From the extent and tone of early media reports of the H1N1 virus, it seemed that ‘swine flu’ was as ominous as a modern-day plague. The disease broke out in Mexico City in March 2009, resulting in a swift death toll that drew attention from around the world. By late April, all major cruise lines had discontinued travel to Mexico, following an advisory from the US Centers for Disease Control (CDC).

However, by December an update by the World Health Organisation (WHO) reported that the H1N1 death toll was fewer than 10,000 people. According to a WHO report published in 2003, normal or ‘seasonal flu’ kills up to half a million people.

“When you think of a large cruise you think of a biological island.”

While the virus may not have caused the high death toll predicted, its presence and perceived threat made the cruise industry take notice, especially when, in May, two cases were confirmed on an Alaskan liner.

Indeed, the threat of the virus on cruising was heightened when the Pacific Dawn, a unit of Carnival’s Princess line, became dubbed the "swine flu ship" after it became known that some of the 2,000 passengers were confirmed to have H1N1 and Australian authorities had diverted the South Pacific cruise from its intended course to the Barrier Reef. The company issued a statement at the time of the outbreak detailing its "abundance of caution" on board its vessels.

Government protectionism soon hit Royal Caribbean Cruise Lines (RCCL). The Ocean Dream, operated by Pullmantur, a Spanish unit of RCCL, had to cut short a Caribbean cruise after being denied dock in Barbados and Grenada and delayed embarkation in Venezuela.

"When you think of a large cruise you think of a biological island," notes Dr Phyllis Kozarsky, an expert consultant in the CDC’s division of global migration and quarantine. But she warns against singling out cruising. "It’s no different from people being in any other space for a long time; planes, buses or crowded shopping malls before Christmas."

Preventive medicine

Michael Crye, executive vice-president of technology and regulatory affairs with the Cruise Lines Industry Association (CLIA), is realistic about the threat of the virus. "The morbidity rate of this virus is way less than with avian flu," he notes, "The important thing is that more people are susceptible to this illness than a normal seasonal flu."

It’s not surprising that cruise industry sources suggest that their biggest challenge is the perception of H1N1 and arbitrary government reaction to it rather than the virus itself. "As our knowledge of the virus has evolved, our concern has diminished," says Dr Art Diskin, vice-president and global chief medical officer with RCCL. Gary Bald, corporate senior vice-president of safety, security, environmental, medical and public health with RCCL, adds: "There’s a reaction that isn’t consistent with the concern.

For example, a particular port that reacts in an unexpected way can cause challenges and disruptions. We call ahead to the port to ensure that we won’t have surprises, if a particular island or nation has never had H1N1 and we’re coming in with one case on board." The recommended ways to prevent people catching H1N1 are the same as for regular flu, or most communicable diseases: an array of hand-washing; cleaning and sanitising common areas; and isolating the infected as early and as much as possible.

One industry-wide change CLIA initiated in the spring of 2009 was a questionnaire and secondary screening at the point of embarkation. Depending on how passengers answer and look, they may be further evaluated by medical personnel, including, for example, having their temperature taken. MSC cruises has even installed thermal-imaging cameras in Italy to detect possible fever/ flu at embarkation.

“Historically, pandemics have three waves, so we may have one next year. The third wave tends to be mild.”

Carnival spokesman Vance Gulliksen echoed others in saying that the numbers of those turned away at embarkation would be "extremely small". As with other operators, Carnival has educated crew and customers on H1N1 and carries anti-viral medications on board. Since the disease is viral, not bacterial, drugs will not kill it, but can lessen sufferers’ symptoms and their duration.

However, Carnival has not added any new sanitation procedures specifically to address H1N1 beyond those routinely used to prevent communicable diseases. Gulliksen says the company’s protocols are "extremely effective" already.

Kozarsky is more cautious: "Most think H1N1 doesn’t take the form of tiny droplets that become airborne, but it’s hotly debated." She stresses vaccination and hand washing as the best protections and warns that consumers might be disinclined to admit that they are ill and forfeit their vacation plans.

Bald says RCCL has impressed on staff to pay closer attention to tell-tale signs that someone might be sick: "someone not coming out of their cabin or cancelling dinner."

Even if cruise officials get involved, Diskin says, "We don’t know if they have H1N1, only that they have flu-like symptoms." The screening tests on board, are very inaccurate, with just a 15% to 50% hit rate, he adds. Cruise operators have the right to isolate contagious passengers and to put them off the ship if they do not comply. They are also urged to minimise the number of crew catering to sick passengers. "It’s not altogether an honour system, because we’re obliged to contain diseases, but we do a lot of things, like providing movies, to help make the time pass," Bald says.

With the worse of the virus seemingly passed, there is still concern for the future. "Our biggest concern is that the virus could mutate, grow and become resistant to medication," Diskin says, but he hopes the worst is over. "Historically, pandemics have three waves, so we may have one next year. The third wave tends to be mild." Kozarsky is also cautious. "We have to see. We have yet to go through the typical influenza season, which peaks in the New Year." All she can say with certainty about the cruise industry overcoming H1N1 is that "Everyone is making a good effort and a stronger effort than ever."