Royal Caribbean Norovirus Nonsense

There seems to be annual news stories about cruise line passengers being sickened with gastrointestinal illness. This illness is commonly a strain of the highly contagious Norovirus. Norovirus is a tricky virus easily transmitted, and highly contagious. Norovirus is generally is difficult to tolerate and uncomfortable, but it is not usually life threatening.

In the setting of close quarters like a cruise ship a stomach bug can become a mini-disaster. Media reporting often shows the ship being cleaned after the ship makes port. Although necessary, medically speaking this is in reality a show. A show to make people think that the ship is now “safe”. It is a well orchestrated deception. The significant transmission vector for this disease is not the ship. The true origin is usually avoided by both the media and the cruise lines. The cruise line avoids the truth, probably deliberately. In the media’s case it is more likely poor epidemiological understanding.

For you see it’s not the ship that is the problem, it is the crew. 

Recently the Royal Caribbean cruise lines suffered a probable outbreak of Norovirus. In typical fashion they are “Sanitizing the Ship” now.

BAYONNE, N.J. (AP) — Kim Waite was especially disappointed to fall ill while treating herself to a Caribbean cruise after completing cancer treatment. The London woman thought she was the only sick one as her husband wheeled her to the infirmary — until the elevator doors opened to reveal hundreds of people vomiting into bags, buckets or on the floor, whatever was closest.

“I started crying, I couldn’t believe it,” Waite said. “I was in shock.”

Waite was among nearly 700 passengers and crew members who became ill during a cruise on Royal Caribbean’s Explorer of the Seas. The voyage was cut short and the ship returned to port Wednesday in New Jersey, where it was being sanitized in preparation for its next voyage.

Long lines of weary travelers arrived to freezing temperatures in Bayonne, as Waite and other passengers recalled days of misery holed up in their rooms with extreme stomach cramps, vomiting and diarrhea.

“I’ve never wanted to go home so much in my life,” Waite said. “I’ve never slept so much in my life, and I’ve got no suntan.”

Health investigators suspect norovirus, but lab results are not expected until later this week. The U.S. Centers for Disease Control and Prevention said its latest count puts the number of those sickened at 630 passengers and 54 crew members. The ship, scheduled for a 10-day cruise, was carrying 3,050 passengers.

“Sanitizing the Ship” will not fix the problem. I will attempt to explain…

Infections with Noroviruses, sapoviruses, and astroviruses present with a spectrum of illness. From mild fevers and diarrhea, to severe fevers, vomiting and constitutional illness. Norovirus is usually characterized by vomiting. Like most infectious disease it is most dangerous for the immune suppressed, the young, and the very old. Sapovirus is similar to Norovirus and can have vomiting too, but it seems to be harder to spread. Astrovirus seems to have prolonged incubation period, occurs primarily in children, and usually with less vomiting. Cruise ships outbreaks have been primarily a Norovirus.

I always find the video of employees cleaning the ship decks with hoses to be laughable. It is certainly true that the virus can contaminate surfaces and it can be spread by contact. Norovirus can live on a surface for about a week. There is a reason to clean the ship.

In my opinion that is not the reason why they make such a show about it. Surface contamination is not the primary way the outbreak begins. Nor is it the primary reason why it develops into such a logistical problem so fast. Cleaning the ship looks like due diligence from the cruise line. It is a flawed prevention method.

Like most businesses that have difficult problems, the cruise line is trying to direct your attention to the easy fix. Rather than dealing with the real issues of Norovirus. The cruise line is putting on a show. Look at my sparkling clean ship. It is a sham, a show, an illusion to give you the warm huggies about your upcoming cruise. Crew illness, employee working conditions, infection control procedures, and proper food service sanitation are the real issues with this disease.

