?

As Russia’s capital city, tourists are well accommodated in Moscow. There should be English-speaking staff in restaurants, bars, hotels, shops and attractions in tourist hotspots, and there are also English-speaking tourist police. Transport services have English translations on their maps and English announcements via intercom; alternatively, order taxis from the Yandex Taxi app (Russian Uber), though it’s unlikely that your taxi driver will speak English. If you get stuck and cannot communicate, it’s fine to use Google Translate.

Is it safe to travel to Moscow?

It is no less safe to travel to Moscow than to any European city if you exercise common sense and look after your belongings. As with every city some regions can be more unsavoury than others, but no tourist attractions are located there. The traffic in Moscow is notorious, so exercise caution when crossing roads. Do not take unlicensed taxis; book in advance or take public transport, which is widespread and perfectly safe. If you encounter any problems, look for the special tourist police who can help you. For more information, read our guide about staying safe in Russia .

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Florida releases emergency rules on exceptions to new 6-week abortion law.

The new rules cover documentation and clarify that it will not "constitute an abortion” to induce live births and babies die because of prematurely ruptured membranes, or for treating ectopic pregnancies and trophoblastic tumors.

With a law now in effect preventing abortions after six weeks of pregnancy, Florida health care regulators on Thursday released rules related to treating emergency medical conditions that pose dangers to the lives of pregnant women or unborn children.

The state Agency for Health Care Administration published two rules that apply to hospitals and abortion clinics. The rules came a day after the six-week law took effect that significantly restrict abortion access in the state.

Regulators focused on certain medical conditions that might occur after six weeks of pregnancy and “can present an immediate danger to the health, safety and welfare of women and unborn children in hospitals and abortion clinics,” according to the rules.

Those conditions are “premature rupture of membranes,” commonly known as a pregnant woman’s water breaking prematurely; situations when prematurely ruptured membranes cause doctors to induce births and babies die; ectopic pregnancies; and treatment of what are known as trophoblastic tumors.

The rules involve record-keeping and reporting about the treatments. One of the rules requires hospitals to have written policies and procedures about maintaining records related to treating the conditions. It also includes directives about what must be included in policies.

As an example, the rule said that, under the hospital policies, when a woman is diagnosed with premature rupture of membranes, “the patient shall be admitted for observation unless the treating physician determines that another course of action is more medically appropriate under the circumstances to ensure the health of the mother and the unborn baby.” If doctors choose another course of action, they would have to document the reasons.

Also, both rules say that it “does not constitute an abortion” if doctors try to induce live births and babies die because of prematurely ruptured membranes. Similarly, treatment of ectopic pregnancies and trophoblastic tumors will not be considered abortions. The hospital rule would require doctors to document such treatments in patients’ medical records.

An ectopic pregnancy occurs when a fertilized egg grows outside the main cavity of a woman’s uterus. “The fertilized egg can't survive, and the growing tissue may cause life-threatening bleeding, if left untreated,” information on the Mayo Clinic’s website said.

Trophoblastic tumors “form during abnormal pregnancies,” with some tumors malignant but the majority benign, according to information on the Cleveland Clinic website. What is known as gestational trophoblastic disease is rare, the website said.

Florida lawmakers and Gov. Ron DeSantis in 2023 approved the six-week abortion limit. But it did not take effect until Wednesday, a month after the Florida Supreme Court upheld the constitutionality of a 15-week limit passed in 2022. The Supreme Court ruling also allowed the six-week law to move forward.

The law includes limited exceptions for when abortions can be performed after six weeks. For instance, it would allow abortions if two physicians “certify in writing that, in reasonable medical judgment, the termination of the pregnancy is necessary to save the pregnant woman’s life or avert a serious risk of substantial and irreversible physical impairment of a major bodily function of the pregnant woman other than a psychological condition.”

But the law’s opponents have contended that the exceptions are impractical and that the six-week limit will threaten the health of women who might have a variety of medical conditions but are unable to obtain abortions.

The rules published Thursday in the Florida Administrative Register pushed back against opponents, citing “disinformation.”

“The Agency (for Health Care Administration) finds there is an immediate danger to the health, safety, and welfare of pregnant women and babies due to a deeply dishonest scare campaign and disinformation being perpetuated by the media, the Biden administration, and advocacy groups to misrepresent the Heartbeat Protection Act (the six-week law) and the state’s efforts to protect life, moms, and families,” the rules said.

AstraZeneca’s COVID-19 vaccine and blood clots — what you need to know

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AstraZeneca admitted in court that its vaccines can cause rare blood clotting condition. Should that give its recipients pause?

