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.Â

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) â€" 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 â€" 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. Â 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.