Viruses: the First Line of Defence

Manuel Rivas, public health manager, Royal Caribbean International, Celebrity Cruises and Azamara Club Cruises:

As an industry we are getting much better at controlling outbreaks of gastrointestinal illness, despite there being more and bigger ships at sea. This year there have been only ten cases in the industry on ships coming into the US, compared with 15 last year, 15 in 2008 and 23 in 2007. As a whole, there are better protocols in place, advancing technology and new chemicals that need much less contact time to be effective.

During 2008 Royal Caribbean International recorded no outbreaks with the Center for Disease Control. Our newest and largest ship Oasis of the Seas has no recorded outbreaks. Developing and executing policies to prevent and mitigate outbreaks is a priority for us.

All cruise lines share best practice because an outbreak affects everyone, whether it’s Carnival, NCL or ourselves. We compete for business but we have no secrets if it’s anything to do with public health. We have a common goal.

Current outbreaks tend to connect to a geographic destination or the length of cruises. There have been a low number of outbreaks in the US this year, but more in Europe, particularly in the Scandinavian countries, the Baltic and the UK.

A new Norovirus strain, GII- 4 New Orleans, has also emerged in recent years. Usually, this strain doesn’t last more than 24 hours, but is much more aggressive and causes more vomiting, which aerosolises the virus.

Outbreak operating codes

At Royal Caribbean, Celebrity and Azamara we have changed our operating procedures, which has helped keep numbers down. We previously operated with Green, Yellow and Red codes, where Green was normal operating procedures, Yellow was 0.5% of passengers with symptoms and Red was 1.5%, still half the number for a reportable outbreak.

We removed code Yellow and now have Level 1 and 2, where Level 1 is standard operating procedure. If a ship has six cases reported in six hours or 0.5% of passengers we automatically go to Level 2 and this has helped us react much faster than previously.

Also, if we visit a port where Norovirus has been reported locally or on another ship, we automatically upgrade our processes and take preventative actions such as disinfecting the transportation for shore excursions and tendering. We’re also using friendlier chemicals with electrostatic sprayers on hard and soft surfaces which help us cover large areas and those which may have been previously overlooked.

If passengers reported every case it would help us to be more effective. Now, with access to the internet, passengers bring their own medicines to control symptoms, don’t see the doctor and spread the virus. Hand washing is still the key and we have updated our guides, videos and hand sanitisers. If everybody washed their hands there would be fewer problems. However, norovirus is still the main challenge. Last year everyone thought the H1N1 outbreak was going to be more aggressive than it was. We brought in protocols by the World Health Organisation, CDC and CLIA in record time and it was very effective.

Tim Skinner, hotel manager, MSC Cruises:

Throughout the cruise industry, we face challenges presented by the ubiquitous potential of some kind of infection, whether from food, water or air. As we carry so many people of all ages and origins through so many regions and climatic conditions, we have to be aware and prepared.

Our first line of defence is understanding if we face any health risks by cruising in some areas. If there is a real risk, we don’t go. If there is an endemic health issue that we understand, and can handle, we take whatever steps are necessary to stay on the good side of health. Our arsenal of understanding and controlling infection caused by any kind of illness includes a well-trained crew, and tested, reliable procedures.

Preventing illnesses onboard

In every case, the action of choice is prevention. A good example is the way we tackled last year’s global rise of the Human Swine Flu pandemic (H1N1). The cruise industry worked together, shared information and introduced protocols to help detect the presence of H1N1 before passengers even put their feet onboard. This was done by introducing specific questionnaires to all embarking passengers in every port to self-declare any pre-existing symptoms of the virus.

A positive answer took us to the next step whereby our medical staff tested their temperatures. If fever was detected, the passenger was then given a quick test to determine if they were suffering from the type of fever that indicated the presence of H1N1. At that stage, we denied boarding and offered the passenger a future cruise.

MSC took this preventative process a step further by introducing Thermal Imaging Cameras to rapidly detect the presence (or absence) of a fever-level temperature as passengers were embarking.

We figured there was an even chance that some people would not want to admit (on paper) to having a fever if it meant they risked not being able to cruise. The thermal imaging system is highly accurate, quick and non-intrusive, and it has helped keep our ships free from H1N1.

I think the cruise business generally gives more attention, research and pro-active measures than any other sector of the leisure industry to prevent the onboard introduction of illness of any kind. This is in large part due to our collaborative involvement with authorities like US Public Health and the World Health Organization.