Last week two media narratives involving the cruise industry appeared in quick succession. The first was that the CDC was preparing to release yet another extension to the no sail order for cruise ships that was originally released in March. If the CDC had their way this third extension would have prevented cruise ships from sailing until late February, 2021. The second story came out the next day, reporting the White House rejected the CDC’s extension, limiting it instead to October 31st. What does it all mean and is it safe to cruise?

Risk

As a travel advisor and a cruise lover I am a cheerleader for the cruise industry…I won’t make any apologies for that. As a critical thinker, I am also a stickler for data and data driven decisions and I won’t make any apologies for that either. The CDC’s latest no sail order extension failed on that latter point as I’ll cover in my next blog article. That said, the purpose of this article is not to tell you or anyone else whether it is safe or unsafe to cruise. That is a decision only you can make, based on your own circumstances and risk tolerance.

What I hope to do with his article is inform you of the measures cruise lines are taking to mitigate and manage the risk of COVID-19 on a cruise ship. Cruise ships represent closed environments where infectious diseases can spread far more readily than on land, particularly when the ship carries 4000-8000 passengers and crew. But they aren’t cesspools of germs as many have characterized them. That is a narrative the media, and even the government at times, perpetuate because it gets clicks. But it isn’t true. Cruise lines go to great lengths to implement sanitization protocols multiple times per day, and they are quite good at ensuring their ships are not cesspools of germs. They are so good at it that most people don’t even notice. To that end, cruise lines are adopting COVID-19 risk mitigation and management protocols that will bring the risk of contracting COVID-19 on a cruise ship below that of the risk of contracting it on land, but it won’t completely eliminate the risk…nothing short of an effective vaccine can do that and hopefully we’ll have that in the next 2-6 months.

The Healthy Sail Panel

One of several areas where I believe the CDC has failed cruise lines is that they haven’t given them explicit measures they expect to be taken to reduce the risk of contracting COVID-19 aboard a cruise ship. Much of what little guidance they have given seems to be directed at ensuring there are no COVID-19 infections onboard cruise ships ever…an admirable but impossible goal. In the absence of specific guidance from the CDC, the cruise lines developed their own COVID-19 risk mitigation and management plans.

The Royal Caribbean Group and Norwegian Cruise Line Holdings Ltd jointly commissioned an independent panel of experts to conduct a study of COVID-19 in the cruise industry. Royal Caribbean and Norwegian are the second and third largest cruise companies in the world respectively, behind Carnival Corp. The expert panel they commissioned, which came to be known as the Healthy Sail Panel, was co-chaired by Dr. Scott Gottlieb and Mr. Mike Leavitt. Dr. Gottlieb is a former commissioner of the U.S. Food and Drug Administration, attending physician at New York University’s Tisch Medical Center, member of the policy board of the Leukemia & Lymphoma Society, staff writer for the British Medical Journal, and one of several editors for the Journal of American Medicine. Mr. Leavitt formerly served as the U.S. Secretary of Health and Human Services, former Governor of the state of Utah, and former Administrator of the Environmental Protection Agency.

Aside from their co-chairs, the Healthy Sail Panel was composed of independent experts in public health, infectious disease, biosecurity, epidemiology, hospitality, and maritime operations. The experts selected to serve on the panel all brought impeccable credentials to the study and include a former CDC director, former acting commissioner for the FDA, and several highly qualified experts in infectious diseases. The panel members representing the hospitality and cruise industry were charged with providing input on the operational impact of the panel’s recommendations to ensure the implementation approaches would be effective without placing an undue burden on crews. If something is too hard to do, no matter the benefit, it is less likely to get done. The panel conducted a four-month study resulting in a 65-page report titled “Recommendations from the Healthy Sail Panel.” The report contains 74 discrete recommendations in forming an effective COVID-19 mitigation and management plan.

Given the lack of specificity from the CDC…this was not their finest hour….it is refreshing to find that the cruise lines’ Healthy Sail Panel decided on their own to follow an approach based on science and data, supporting their conclusions with verifiable and defensible facts. The only thing I’ll say here about the CDC’s approach is that it was bureaucratically lazy. The Healthy Sail Panel stated in plain terms, “The paramount goal and guiding principle of our work was to define a set of protocols and procedures that would protect guests, crews, and the communities cruise ships visit from SARS-CoV-2 and reduce the risk of transmission below the level people would experience in other normal activities.”

