[This article is written by Iain Hay, Anchor Hygiene Services Limited]

The entire concept of designing outbreak prevention and cruise ships’ responses has changed beyond measure since the COVID-19 pandemic. Suddenly it is not just the usual suspects – the United States Public Health Service (USPH), and other port health authorities who are interested in how cruise operators manage compliance and how they respond to illness on board. We must now also consider that the countries and port authorities we visit have a critical say with regard to the disembarkation of infected people and those who have tested positive and how that process is managed at every step of the way.

Prior to the coronavirus pandemic public health authorities in certain key countries followed the lead of the United States’ Centers for Disease Control (CDC) Vessel Sanitation Program (VSP), requiring that each vessel has a written Outbreak Prevention and Response Plan (OPRP) in place that details standard procedures and policies. But those OPRPs are geared to specifically address gastrointestinal illness onboard and nothing else as that is all the CDC were interested in.

Cruise ships were simply unprepared for the onset of a major outbreak of an illness unrelated to gastroenteritis and they had minimum plans or resources in effect to manage isolation for a highly infectious and potentially deadly outbreak the likes of COVID-19. They had never considered an outbreak in which port authorities and even the CDC would prohibit ships from disembarking infected people to medical facilities ashore. Having said that, however, the day-to-day protocols in effect on every cruise ship, although designed to principally protect against norovirus and gastrointestinal illness, were sufficient to deflect an all-out industry-wide pandemic within a world-wide pandemic. Only circa 57 ships (22% of all ships in the cruise industry) reported 2,787 COVID-19 cases and of the 520,000 world-wide deaths only 74 were attributed to cruise ships, which represents a startlingly low 0.07% of the world’s COVID-19 fatalities. In other words, 99.93% of confirmed cases around the world had no direct tie to cruising (source: Cruzeley, May 2020). A stark realisation then, that cruise ships are not overtly dangerous, as some sensationalist media organisations described them, veritable petri dishes (New York Times, Feb 2020) spreading the virus willy-nilly.

At the height of the pandemic Diamond Princess was prevented from docking in Yokohama, Japan, which resulted in catastrophe; Ruby Princess was denied docking in Australia and the Grand Princess in the United States to name but a few. These decisions led to exponential spread of the virus on those ships as well as to unnecessary deaths onboard. Aboard the Diamond Princess 712 people (567 passengers and 145 crewmembers) contracted COVID-19, of whom 14 died. This was a humanitarian disaster that must never be allowed to reoccur and it was thanks to the refusal of the port to allow the ship to dock from the start of their crisis, to quickly isolate the sick in hospitals ashore, or to effectively quarantine the healthy people. Of the total 74 cruise-ship-related COVID-19 deaths the 14 who died aboard Diamond Princess represented a staggering 19% of world-wide shipboard COVID-19 deaths.

By mid-March 2020 at least 10 ships around the world – carrying nearly 10,000 passengers were stuck at sea after having been turned away from their destination ports in the face of the Covid-19 pandemic, according to a Guardian newspaper analysis in the UK. Some of those ships were facing increasingly dire medical situations, but the clear threat to human life did not sway those ports or the CDC to act decisively to potentially save the lives of ill people onboard the ships.

Cruise ships are, first and foremost, holiday destinations with only a minimal medical response team on site and limited facilities (medical and testing equipment, isolation wards, etc.) so a major outbreak can very quickly overwhelm the ship’s hospital, allowing illnesses to spread at an alarming rate if local port and health authorities stand back and fail to allow access to shoreside medical care.

Ships must train their crew and be prepared for outbreaks that are not gastrointestinal in nature and which effectively fall under the radar of the VSP and the other health authorities cruise ships work with globally, including the likes of Health Canada, EU Shipsan, Brazil’s ANVISA and UK Port Health.

It is no longer feasible for ship operators to focus purely on passing inspections and achieving high public health scores twice per year. Ship operators’ claims that they are building ships that are USPH-compliant whilst simultaneously cutting back on the costs incurred to achieve that status has to be reversed.

Cruise ship management culture, both corporate and shipboard, needs to change. The days are over when a score is all that matters whilst ignoring critical violations. COVID-19 has driven home the reality that public health inspections are about highlighting risk and that ship managers’ responsibilities lie in alleviating those risks.

It is now time for the VSP to revamp their inspection platform to NOT focus on scores, but to look at the critical violations, and for the ships to respond with detailed corrective action statements accurately outlining what has been done to correct infringements. Public health and the prospective cruise clients who read public health inspection reports on the internet do not need to know what still needs to be done; only what was actually done to make good findings.

