95,000 stranded at sea: What happens when a cruise ship becomes a hot zone

The last place anyone wants to be during the coronavirus pandemic is stranded aboard a cruise ship, where disease can spread with lightning speed.

This week, the last 3,500 or so passengers aboard three cruise ships stuck at sea will be coming into port at last. The Pacific Princess and the MSC Magnifica, are scheduled to berth today in California and France with 1,880 passengers, who will be transferred into home isolation. The Costa Deliziosa had to evacuate one passenger with health issues last week at the port in Marsala, Italy. The ship’s nearly 2,000 passengers were reportedly quarantined until a coronavirus test came back negative, and the ship is said to be disembarking most of them in Barcelona today before returning to Genoa, Italy with its remaining 453 Italian citizens. There are still 124 additional ships in U.S. waters with 95,000 crew members of varying nationalities on board with no clear timeline for when and how they will all return to their home countries, some of which have closed their borders.

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Since the March 14 no-sail order issued by the U.S. Centers for Disease Control (CDC), the agency has helped bring more than 12,000 citizens and foreign nationals into home isolation. At least 17 cruises have had passengers testing positive for COVID-19. “We’ve even had people coming back positive from Nile River cruises,” says Cindy Friedman, a medical epidemiologist who leads the CDC’s cruise ship team.

Even when quarantined inside their cabin, passengers are not necessarily shielded from infection, says Joacim Rocklöv, an epidemiologist at Umeå University in Sweden. Rocklöv estimates that a single person on board the Diamond Princess cruise ship in January infected 15 others, a rate four times higher than observed in Wuhan, China, where the new coronavirus virus first emerged. Rocklöv suggests this could’ve been partly due to a “super spreader” event, such as a social engagement on-board where the first infected passenger or passengers mingled with uninfected ones.

(Related: Here’s how to fight germs wherever you go.)

The virus is primarily transmitted through small respiratory droplets, which can spread on surfaces, through close contact, and, possibly, the ship’s ventilation system. Crew members packed up to eight to a room and delivering food to passengers can also expedite its spread. The disease has been particularly insidious because as many as a quarter of people who get it may not show symptoms, and infected individuals can spread the virus to others before they show symptoms. Because cruise ship passengers tend to be older than the overall U.S. population, they are also most susceptible to becoming critically ill or dying.

Michael Callahan, a medical doctor and infectious disease expert at the Massachusetts General Hospital in Boston, participated in medical evacuations of the Diamond Princess and Grand Princess cruise ships. He says that if it were up to him, cruises around the world should have been immediately evacuated and passengers and crews quarantined inside hotels for 14 days. “You’ve got to break the chain of infection,” he says.

Diamond Princess evacuation

The true scale of the threat of COVID-19 first became clear with the outbreak aboard the Diamond Princess. The infection is thought to have been brought on board by an 80-year old Chinese man who had disembarked by the time his positive test came back on February 1. Even after guests were sequestered in their cabins and the ship docked in Yokohama, Japan, the disease continued to spread among the 2,666 passengers and 1,045 crew. The first 10 cases were confirmed on February 5. Japanese authorities removed sick passengers one by one and treated them at a local hospital, but passengers were otherwise confined on board.

Deluged with emails and phone calls from passengers and family members, the CDC waited a week to authorize a quarantine operation, at which point more than 200 passengers had tested positive along with 20 crew members, including many in food service. Inconsistent testing and delays in receiving the results, however, meant that many more were likely infected.

The U.S. had never conducted a large-scale mission to evacuate citizens from abroad amid an infectious disease outbreak. Doing it on a cruise ship? That was new, too. “There was no rulebook,” says Callahan.

A little-known agency inside the Department of Health and Human Services known as the Assistant Secretary for Preparedness and Response kicked into action. Officials there cobbled together teams of doctors, nurse practitioners, nurses and pharmacists, and brought in Callahan and another infectious disease expert, both veterans of Ebola hot zones in African nations.

(Related: Learn how the coronavirus compares to Ebola, flu, and other outbreaks.)

James Lawler, a medical doctor and co-executive director of the Global Center for Health Security at the University of Nebraska Medical Center, got the call on a Tuesday and was on a plane to Japan the next day, having plunked down a $35,000 government grant to buy 21 pressurized bio-containment suits. “That’s a lot of extra carry-on bags,” he says.

Because of the virus’s high fatality rate—as high as one to two percent—the team treated the entire cruise ship as a “hot zone,” meaning they had to use the strictest infection control procedures. A tent set up at the farthest end of the dock was used to remove and decontaminate or dispose of their gear upon stepping off the vessel.

Doctors scrutinized Diamond Princess’s manifest to identify American citizens and checked on each one, beginning with passengers most at-risk, including the elderly and those with conditions such as diabetes or mobility issues. A pharmacist based in the ship’s library maintained radio contact, obtaining appropriate prescription refills from Japanese pharmacies.

Once cleared, 329 Americans wearing masks were then taken by bus to two cargo planes and flown to quarantine on military bases in the United States. Eleven passengers would end up testing positive by the time they arrived and were flown on to Nebraska. Three more would fall ill later. An additional 111 Americans were either hospitalized in Japan or remained there for other reasons.

Overall, the Diamond Princess outbreak infected 712 passengers and killed 9. Had the passengers been isolated and quarantined on February 3, those actions likely would have prevented at least 76 infections, according to an analysis in the Journal of Travel Medicine.

“It was absolutely the right move to get Americans off,” Lawler says.

The March 8 cruise ship evacuation of the Grand Princess, which began 50 miles off the coast of California, proved to be even more harrowing for rescue workers. Amid rough waters, the medical team had to leap from a small Coast Guard vessel to a lifeboat and on to a ladder dangling from the cruise ship—all while wearing clumsy bio-containment suits.

“A mistake would have resulted in severe injury, or death from drowning or crushing injury between the two vessels,” reads a government commendation letter given to Bryan Lovejoy, a nurse practitioner on that mission.

All aboard

In the six weeks since the Grand Princess medical evacuation, cruise ship quarantine procedures have changed as COVID-19 has become endemic in U.S. communities and as various states and localities have enacted social distancing measures.

Under CDC oversight, cruise lines are responsible for getting passengers safely into home quarantine through charter flights and buses. Symptomatic and asymptomatic passengers are separated, while the Coast Guard and ambulances handle those needing medical evacuation. With a vaccine not expected until next year, it remains unclear when cruises will be safe. On April 15, the CDC’s no-sail order was extended for 100 days or until the agency rescinds it. “With this pandemic, it’s really not advised to go on a cruise,” says the CDC’s Friedman.

Princess Cruises, Holland America, and Carnival Cruises have canceled all their bookings through the middle of the summer, though reservations are reportedly up for 2021. In a statement, Cruise Lines International Association said that “cruising is neither the source or cause of the virus or its spread” and that “it would be a false assumption to connect higher frequency and visibility in reporting to a higher frequency of infection.”

(Related: What to do if your vacation has been canceled.)

Carolyn Wright, a Santa Fe, New Mexico-based photographer who was quarantined on the Grand Princess in Oakland in March, says that she and a friend have a reservation for a cruise in Germany this fall.

“I’m certainly not looking forward to the Viking Cruise like I was,” she says. “I don’t know if it’s going to happen.”