Note that the Healthy Sail Panel’s charge did not direct them to come up with a plan to ensure no cases of COVID-19 would occur on any cruise ship which, reading between the lines in the CDC’s no sail extension orders, seemed to be the CDC’s unspoken objective. Reducing the risk of transmission below the level people would experience on land, the Panel’s charge, is consistent with the cruise line’s prior approach to infectious diseases, including Norovirus, and in the past their protocols have satisfied the CDC. The CDC previously published a report praising the cruise lines’ approach to combating Norovirus, noting the risk of acquiring Norovirus on a cruise ship is well below that of on land.

The Panel further noted that, “these recommendations rely on the ability of the cruise operators to implement them with determination, care, and a strong commitment to protect the health and safety of guests and crew. Fortunately, the Expert Panel’s experience over the past four months has been that cruise operators are approaching the challenges presented by the COVID-19 pandemic in a thoughtful, positive, and aggressive manner and, to ensure they have the highest levels of execution, are planning to employ appropriate auditing, verification, and continuous learning systems.” It sounds to me like this panel of experts felt the cruise lines got it right.

Note: SARS-CoV-2 is the scientific term for what we call COVID-19.

“The Panel’s guiding principles:
1. Risk can never be fully eliminated, but with appropriate measures in place, it can be substantially reduced, and many layers of risk reduction are needed since each alone is insufficient.
2. Risk mitigation strategies must be practical and balanced with operational feasibility.
3. Aggressive measures to minimize or prevent SARS-CoV-2 from entering a ship are the single most important step that can be taken to reduce risk of an outbreak on board.
4. Despite all the measures put in place, SARS-CoV-2 infections may still occur on cruise ships. If they do, cruise operators’ goals should be to (1) minimize risk of transmission among individuals and prevent a widescale outbreak, (2) provide appropriate care on board for those infected, and (3) arrange in advance for appropriate transfers of impacted guests or crew.
5. Previous incidents (such as the situations in Yokohama and San Francisco) provide important lessons to enable cruise operators to avoid similar situations in the future.
6. There is an opportunity to train and learn from a phased-in return to sailing before full guest operations resume.
7. Vigilance in implementation, continuous improvement, and innovation will be needed.”

After much consideration of various “gating” criteria regarding the decision of when to allow the cruise lines to return to normal operations, the panel determined that they, “are unable to suggest specific parameters (e.g., local incidence of SARS-CoV-2) that would indicate that it is “safe enough” to begin sailing again. There is no moment when we will definitively know we have reached that threshold.” Instead, the panel noted, “…ultimately, the thoroughness of a cruise operator’s testing plan and implementation of onboard mitigation measures should be the driving factor in creating a safe environment for cruising.”

While the expert panel came up with 74 recommendations in their 65-page report, I distilled them down to the 11 recommendations that are most relevant for individuals making the personal risk decision whether or not to cruise. Here is the summary…note that the wording represents verbatim extracts from the panel’s report. I consolidated several of the recommendations that were annotated separately, but with a common focus, into one recommendation for brevity sake. The panel’s report provides a detailed description of each recommendation included in their summary which you can access following the link to the report earlier in this article.