Ships must operate to the highest standards of public health compliance at all times, irrespective of their geographical location, if virulent person-to-person spread contagious diseases like coronaviruses continue to lurk as in all probability, at least until a vaccine is developed, they will. And new viruses will undoubtedly follow in the future to keep us on our mettle. Thus, crew public health training is of utmost importance, pre-boarding and throughout the contract, more than ever before.
The outbreak prevention focus for the future needs to radically change. Cruise operators need to develop plans that are three-tiered:
– Prevention: A robust and mandatory screening protocol is needed for all guests, crew, and for the vessel itself prior to embarkation with a view to ensuring voyages are 100% COVID-free prior to setting sail.
– Mitigation: Detailed processes and thorough reinforcement of the preventative actions, with measures that must be carried out during pre-boarding, onboard and post-cruise.
– Response: A detailed plan focused on patient care, management of passengers and thorough company and vessel protocols with shoreside and health authority support needs to be developed.

Note that in June 2020 the European Union (EU) released an excellent document on which to model a new cruise ship infection control programme and the World Health Organisation (WHO) is working on additional information/guidance. Furthermore, there has been some excellent scientific literature published outlining robust screening protocols, which are accessible through the internet.

During the pandemic crisis, ships’ managements felt helpless; incapacitated by unhelpful port authorities who refused to wake up to their altruistic responsibilities and permit coronavirus-infected people to disembark in their ports to be medically treated and/or isolated.

Ships were simply unable to quarantine healthy people onboard to an extent that would protect them from the virus. Nor could ships safely isolate ALL those who were infected and/or tested positive for COVID-19, whether symptomatic or not. Thus, new prerequisites to a restart of cruising will undoubtedly include the need for a number of cabins to remain unoccupied every voyage for use as isolation facilities.

It was generally felt that the cruise industry was let down by the world’s media whose sensational, one-sided and deliberately misleading creative portraits of the industry’s capability to handle outbreak crises were designed to apportion blame without consideration of facts, and to instil fear into prospective passengers. And they were also let down by those the industry considered allies - The CDC issued a 100-day “No Sail Order”, which they later extended, banning all foreign-flagged cruise ships to use American ports; and many ports themselves, world-wide, failed to allow ships to dock or even to allow the many thousands of serving crew to travel home long after the guests had departed.

The crew may have been accommodated for free and were well fed while they floated around the world in surreal uncertainty, but food and shelter alone for stranded crewmembers, given that those with no job to perform on a ship void of guests were not being paid, does not put food on the tables of their families far away; and the realisation that many jobs would be ultimately lost to the pandemic led to and continues to cause much high-stress anxiety, the sad consequence of which has resulted in several crewmembers of different cruise lines committing suicide out of sheer desperation.

The CDC holds the cruise industry to the highest standards and the VSP is very supportive with regard to offering guidance and training as well as epidemiological assistance in gastrointestinal and norovirus outbreaks. However, once the industry faced a problem that was not gastrointestinal in nature the CDC was no longer there offering their support. Instead, they unilaterally took the decision to close all U.S. ports to foreign-flagged vessels despite the CDC’s knowledge that those same cruise ships operate at the highest public health standards way beyond the reach of any US-flagged ship, or shoreside operation. No hotel or state/provincial institution could keep up with the plethora of public health programmes aboard foreign, or flag-of-convenience cruise ships. US-flagged ships, airlines and ground transportation in the United States are held to much lower Food and Drug Administration (FDA) standards that also applies to shoreside American hotels, catering and institutions, but despite that they could operate while the foreign flagged cruise industry was effectively punished.

The cruise industry was one of the first to cease operations once the pandemic took hold and they will be amongst the last to resume, at great cost to themselves and to the many supporting businesses, ports and authorities they work with around the world; not to mention the cost to the many thousands of crew sitting at home void of income and with no idea what the future holds for them.

It is no secret that on cruise ships, just as in any other confined space like airplanes, hotels, clubs and even hospitals, the risk of person-to-person viral spread is increased. However, COVID-19 illness and death figures prove that the cruise industry was far from complicit in spreading coronavirus. Yet, thanks to biased reporting, cruise ships are portrayed as pariahs. With this in mind, the importance of putting airtight systems and effective training in place before the restart of operations commences has to be the industry’s No. 1 priority. They cannot afford to give the press a reason to try to destroy their reputation a second time given that coronaviruses will still be with us for the foreseeable future and we all know that bad news sells.