***Warning the following discussion will be somewhat stomach turning for some****

The primary origin of Norovirus disease is Fecal/Oral contamination. A person suffering from a prodromal infection (meaning early symptoms IE stomach cramps but no diarrhea/vomiting) can spread Norovirus. An infected person can be asymptomatic up to 5 days before the start of any symptoms. They are still shedding the virus. They directly come in contact with their own feces/fluid in course of normal activities of daily living. The infected can wash their hands but the virus is difficult to eliminate. In particular Norovirus may only take 18 virus particles to infect someone else. Plus the infected have to touch surfaces in the washroom to wash. That spreads the virus onto surfaces that others touch. This can all occur before anyone is openly sick. Uninfected get it onto their hands eventually into their mouth and then they are infected and so on. Some studies suggest when there is extensive vomiting and diarrhea cleaning it up can aerosolize it(meaning airborne). Although it seems to be a problem only in close contact. There is no good evidence that it spreads through the ventilation system.

Then there is a snowball effect with this disease. You get sick but by the time you have symptoms mostly everyone around you has been exposed. Then they get sick. They spread it before they have symptoms and so on.

Cruise ships are problematic because they have close quarters, share recreational bathing and restroom facilities. The disease can spread logarithmically in the right conditions.

Cruise lines love to put the “ship being cleaned on the news”. The ship is not the problem. The problematic outbreaks usually originate from the crew in the food service division. The crew on these cruise ships are often no more than indentured servants. The are not subject to any US labor laws. Standards are at best murky.

Crewmen say they are fed cheap food, housed in cramped quarters and work dangerous jobs without safety equipment.

When they complain, they can be fined, jailed in the ships brig or deported in handcuffs, according to marine experts.

The same system is used by all of South Florida’s cruise ship companies. Sailing foreign-registered ships, they hire largely untrained crews from Third World countries to work at salaries and under health and safety conditions that would be intolerable to American workers.

While cruise industry spokesmen concede many of the allegations, they argue that they provide one of the few chances for thousands of Third World peasants and urban poor to improve their lives.

“They are coming for economic opportunities. Nobody puts a gun to their head,” said Ruthano Devlin, spokeswoman for the Miami-based Tropicana Cruises.

“We all do the same thing,” said Tim Gallagher, spokesman for Carnival Cruise Lines.

“I work all the time,” said Jerry Modesto. “From 6 in the morning until after midnight I wash pots. It’s hot. It’s noisy. I live with eight others in the cabin. But when I complain…” He drew a finger across his throat to indicate he was fired.

Modesto, a Filipino, said he worked 14 hours a day, seven days a week on Royal Caribbean’s Sun Viking for less than $400 a month. He said that is the norm, not the Exception.

So why are draconian work and hiring policies connected to Norovirus?

Simply put this is the law of unintended consequences in action. Crew are poorly trained and live in crowded conditions. Breeding grounds for these diseases exist everywhere. Secondly the crew is required to work or lose their valuable job. This is a huge incentive to hide any illness.

Simple scenario that results in disaster.

Patient zero is a sick crewman that is crewed with someone from the food service area. He/she is sick but hides it. His/her roommate works in the galley. Soon they are both infected. Patient zero is slowly infecting other crew members and slowly spreading it around the ship. The other is introducing it into the food supply. Suddenly an overwhelming 100 passengers become ill simultaneously. Family/friends that didn’t eat the food get sick. Plus the various crew infected by patient zero are spreading it to assorted areas. Even if the medical staff quickly recognizes the problem, it is too late. Some times quarantine helps. Mostly people withdraw from public areas and the infection becomes self limiting. A horror show for the infected and a ruined vacation for the uninfected.

That is just if you have two infected crew members. Imagine 8 people. The decks on the ship or the contaminated toilets are not the problem. It is the crew. Crew can move onto the next ship looking for work.

So what does this mean? Cleaning the ship is a tiny part of this issue. The crew need to be medically screened periodically. Reporting an illness needs to be rewarded not disciplined.