“Recommendations summary…
1. All crew should be tested for SARS-CoV-2 between 5 days and 24 hours prior to leaving their home location to join the ship and receive a negative result, quarantine for seven days on board the ship upon arrival, and take a test at the end of that seven-day period and receive a negative result, before beginning their duties. Additionally, if feasible based on cost and available technology, cruise operators should consider administering an additional test and requiring a negative result shortly prior to boarding. Cruise operators should implement a crew surveillance program, including periodic testing for SARS-CoV-2, to provide a reasonable level of assurance that the virus is not circulating among crew.
2. All guests joining a ship, regardless of method of travel to the ship, should be tested for SARS-CoV-2 between 5 days and 24 hours before boarding and receive a negative result that is shared with the cruise operator, before coming on board.
3. At embarkation, all guests and crew boarding the ship should undergo health screening to identify any symptoms consistent with COVID-19 (or other infectious diseases) and any contact with individuals suspected or confirmed to have a SARS-CoV-2 infection prior to the cruise. This will include temperature screening.
4. Any individual who discloses symptoms of possible SARS-CoV-2 infection or close contact with an individual with suspected infection, or who displays a temperature of 100.4 degrees or above, should undergo secondary screening by medical personnel to determine whether they may board the ship or whether they will be denied boarding.
5. In addition to the information typically communicated at booking, guests should be provided sufficient information on SARS-CoV-2 to assess their individual risk, to fully understand the safety precautions being taken by the cruise line to address SARS-CoV-2, and to agree to comply with the necessary safety protocols while traveling. To prevent the spread of SARS-CoV-2, cruise operators should require guests and crew to wear cloth face coverings/face masks in accordance with CDC recommendations. Crew members with prolonged contact (i.e., contact that may result in exposure by CDC’s definition) with guests on board the ship should be required to utilize complementary PPE, in addition to wearing a face mask/face covering.
6. When returning to sailing, cruise operators should adjust guest and crew load factors in a manner that allows for appropriate physical distancing on board in accordance with applicable guidance, taking into consideration the size and design of each ship.
7. Cruise operators’ facilities on board the ship, at terminals, and at cruise line-owned and operated destinations should be modified to promote and facilitate physical distancing in accordance with the CDC recommendation of a distance of at least six feet.
8. Enhanced sanitation protocols should be employed to protect against the risk of SARS-CoV-2 transmission via inanimate surfaces or objects, with attention to both high- and low-touch areas of the ship, terminal, and cruise line-owned and operated destinations. Cruise operators should follow CDC recommendations regarding the use of hand sanitizers and hand washing with soap and water to craft their recommendations for guests. Cruise operators should ensure that hand sanitizer stations, wipes, or hand washing stations are conveniently placed around the ship for guests’ and crew members’ usage. Cruise operators should use a variety of indoor air management strategies aimed at reducing occupant exposure to infectious droplets/aerosols. All cruise operators should upgrade the HVAC systems on their ships to, ideally, MERV 13 filters to minimize pathogen dispersal from infected guests and crew.
9. Cruise operators should designate certain cabins on the ship as isolation and quarantine spaces. In the startup phase, cruises itineraries should be as simple as possible, utilizing private, cruise line-owned and operated destinations or ports where there can be tight control of the onshore experience. Cruise operators should initially return to service with shorter length trips.
10. During the initial return to sailing, cruise operators should only allow guests debarking from a ship at a destination port to participate in cruise line-sponsored or verified excursions as a way of limiting potential exposures in the destinations they visit. Cruise operators should establish expectations of the vendors at the destinations they visit to ensure that they are taking recommended steps to reduce the transmission of SARS-CoV-2. Cruise operators should incorporate verification of compliance with SARS-CoV-2 protocols into their routine ongoing monitoring guidelines for excursion vendors. Cruise operators should offer indoor excursions only if physical distancing, use of masks, and other recommended protective measures can be implemented.
11. In their return to sailing, cruise operators should use a phased approach to demonstrate that protocols can be successfully implemented on board their ships before returning to full operations with guests on board.”

The largest cruise company in the world, Carnival Corp., responded to the CDC with their own COVID-19 risk mitigation and management study. Though they haven’t made the results of their study public as far as I can determine, according to the CDC they are similar to that of the Healthy Sail Panel.

I have several comments and observations based on the panel’s recommendations, and my own observations from my interactions with cruise company executives. The cruise lines have already implemented many of the practices noted in the Healthy Sail Panel’s report, as well as others not mentioned in the report. They are moving to touchless check-in, an approach they have been phasing in with their newest ships. Cruise lines will be extending this approach to all of the ships in their fleet, significantly reducing touch points and the risk of contracting COVID-19 during the time guests spend in the cruise terminal.

