TOPIC VI: PASSENGERS AND RISK

Cruises are an increasingly popular style of vacation enjoyed by millions of people –

more than 20 million in 2014. A market report produced by the Cruise Lines
International Association (CLIA) to assist shipping companies with their occupancy
projections, states that 94.8% of cruisers report satisfaction with their cruising
experience (CLIA, 2008), but with passenger numbers of 20 million, that left over 1
million dissatisfied passengers in 2014 alone. Although there is clear majority in terms
of customer satisfaction, apart from the obvious causes such as bad weather and
seasickness, an unsettling question remains: what went wrong? This chapter explores
three issues that may explain some possible causes of this dissatisfaction: illness
outbreaks, onboard crime and health services. Each will be considered in turn.

LEARNING OBJECTIVES:

● To discuss how illness outbreak begins and progress

● To determine common onboard crimes in cruise ships.
● To discuss how passengers, staff, and crew can take steps to protect
their safety, security and health.

CONTENT

ILLNESS OUTBREAKS

The complexity and variety of illnesses on cruise ships has shifted over the past three
decades. In the 1980s and 1990s outbreaks were commonly caused by food-borne
bacteria such as Shigella, Salmonella and Escherichia coli, but these gave way to
norovirus, which increased in incidence in 2001.

Also in 2001, the Food Standards Agency (FSA) in the UK announced health officials
would be given the statutory right to enter and inspect cruise ships, in a similar
manner to the Vessel Sanitation Program in the USA. The FSA was reacting to a report
from the Consumers’ Association indicating an increase of food poisoning cases among
cruise ship passengers with better food processing and refrigeration, and more careful
testing and treatment of drinking water loaded from shore, incidents caused by
bacteria have reduced significantly.

From 2002 through 2014 there were only four known outbreaks caused by
Salmonella, affecting just two ships (i.e. back-to-back cruises of Celebrity Cruises’
Mercury in July/August 2002, and Radisson Seven Seas Mariner in 2002, and again
in 2005) and ten caused by E. coli. There were four reports of Legionnaires’ disease
between 2002 and 2007 (Ocean Monarch and Pacific Venus in 2003, Legend of the
Seas in 2005 and Black Watch in 2007), but none since. As bacteria-caused illness
has decreased, the incidence of illness caused by norovirus has increased
significantly.
Because illness outbreaks on cruise ships are highly visible, especially when more
than 20% of passengers become ill, norovirus has been nicknamed the ‘cruise ship
virus. The obvious question however, is whether norovirus is more common on cruise
ships than elsewhere. The cruise industry claims the label is unfair because the virus
is often found in institutional settings (e.g. schools, camps, prisons, nursing homes
and hospitals). Although this is technically correct, their defense fails to acknowledge
that cruise ships are perfect incubators for norovirus and a host of other viruses and
bacteria because of the constant socializing within closed spaces.

Norovirus Explained

Norovirus refers to a family of unclassified, small round-structured viruses previously

referred to as Norwalk-like virus. It is named after Norwalk, Ohio, USA, where the first
outbreak was documented in a school cafeteria. There are more than 100 known
viruses within the norovirus family; these break into at least five norovirus genogroups
that in turn are divided into at least 31 genetic clusters. Norovirus causes nausea,
vomiting, diarrhoea, abdominal pain, and sometimes a headache and low-grade fever.
The most frequent complication is dehydration, especially among the very young and
elderly. The disease usually develops 24 to 48 h after contaminated food or water is
ingested (a median of 33 to 36 h, but can be as short as 12 h) and lasts for 24 to 60 h.
Recovery is usually complete and there is no evidence of any serious long-term
problems. A victim will normally be asymptomatic after 4 or 5 days, but continues to
shed the virus for as long as 2 weeks. For this reason conscientious and correct hand
washing is as essential on cruise ships as anywhere else.

Norovirus is transmitted by a faecal–oral route. It is contracted either by consumption

of faecal-contaminated food or water or by direct person-to-person spread. Person-to-
person spread occurs when someone touches an object previously touched by an
infected person who has not washed their hands. It also includes transmission due to
aerosolization of vomit where droplets contaminate a surface, which is then touched
by another, or are transmitted via air and enter the oral mucosa and are swallowed.
Noroviruses are highly contagious and as few as ten viral particles may be sufficient to
infect an individual.