A US flagged ship must comply with workplace regulations. Foreign flagged ships are the problem. When you have cheap unskilled labor that at treated like workhorses this is what can happen.  Crew conditions are the real problem.

Cruisers should demand reasonable standards for crew working conditions. Mandatory sanitation and food service checks. Notably there needs to be rewards, not penalties, for medical complaints by crew. All crew that are noted to be ill by supervisors should be removed from service until medical staff can clear them.

Steaming the hallways with a 145 degree sodium hypochlorite (bleach) solution is fine. Yet it does not address the real issues in any way. Public health is not a dog and pony show and it is not a business. Having well trained and competent crew would make a huge difference in these situations. Both in prevention and control. It will never happen as long as cruise lines continue to use poorly trained and abused 3rd world laborers.

There will have to be a real regulatory change before you will get me onto a cruise ship.

This is not just wise from a medical standpoint but from a safety standpoint. Incompetent crew contributed to the lives lost in the Concordia disaster. I think that it is laudable to employ people that are poor and need help. Packing poorly trained workers into tight quarters to pad your bottom line is placing the people in your care at risk. This is short sighted and dangerous. Lining up 100 guys in hazmat suits won’t make your next cruise any safer. Plus it perpetuates the myths that surround the disease.

Cruise vacations I am told are very fun. I will have to take your word for that. For the foreseeable future no matter how many hazmat suits I see get on the ship I will not join the passenger list.

References:

http://www.lipcon.com/news_archive/news_article3.php

http://www.chron.com/news/us/article/Ship-where-nearly-700-fell-ill-being-sanitized-5188034.php

Bresee JS, Widdowson MA, Monroe SS, Glass RI. Foodborne viral gastroenteritis: challenges and opportunities. Clin Infect Dis 2002; 35:748.Hutson AM, Atmar RL, Estes MK. Norovirus disease: changing epidemiology and host susceptibility factors. Trends Microbiol 2004; 12:279.

About Stephen Propatier

Stephen Propatier is a board certified acute care nurse practitioner who specializes in spine and sports medicine. He is a member of the Society for Science Based Medicine. He is adjunct faculty for both Brown University Warren Alpert Medical School and Rhode Island College Graduate School of Nursing.
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13 Responses to Royal Caribbean Norovirus Nonsense

  1. Drew says:

    Even worse then Norovirus is the virus of greed.

  2. jeffwagg says:

    It’s important to keep in mind how small these numbers are. There are about 100,000 people on cruise ships at any one time. 700 getting sick on one ship is a very large and unusual number, but even still it only accounts for about 15% of people on board.

    There are no US flagged cruise ships, so there’s no way to compare. Also, it’s likely that the passengers are introducing the illness, as the crew has lived together for weeks.

    Cruise lines do everything possible to reduce the risk of illness. In fact, it was cruise lines that developed the new antiseptic gels that include citric acid so as to kill norovirus, since alcohol alone won’t do it.

    Your source for working conditions mentions someone being on the Starward, which hasn’t been in service since 1995. I’ve seen the crew quarters, and they’re tight, but they’re certainly more luxurious than the military has. Why doesn’t the military have the same problem?

    If we could isolate everyone who goes to a convention or even a theme park, it’s possible we’d see similar numbers. The fact is that whenever people get together, disease will spread. At least on a cruise ship, you have an emergency room traveling with you.

    Full Disclosure: I’m a frequent cruiser, and own a cruise-only travel agency.

    • skeptonomicon says:

      Jeffwagg, the reason the us military does not have the same problems is because they are highly trained soldiers, not endentured servants. IMHO, If you take a cruise or make your living off of cruise lines, you are only a tad better than a southern plantation owner prior to emancipation.