To allow for proper social distancing in the terminal, cruise lines will be assigning specific check-in and boarding times for all guests. This will avoid the usual congestion in cruise terminals as guests arrive in gaggles in an effort to make the most of their time on the ship. They’ve tried this before and it didn’t work so well, but this time the cruise lines will strictly enforce the boarding times. Now, if you try to enter the terminal building before your assigned boarding time, you will be asked to wait outside of the cruise terminal until your assigned time. At least that’s the plan.

Enhanced sanitization is another of the panel’s recommendations that the cruise lines already practice, just not all of the time. The enhanced sanitization protocols that cruise ships follow when any infectious disease is discovered on a ship have been effective at reducing the risk of an outbreak, and in fact have been so effective in the past that the CDC has praised them. When it comes to the highly contagious Norovirus, the CDC has reported guests are more likely to contract Norovirus on land than they are on a cruise ship. That is the goal cruise lines seek when dealing with COVID-19. Their plan is to adapt their existing sanitization protocols to be consistent with the highly contagious nature of COVID-19, using more effective products and sanitizing public areas more frequently.

Cruise lines have also adapted their dining practices to meet the risk posed by COVID-19. Already hand sanitizer and hand washing stations are positioned at the entrance to just about all dining areas on the cruise ships we have been aboard for the past few years, and they are staffed with crew members to ensure guests wash or sanitize their hands prior to entering. Royal Caribbean has a clever video accompanied by a catchy tune encouraging hand washing. The video plays in a continuous loop on all of the ships in their fleet. It plays in your cabin at initial boarding and throughout the ship periodically throughout the voyage. It is so catchy that as I write this the tune popped into my head and now I can’t get rid of it!

Self-serve buffets will be a thing of the past. Some ships are doing away with buffets all together while others are assigning crew members to serve guests from the buffet. Some cruise lines will no longer seat guests who aren’t traveling together at the same table. For singles and extroverts who enjoy conversing with strangers, this will be a disappointment. For introverts like me, it marks a welcome change. Additionally, cruise lines have already considered the issue of lower fill rates. From what we are hearing, most cruise lines are looking at initial fill rates on the order of 50-60%, depending on the ship’s design, to accommodate proper social distancing. And yes, masks are required anytime you are in a public space.

Perhaps the most significant recommendations the panel made deal with quarantine. The panel acknowledged in their report that it is impossible to eliminate the risk that a single case of COVID-19 could appear on a cruise ship. The panel made several recommendations to avoid the outbreak situation that occurred back in February and March aboard the Diamond Princess. The one common thread of all COVID-19 outbreaks prior to the no sail order in March has been the crew’s failure to follow quarantine protocols established to reduce the risk of infectious diseases spreading throughout the ship. The greatest failure was in managing crew activity to ensure they were not spreading the disease among themselves or seeding infections elsewhere, even as they worked to ensure an effective quarantine was maintained to protect passengers.

The cruise lines’ performance with the periodic cases of COVID-19 that have cropped up among crew members since the CDC’s no sail order have established they got the message. They have properly implemented the quanrtine protocols and effectively limited the spread of those individual cases of COVID-19 that do make it through all the other precautionary protocols. In their latest no sail extension order, the CDC painted the cruise lines’ quarantine protocols as being ineffective. Sorry CDC, the data you cited to prove that case actually proves the opposite…the latest quarantine protocols have been highly effective at containing single cases of COVID-19. More on that in my CDC article.

The panel’s report concluded with a summary of their work and an introspective self-examination of how effective they were in achieving the objectives placed before them by the cruise lines. The panel included the following in the conclusion section of their report: “Looking toward the future, we believe we have charted a path for a healthy and safe return to operations. Our comprehensive report represents a holistic plan to reopen the cruise industry in the safest ways possible. Safely returning more elements of our leisure sector is critical to helping Americans return to a life of normalcy. We believe that taken in totality, our recommendations are able to help provide these assurances.”

As noted from the outset, the decision whether or not to cruise once the cruise lines resume normal operations is a personal risk decision. If your risk tolerance and desire to cruise have you interested in cruising once the cruise lines resume normal operations, give us a call. If you want to wait a bit, we’ll be there for you when you are ready.