Food and water contamination has clearly been reduced as a result of the Vessel
Sanitation Program’s twice-yearly ship inspections, but scores reflect cleanliness and
are not a safe indication that the risk of illness from norovirus is reduced. If cruise
industry claims are correct, transmission today is more commonly through direct
person-to-person physical contact or from contact with a surface previously touched
by someone with the virus on their hand. This renders norovirus a significant
challenge for a cruise ship. Once the virus ‘goes public’, the immediate goal is
containment, but with wide-scale infection, its source might never be determined.

Incidence of the Illness

The cruise industry claims passengers bring the norovirus with them. This was first
asserted in November 2002 after three successive illness outbreaks sickened more
than 400 passengers and 50 crewmembers on Holland America Line’s Amsterdam. The
company’s vice president of public relations, Rose Abello, declared at a press
conference, ‘The ship is not sick. There are sick people getting on the ship’. With large-
scale illness outbreaks affecting other cruise ships as well, the industry’s trade group,
International Council of Cruise Lines (ICCL), adopted Abello’s defence, and the
industry’s excuse that ‘passengers bring it’ became common. The industry’s position
implicitly assumes that outbreaks are random, but a review of cases suggests this is
not the case. Notably, the frequency of illness outbreaks is related to cruise length;
shorter cruises have the lowest rates. A study by Cramer et al. (2006) found 27.4
outbreaks per 100,000 passenger days on cruises of 3–6 days, 26.5 per 100,000
passenger days on cruises of 7 days, 38.8 per 100,000 passenger days on cruises of 8–
15 days, and 48.7 per 100,000 passenger days on cruises of 16–21 days.

While it is tempting to conclude from these data that short cruises are safer, this
might not be the case. To register as an outbreak, more than 3% of passengers or 2%
of crewmembers must report illness, and the 3% figure is more easily reached over a
longer period of time. Thus, one might conclude that while the rate of outbreak is
higher for cruises that are longer, the risk may be greater on a short cruise where the
3% threshold is reached within a very short time. It may be more enlightening to see
whether there is a relationship between illness outbreaks and cruise line or cruise
ship, i.e. whether some cruise lines or ships are more prone to illness outbreaks than
others. Table 6.1 shows the number of outbreaks by cruise line from 2002 through
2014. Princess Cruises and Holland America Line are disproportionately represented
as a percentage of all reported outbreaks, together accounting for 167 cases, or one-
third of all illness outbreaks recorded during that 13-year period. Both cruise lines
have smaller passenger capacity than Carnival Cruise Lines (CCL) and Royal
Caribbean International (RCI), but their share of outbreaks is greater.

Evidence of ship-specific outbreaks further supports the view that illness outbreaks
are not entirely random. Table 6.2 shows ships having had five or more illness
outbreaks from 2002 through 2014, and cases where there were outbreaks on back-
to-back cruises (two or more successive cruises). The table identifies ships with the
most frequent illness outbreaks and reveals wide variations between ships within a
single cruise line. Not only can it be said that Holland America Line has the highest
rate of illness, but three or four of its ships are disproportionately problematic. This
raises more questions than it provides answers, as it is an empirical question as to
why these ships have more frequent outbreaks than others.

THE ROLE OF CREW

These outbreaks reflect how easily the norovirus can be transmitted from person to
person or via food in a closed environment such as a cruise ship. The continuation of
outbreaks on consecutive cruises with new passengers and the resurgence of
outbreaks caused by the same virus strains during previous cruises on the same ship,
or even on different ships of the same company, suggest that environmental
contamination occurs. Infected crewmembers therefore seem the most likely reservoirs
of infection for passengers. This view is supported by research that found nearly half
of all norovirus outbreaks are linked to ill food-service workers, indicating that even if
passengers bring an infection onboard, it is the ships that keep it alive, mostly likely
through inadequate hand washing and sanitization processes.
The industry would argue against this conclusion, insisting that crewmembers are not
key because of the relatively small number of reported illness among them compared
to passengers. As far back as the 1980s and 1990s reported illnesses among
crewmembers were at levels lower than passengers. However, those who choose to
work at sea may be naturally less susceptible to gastrointestinal upsets, or are simply
more stoic. More likely, however, is that there are strong disincentives against crew
members reporting when they are ill. If they depend on tips, they may work even when
they are ill, and as some risk losing their job if absent for more than 2 or 3 days, they
will be pressured to return to work even when unwell. This is reflected in the number
of health inspections indicating that crew are not removed from work when ill (Cruise
Law News, 2015). This poses a serious problem for controlling spread of the virus. Not
only are ill crewmembers likely to work, but those ‘quarantined’ in their cabin – a
cabin normally shared with other crewmembers – for 48 to 72 h, are likely to return to
work when their symptoms ease, but while they are still contagious. The virus can
easily be reintroduced and carried over from one cruise to another, especially by
kitchen workers, food and beverage servers and those engaged in regular, direct
contact with passengers. Crew, as much as passengers are potential sources of
person-to-person contact. However, this problem cannot be addressed until the issue
is considered more objectively, and causes of outbreaks are solely attributed to
passengers bringing illness onboard. Quarantine practices for passengers are also
disincentives to reporting illness, further complicating containment. If passengers
report the slightest sense of illness, they risk being quarantined in their room for
several days, missing ports they were looking forward to seeing, rather than keeping
their illness a secret and continuing with their vacation.