    • Stephen Propatier says:

      I would disagree with your assessment Jeff. The review of the carnival cruise line 2006 outbreak clearly originated from the kitchen staff. 300 cruisers from one dining room simultaneously became ill within 24 hours. That is not a person to person transmission that is food borne exposure. Also making my point is that they are foreign flagged to avoid US regulatory evaluations. The data is not available for this incident yet. However 700 persons with one illness with 24-48 hours in not likely to be person to person. So unless there is only one bathroom on this ship or passengers help out in the kitchen this is a unlikely scenario as origin for this outbreak.

  3. Jon Richfield says:

    Jeffwagg,
    The situation here is more complex, and with more dimensions than just virus or just abused labour, and one result is a plague of confused issues, special pleading, & begged questions. I am embarrassingly ignorant in matters concerning cruise ships and epidemiology, but there are a few points that it would be nice treat with citrate gel before we swallow them whole.

    “Small numbers” might have been nice if the issue were what one’s probability of infection were, distributed evenly, but firstly, they were not. Still, using your own figures, that is about 0.7% individual risk, roughly 1% if you like.
    Secondly, that is pretty handy misdirection from the real situation; 700 on one ship might have been a lot, but given that there are two cruise vessels, or maybe even more, are we to believe that on the other vessel or vessels, there were no other, less disastrous infection rates? Not even enough to raise the gross risk to over 1%?
    And a risk of 1% is small? Weeellll, sorta, when one says it quickly like that, but how many epidemics of any disease on land have a higher morbidity rate than 1%? Those numbers may be small, but not reassuringly small.
    And as for a 15% infection rate, that might be OK in a family of six cooped up in a flat, but in a community of a few thousand cooped up in a ship it is another kettle of slops. Are you telling me that the average cruise liner budgets for a 15% sickbay and case isolation rate? If so, then how come the infirmary was full of “people vomiting into bags, buckets or on the floor, whatever was closest”?
    Have you ever had a good dose of Noro, Jeff? I have; mercifully not aboard ship! In case you haven’t, let me warn you against sneering at those patients’ lack of self-control, or you might have to face a few uncomfortable challenges! One of the least comfortable aspects of such an infection is the problem of which end’s demands to service first, and to have the decision pre-empted when both let go at once. That is hysterically funny of course, when it happens to oneself, but the fun wears a bit thin when it happens to family members and you can’t do much to help them.
    One thing you had better understand is that the problem of dealing with 700 well-behaved, non-infectious patients in a dedicated hospital is far less than 700 times as great as dealing with a single case, but dealing with 700 dramatically sick, filthy, demoralised, humiliated guests in a vessel that could not realistically be equipped for anything like such numbers, is not 700 times greater than dealing with 1, but many times more. So don’t let us be too cheerfully dismissive of the numbers as proportions of the total numbers of passengers on all the ships world wide, shall we?
    Let’s leave you to digest that while I go off to contemplate my inner economy…
    See you soon if my citrate gel works!