Pharmaceutical giant AstraZeneca admitted in court this week that its COVID-19 vaccine can cause a rare but deadly blood-clotting condition. But experts say the admission only confirms prior knowledge.

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Pharmaceutical giant AstraZeneca admitted in court this week that its COVID-19 vaccine can cause a rare but deadly blood-clotting condition that has become the central focus of a class-action lawsuit worth potentially $125 million.

A Northeastern University legal scholar says the admission isn’t especially damning, as the rare condition — called thrombosis with thrombocytopenia syndrome, or TTS — was well-studied prior to the ongoing litigation. 

“The fact that this had already been listed as a potential side effect reduces its legal impact,” says Richard Daynard , university distinguished professor of law and president of the Public Health Advocacy Institute . 

Daynard continues: “After all, the vaccine saved many more lives in Britain than were affected by this side effect, so AstraZeneca’s admission — of what had already been listed — would not seem to be a big deal.” 

There are 51 cases of TTS associated with the AstraZeneca vaccine cited in the U.K.-based class action suit. The Centers for Disease Control and Prevention notes that there are roughly four cases of the condition reported per one million administered doses of the Johnson & Johnson vaccine which, like the AstraZeneca, is an “adenovirus” vaccine. 

If you received the AstraZeneca vaccine, should you be concerned about TTS? Northeastern Global News spoke to Mansoor Amiji , Northeastern distinguished professor in the departments of pharmaceutical sciences and chemical engineering, to get some perspective on the link between the shot and this rare side effect.

Amiji’s comments have been edited for brevity and clarity.

What should people know about this blood clot condition that has become the focus of this lawsuit?

There are a couple issues to discuss here. First of all, the AstraZeneca vaccine is an adenoviral DNA vaccine, so it doesn’t use the mRNA molecule delivered through the lipid nanoparticles that Moderna and Pfizer developed. 

Through a collaboration with Oxford University, the AstraZeneca vaccine was first approved in the United Kingdom. It uses a modified form of what basically is a cold virus, or an adenoviral vector, and the vaccine delivers a DNA molecule that then gets into the human cell and encodes for the spike protein — very similar, in terms of the final product, to how the mRNA vaccines work.

In the United Kingdom and other places where this particular vaccine was prevalent, we did see a small number of people develop thrombocytopenia, or blood clotting that is initiated by a protein called platelet factor 4. It’s a very rare side effect, but it was seen in a number of cases post-approval of this vaccine back in 2021 and the early part of 2022. 

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The news this week isn’t news to the medical community. The reason it is coming to our attention is because AstraZeneca is now saying that this is a side effect of their vaccine. Initially, they was sort of hand-waving about the connection, saying that the development of the blood clots could be due to other factors, like a person’s comorbidities, vascular disease or other secondary considerations. It wasn’t clear that it was linked directly to the vaccine itself.

However, when you see that the majority of those who developed this condition did so post-vaccination — and it is in a very small percentage of those who received this vaccine, to be clear — the link becomes much more apparent. Now, they’re admitting that the vaccine may be responsible.

When the AstraZeneca vaccine was initially suspected in cases of thrombocytopenia, the causal mechanism wasn’t clear. What do we know about how the vaccine might cause this condition? 

Like I said before, the adenovirus has a DNA molecule inside it, which is then injected intramuscularly. But when in the bloodstream, this DNA molecule attracts a protein in the blood called platelet factor 4, and in certain individuals — not in all, but in a very small number — platelet factor 4 can exaggerate the body’s own immune response. Typically when you see clot formation in the body, it’s a mechanism by which the body is attempting to shield something from everything else in our body. It creates a capsule around the viral particle and recruits more platelets and red blood cells and fibrin, creating a blood clot, and this is referred to as thrombocytopenia. 

The U.K., where this lawsuit is ongoing, has a pretty high uptake — about 150 million people — of the COVID-19 vaccine, but the majority of people there have received the Pfizer vaccine. This issue is not prevalent in the mRNA vaccines — at least, we haven’t seen that level of clot formation here in the United States, where a majority of individuals have been vaccinated either with Moderna’s or Pfizer’s mRNA vaccine that is delivered using a lipid nanoparticle formulation. 

But in terms of the number of cases of thrombocytopenia and whether this is truly an issue that should worry people, the mechanistic studies have already been conducted, and only a tiny fraction of individuals were affected. Also, we aren’t seeing any other serious or new side effects associated with these vaccines.

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