ONBOARD CRIME

A second area explored in this chapter is crime on cruise ships. As seen in Table 6.3,
the most common crimes reported on cruise ships are assault, sex-related incidents
and theft. Also worth mentioning are incidents of assault with serious bodily injury
(SBI) and persons overboard. Because persons overboard are not consistently reported
to the Federal Bureau of Investigation (FBI), even though this is considered reportable
under the Cruise Vessel Security and Safety Act of 2010, the actual number is higher
than this table shows. According to Cruise Junkie dot com’s dataset of persons
overboard, there were about 15 incidents in 2007/2008 and 23 in 2011.

Theft

As seen in Table 6.3, Carnival Cruise Lines, Royal Caribbean International (RCI) and
Celebrity Cruises have the highest number of thefts. The number of incidents on
Carnival for the 2 years is three times greater than RCI even though Carnival’s
passenger capacity is 10% less than RCI; the number of thefts on Celebrity in 2011 is
two-thirds of the number for RCI even though RCI has three times more capacity.
Converting these numbers to a standardized rate shows theft under $10,000 is
highest on Celebrity Cruises (85.4 per 100,000), followed closely by Carnival (82.4 per
100,000), and RCI has a rate almost half that of the others (43.8 per 100,000).

It is difficult to know what accounts for these differences, but it is apparent that theft
is also cruise line-specific. Many incidents involve possessions going missing from
passenger cabins (jewelry or other items left in the open) or being removed from the
safe in a passenger cabin. In very few cases is a perpetrator identified and property
recovered.

Assault

As with theft, RCI, Celebrity Cruises and Carnival Cruise Lines report the largest
number of assaults. As seen in Table 6.3, incidents on RCI were ten times those on
Carnival in 2007/2008 and 20-fold higher in 2011. The rate for Celebrity was also
higher in 2011. Standardized rates show the rate of assault on RCI in 2011 was 227
per 100,000, compared to 124 on Celebrity Cruises and 11.8 on Carnival. It is difficult
to know whether these differences are an artefact of the cruise line and the passengers
it attracts or a reflection of a lower tolerance level for reporting incidents. However, a
detailed analysis indicates that a large portion of the difference between RCI, Celebrity
and others lies in the high rate of domestic violence reports. Approximately half of the
assaults on RCI in 2011 were assaults involving travelling companions.

While simple assaults often involve casual acquaintances or travelling companions,

this is not the case for assault with serious bodily injury. Determination of which
category an incident falls under is made aboard the cruise ship on which the incident
occurred, but an assault with serious bodily injury is quite different. The case of San
Diego grocer Scott Boney illustrates this point: in September 2007, Scott celebrated
his 50th birthday with his wife and a number of friends on Carnival Cruise Lines’
Elation. On the first night, he was pushed down a flight of stairs by a 21-year-old
passenger, and when found, was non-responsive. Seven months later he still could not
speak or write, or stand independently, was fed through a stomach tube, and did not
appear to recognize many family members and friends who visited and helped care for
him (Klein, 2012).
The Boney case highlights two relevant issues, the first of which questions the
adequacy of security personnel on cruise ships. This question has been repeatedly
asked in relation to sexual assault incidents, not just in relation to the number of
security staff, but also to their training. Several cases indicate security personnel may
not be adequately trained to deal with crimes and with crime scenes.

HEALTH CARE AND MEDICAL FACILITIES

Most passengers are surprised to learn a cruise ship is not required under
international maritime law to provide medical services. The only legal requirement,
under the Standards of Training, Certification and Watch keeping for Seafarers
(SCTW) Convention, is that identified crewmembers have various levels of first aid and
medical training. Regardless, modern cruise ships maintain an infirmary and almost
all have a physician and nurse on staff. These medical professionals work under
contract as concessionaires and receive a fee plus commissions on medical services,
prescriptions and medical supplies.