  4. Jon Richfield says:

    Hello again Jeffwagg! So much for supper.
    You have a slightly bemusing sense of humour if I am to judge from your remark that “it’s likely that the passengers are introducing the illness, as the crew has lived together for weeks”.
    Look Jeff, the fact that the crew have lived together for weeks has nothing to do with the case. Living in unprivileged circumstances from which they have been recruited (commonly slums if reports are to be trusted, and no more hygienic than most slums if I am to guess, and without any quarantine period that I have heard about, they could maintain the entire ship in an infectious condition for months, notwithstanding fumigating every surface with H2O2 and showering every crew member before embarkation. Desperate to keep their jobs and to stay out of quod, they would have intense pressures to hide it all from the authorities.
    But COULD the passengers have been responsible? At least sometimes? Of COURSE they could! Visiting all sorts of plague holes on the voyage, they would be exposed again and again. In my most recent infection (we have had mercifully few) we succumbed to passengers on a chicken mayonnaise sandwich from a reputable franchise in a backwater town. Being alone, we did not infect anyone else as far as we know, but we cannot be sure. But we could very well have been the source of a major infection on board a cruise vessel you know? And without undue immodesty we then could have been just as effective as the crew, especially because in the circumstances we might well have commenced by infecting some of them.
    Granted of course, our fellow passengers must prefer being infected by us, rather than by the crew, but frankly I cannot imagine why…
    I am not sure why you mention the cruise ship company gel development, always assuming that they really were the developers. Such a gel certainly is a good and no doubt useful idea, but as a bulwark against Noro it is laughable, if only wryly…
    Nor is your question concerning the military very sensible. The resources of the military in dealing with such problems are far more powerful than either cruise companies, or cruise staff, and if they are worth a snowball in a blizzard, they include standard procedures for isolation and shifting of infected personnel according to requirements. Let’s see you do that with paying victims err… guests… err… passengers.
    You predict that if we could isolate everyone who goes to a convention or even a theme park, it’s possible we’d see similar numbers. That sounds speculative to put it politely, but I think you would have a hard time supporting the claim from public health stats. But even if you could, the fact that not everyone is locked into an oversized biscuit tin makes the contact less intimate and more avoidable, so I’m not sure what you thought you were supporting with that very assailable claim. You assert that whenever people get together, disease will spread. Up to a point that is true, but when it is true, it commonly is a negative function of how easy it is to avoid being intimately together. You add that at least on a cruise ship, you have an emergency room traveling with you. That is not much of a recommendation in a Norovirus epidemic; I’d prefer to take my chances at home or anywhere not sprinkled and fogged with infectious effluvia.

    Full Disclosure: I have travelled on board ship a few times in my life, and generally enjoyed it, but never on a cruise liner, and I am not panting to break that pattern. I am not aware that any of my funds are earned from cruise ship companies. I hope (but lack faith) that the staff enjoy it more than seems likely, and are unlikely to spit in the food of particularly detested passengers who offend them. (Not that such passengers as I have heard sounding forth about their cruises aroused much sympathy in me, but maybe I have missed the sympathetic majority.)

    Cheers,
    Jon

  5. DragonLady says:

    S**t happens. Wash your hands.

    • Jon Richfield says:

      @DragonLady, your no-nonsense protestation certainly has merit, but it leaves much to be desired. You will be familiar with the discussion:
      “Do not be too judgmental; it happens in the best of families.”
      “In the best of families it does not happen so often!”

      Yes, s**t happens, no contest, and washing one’s hands really can reduce its incidence, but:
      * It can only reduce the incidence up to a point; in a thoroughly befouled situation such as those described, you will need a lot of prayer and rabbits’ feet as well as hand-washing, face masks and boiling of salads.

      * You can wash your hands till your fingernails drop into your soup, but you may have difficulty with the spit and unwashed hands and clothes of the serving staff and fellow penny-stenchery inmates. (Am I the only one to have stared bemusedly at the little white caps that catering staff wear over perhaps 25% of their scalps, and wondered what makes them think that such dead-chicken-waving is likely to make a scrap of difference?)

      * In a H**t*n or H*****y *nn on land you can go elsewhere if you are among those lucky enough to have washed your hands enough to have escaped the first infections; on board a floating, motion-sick penitentiary there is no time off for good behaviour!

      But don’t let me discourage you, good luck with citric acid gels, and enjoy your trip! :D

      • DragonLady says:

        Jon, you don’t believe is washing your hands?

        The point is: you can only control your own behavior. For everyone else you encounter you must risk the alien presence and consequent assault on your immune system. The only way to completely avoid contamination is to hermetically seal yourself in a self-contained self supporting environment and never come out.

        For living your life out here in the nasty contaminated world you should assess your risk vs reward and then act accordingly.

  6. Jon Richfield says:

    @DL, do you believe in reading what people post before you respond?
    Do you even believe in reading what YOU write before you post? Try again and try harder:

    ” s**t happens, no contest, and washing one’s hands really can reduce its incidence”

    Got that? Is that a sufficient answer to “Jon, you don’t believe is washing your hands?”
    If not, please explain the parts you didn’t understand.