The precise qualifications of onboard medical care providers can vary widely. A 1996
survey administered by two Florida physicians to 11 cruise lines found not just
inconsistencies across cruise lines, but also that 63% of ships had no blood testing
equipment for diagnosing heart attacks, and 45% lacked mechanical ventilators or
external pacemakers. The study concluded that the quality of maritime medical care
was inadequate, from the medical facilities to nurse and physician credentials. This
led the American Medical Association (AMA) to call for greater awareness of the limited
medical services available onboard ships and for the US Congress to develop medical
standards for cruise ships. However, the cruise industry successfully kept the issue off
the Congressional agenda, and instead adopted industry guidelines for medical
facilities and personnel on cruise ships. These guidelines, written by the American
College of Emergency Physicians, are voluntary and therefore not enforced. While they
serve a purpose in public relations and for defusing critics, they do not establish
predictable standards of care for the industry. As they state, ‘they reflect a consensus
among member lines of the facilities and staffing needs considered appropriate aboard
cruise vessels’ (Cruise Lines International Association (CLIA), 2015). These guidelines
have serious gaps. For example, they do not require certification in emergency or
critical care, which is significant given that 90% of deaths on cruise ships are caused
by a heart attack. However, the greatest weakness is the wide variation in actual
equipment onboard a ship. While the guidelines suggest one infirmary bed per 1000
passengers and crew, one intensive care unit bed per ship, and a variety of equipment,
there is no guarantee that these are in place. Actual equipment onboard varies
according to itinerary, size of ship and anticipated demographic makeup of
passengers, as well as by cruise line.

Onboard infirmaries are equipped to deal with minor injuries, including crew
workplace injuries, and stabilizing a patient experiencing a heart attack or other acute
condition. Realistically, they are more like a neighborhood clinic than a hospital
emergency room, and can most effectively deal with routine problems such as scrapes
and cuts, sunburn and indigestion. They also serve as the ‘family doctor’ for the crew,
treating anything from colds and influenza to high blood sugar and hypertension. This
is reflected in the types of problems ship infirmaries tend to deal with; the most
common passenger diagnosis is respiratory illness (26–29%). Injuries, most frequently
sprains, and superficial wounds and contusions also account for a significant
proportion of shipboard medical visits (10–18%), as do gastrointestinal illnesses (9–
16%). Generally, the rate of medical consultation on cruises is higher than on shore.

The Medical Staff

There is wide variation in the training and background of medical personnel. Some
cruise lines draw their physicians and nurses from the UK, the USA and/or Canada,
and pay $10,000 or more a month; all are board certified in one of these countries. In
contrast, personnel on other cruise lines are drawn from a range of countries, have
salaries reportedly as low as $1057 a month, and are not necessarily board certified. A
1999 New York Times article reports that only 56% of doctors on Carnival Cruise
Lines’ ships had board certification or equivalent certifications, and 85% of the
physicians on Royal Caribbean Cruise Lines were board certified.

Board certification itself may not be altogether reassuring. For example, the physician
on one cruise ship had 30 years of practice experience as an anesthesiologist, but his
expertise in emergency responses was untested. Another physician was specialized in
oncological colorectal surgery, and although well respected within his specialization,
was not regularly required to exercise skills in emergency medicine. It is not intended
to question the competence of all onboard physicians, but to illustrate that the quality
of medical qualifications and facilities varies widely from ship to ship and from cruise
line to cruise line.

At the same time, it should be recognized that the Cruise Vessel Security and Safety
Act of 2010 includes minimal requirements for medical care after a sexual assault. Not
only is a cruise ship required to maintain in-date supplies of anti-retroviral
medications and other medications to prevent sexually transmitted diseases after an
assault, but it must also have medical staff with a current physician’s or registered
nurse’s license and at least 3 years of postgraduate or post-registration clinical
practice in general and emergency medicine. It is unclear whether these standards are
enforced or even monitored.

Conclusion

A cruise ship is like a small town, with the largest ships afloat carrying nearly 9000
people. As in any town, there will be health issues, including illness outbreaks, sexual
assaults and other crimes, and issues around medical care. Because cruise lines
typically hide these issues, claiming a cruise is safe and carefree, most passengers and
crewmembers board cruise ships without knowing the problems and without taking
simple precautions. One purpose of this chapter is to provide information that may
help passengers, staff and crew to take steps to protect their safety, security and
health. An awareness of crime makes it easier to take steps for crime prevention,
knowledge of how illness outbreaks begin and progress makes it easier to take steps to
avoid illness and having a clear set of expectations of the nature of health care on a
cruise ship allows one to make informed decisions.

*******END OF LESSON VI******

REFERENCES:

Dowling, Ross. (2017). Cruise Ship Tourism. 2nd Edition.