    When you have assimilated it well enough, try:
    “It can only reduce the incidence up to a point; in a thoroughly befouled situation such as those described, you will need a lot of prayer and rabbits’ feet as well as hand-washing, face masks and boiling of salads.”
    Let us know where you need help with that assessment as well.

    If you imagine that hand-washing is an adequate precautionary measure against the situations described, however they originated and propagated, then I fall back on Johnson: “I have found you an argument; but I am not obliged to find you an understanding”.

    Hand washing is a valuable measure in dealing with the “nasty contaminated world”, but neither always the only one necessary, nor always adequate, as you would need to understand before you could claim to be competent to “assess your risk vs reward and then act accordingly”.

    And if you think that hermetic sealing is an option, you reveal even more profound illusions.

    At the same time, willingly exposing yourself to such combinations of conditions and hoping to control your fate with hand washing and pious resignation, argues a point of view inaccessible to any arguments I have been able to think of so far; perhaps you could give us some examples of your assessments of the risks and rewards that could move you to expose yourself to such helpless degradation, with your stay and trust in hand washing? And having decided that your own wealth and well-being is worth risking on such a trip, what about anyone in your care?

    Now if you will pardon me, you have left me with an urgent desire to wash my hands.

    Have a nice day and all that!

    • DragonLady says:

      I guess you are never going to a public place.

      Public places are rife with bacteria, virus, mold, cat hair, dog hair, pigeon dandruff, rodent excrement dust, paper mites, airborne allergens, halitosis, insect parts, body fluids on surfaces, bed bugs, lice, flea, flies, ticks, people who eat while talking on public phones……did you know that the average person ingests about 70 insects and 10 spiders over his/her lifetime while sleeping?

      • Jon Richfield says:

        Siiiiigh!!! Still not reading?
        Did you know BTW, that:
        1: your statistic is an urban legend?
        2: the figure is a total thumbsuck by statistical incompetents (to judge from its content)?
        3: it would be irrelevant anyway whether it is the wildest over- or under-estimate?
        4: people eating while talking on public phones or other public conveniences are less of a threat to us than people who do not? (They might be a greater threat to themselves, but that isn’t MY problem but theirs, so why not preach to them rather than me? ;) )
        5: you have me gobsmacked with your “public places are… RIFE WITH HALITOSIS”? This is a caution concerning a health threat? Or a joke? Do know what halitosis is?
        6: As a biologist with field experience I think I can JUST about handle cat hair, dog hair, pigeon dandruff, (human dandruff too FTM) rodent excrement dust, paper mites (dear Lord, whatever happened to house mites!) halitosis, insect parts, body fluids on surfaces, bed bugs, lice, flea, flies, ticks. Wish I could say the same for you. Microbes are a bit more difficult, and best dealt with by suitable precautions (such as avoiding places most inimical to such precautions, including tourist traps without time off for good behaviour or bad epidemics, such as certain modes of transport. We recently toured some 30-odd US states by train, presumably infecting hundreds of American citizens with our personal parasitoids and parasites, without blame or scathe to ourselves. But if we had been alarmed by a fellow passenger suddenly succumbing to Ebola, we could have gotten off at the next stop. Inconveniently, but off! Sure, we could have got off a cruise ship at the next passing swell too, but you know, my natatory powers are not what once they were…)

        Any questions? :D

        • DragonLady says:

          Trust me, after working as a bank teller cashing the construction worker’s checks (always got paid on Thursday, always came in after lunch which apparently consisted of garlic and beer) halitosis is a threat.

          My point is still the same: if you find any particular place, such as a cruise ship, is unsuitable for human habitation, don’t go there. The only behavior you can control is your own.

          BTW I get lip kisses from my elderly cat with the same tongue he uses on his sandbox feet. Doesn’t bother me, but I’ll bet you never want to kiss me ever.

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