Coronavirus: Failures on the Diamond Princess shadow another cruise ship outbreak

The email to Princess Cruises was peppered with typos and awkward grammar, but the warning was unmistakable. An 80-year-old passenger had tested positive for the new coronavirus after getting off the Diamond Princess cruise ship in Hong Kong.

"Would kindly inform the ship related parties and do the necessary disinfection," Princess' port representative wrote Feb. 1, relaying a warning from Hong Kong health officials. "Many thanks!"

Nothing happened. Princess says it believes the alert sat unread in unmonitored inboxes. Grant Tarling, the company's top doctor and the person in charge of responding to outbreaks, said he had not learned about the infection until the following day — after being alerted to a post on social media.

The fumbled alert was just the beginning of a broader breakdown by both the company and the Japanese authorities who quarantined the ship in Yokohama. Hobbled by confusion and mistakes, they played down the risk of infection, ignored best medical practice for evacuating passengers, and activated only low-level protocols for dealing with outbreaks. Ultimately, eight people died and more than 700 were infected, including some government officials.

Now, those failures have taken on fresh urgency as Princess and Tarling deal with yet another coronavirus cluster, on a cruise ship that has been turned away from port in San Francisco. A passenger who recently got off the cruise died of the virus last week, and 21 people have since tested positive.

The ship is expected to dock in Oakland, California, on Monday, and passengers will be quarantined onshore.

In conversations onboard, passengers have been asking, "Will we become another Diamond Princess?" said Bill Pearce, a 54-year-old from Lafayette, California.

The crisis on the Diamond Princess exposes the vulnerabilities in the patchwork of international agreements, national laws and corporate policies governing the health and safety of the US$150 billion cruise industry that carries 30 million passengers a year.

After the infection in Hong Kong was confirmed, company officials incorrectly assumed that the immediate risk was minimal because the sick passenger had disembarked. Health authorities recommended action immediately. "We advise thorough environmental cleansing and disinfection of the cruise," Albert Lam, an epidemiologist for the Hong Kong government, wrote to the company Feb. 2.

The company says it stepped up cleaning the next day. But it initiated only the lowest-level protocols for outbreaks. "There's no point in going and start cleaning the ship when we really didn't know what, if any, risk there was onboard," Tarling said in an interview.

The Japanese government and company still disagree on who was — or should have been — in charge. So the responsibilities for quarantining nearly 2700 passengers fell mostly to about 1000 low-paid ship workers who were given inadequate safety gear and guidance.

Tarling, the chief medical officer for Princess' parent company, Carnival Corp., oversaw the response from California. He was unaware of the working conditions onboard.

An outbreak of a new virus aboard a crowded ship unquestionably presented high-stakes difficulties. Princess says it did the best job possible in the face of unprecedented challenges.

But in a series of interviews, company officials offered contradictory and changing accounts about their response. In the end, nearly 48 hours elapsed between the alert Feb. 1 and the captain's announcement to the ship Feb. 3 that a passenger had been infected, giving the virus time to spread.

The Grand Princess cruise ship is seen off the coast of San Francisco, March 8, 2020. Photo / Jim Wilson, New York Times

Princess officials could not point to the social media post, or the platform, that they say tipped them off. They said it took Tarling until the night of Feb. 2 to confirm that a former passenger had tested positive.

Company emails show that he knew by that morning. In an email to a Hong Kong doctor, he listed the patient's name, his hospital wing, his traveling companions and the date of the diagnosis.

The subject line of his email began: "Confirmed Coronavirus Case."

A late response

The response aboard the Diamond Princess reflected concern, to a point. The buffets remained open as usual. Onboard celebrations, opera performances and goodbye parties continued.

"We immediately increased our already robust sanitation protocols," Gennaro Arma, the ship's captain, said in response to questions submitted through Princess. He said the crew had increased the number of hand sanitisers, rotated the buffet utensils more frequently and stepped up cleaning.

Passengers aboard the Diamond Princess say they noticed few shipwide changes after the announcement of the infected passenger. But some crew members began giving out their own more cautious advice, making some passengers suspicious that the risks were higher than the company was letting on. At the end of a trivia game, for example, a worker told passengers not to hand back their pencils.

Underestimating contagion

Underpinning the company's approach was an optimistic, but ultimately inaccurate, belief that perhaps danger had been averted.

The 80-year-old infected passenger had reported no symptoms to the medical staff while onboard. And he had disembarked more than a week earlier, along with his daughter and their two traveling companions.

"They were off the ship," Tarling said. "There's nothing to believe that we have to put face masks on every single guest."

Passengers look out from balconies aboard the Grand Princess as it cruises a holding pattern off the coast of San Francisco. Photo / AP

No restrictions were placed on passengers when the ship arrived in Yokohama on Feb. 3 until around 11pm, when Japanese medical teams boarded the ship and ordered everyone to their cabins.

Two days later, when the first lab results came back, Japan reported that 10 people had tested positive.

'Not recommended'

Halfway around the world, in the Greek port city of Volos, an epidemiologist named Christos Hadjichristodoulou has been studying cruise ship outbreaks for nearly two decades. By happenstance, on the very day that the Diamond Princess pulled into Yokohama, Hadjichristodoulou and a team of European experts released new recommendations for cruise ships.

Those guidelines said that close contacts of a confirmed case should be evacuated and quarantined on shore, a step that is now supposed to happen with the ship off California's coast after several days of waiting. On the Diamond Princess, that would have meant removing many, if not all, of the 273 people selected for the first round of testing.

Instead, the Japanese government asked them to stay in their rooms while awaiting test results. In practice, passengers still moved about and ate at buffets.

When the first batch of positive results were reported on the morning of Feb. 5, the Japanese authorities ordered a shipwide quarantine. Confirmed cases would be evacuated to hospitals, but everyone else would remain aboard, isolated in their cabins.

"The approach they followed is not recommended for many reasons," Hadjichristodoulou said. He would not criticise decisions made under pressure but said it was clear the virus would spread. "We expected this," he said.

Japanese health officials say that some local authorities feared allowing potentially infected passengers ashore. And the country could not immediately quarantine a large number of people. "It's easy to say that they should be moved to an onshore facility," said Dr. Yasuyuki Sahara, a senior assistant minister in Japan's Health Ministry. "But in reality it is not so easy."

'No drilling for something like this'

Princess said it had followed Japan's lead from the moment its health officials boarded the ship. "When we have other outbreaks like norovirus, we send our teams to the ship," Tarling said. "Here, we're sort of taking direction and seeing how we can best make it work."

That responsibility fell to the crew. Cruise jobs are notorious for long hours and low pay. Those crew members drill for many eventualities, said Iain Hay, whose company, Anchor Hygiene, conducts training for cruise companies. "But," he said, "there was no drilling for something like this."

On the Diamond Princess, crew members delivered three meals a day to close to 1500 staterooms. Early in the quarantine, they served food on china. While crew members wore masks and gloves, they risked spreading — or contracting — the virus whenever they opened stateroom doors and passed in trays of food.

Even after switching to paper and plastic, crew members still delivered meals into rooms rather than leaving them on the floor outside, as Tarling believed happened.

But if anyone from Princess objected to the quarantine, nobody is saying so. Tarling said it was the best option available.

The concern now is focused on the other Princess cruise thousands of miles away.

Once again, Tarling is helping manage the crisis. Asked whether he wished he had done anything differently to contain the outbreak on the Diamond Princess, he could not point to a single decision that he would change.

"I believe our initial response was actually pretty good," he said.

Written by: Matt Apuzzo, Motoko Rich and David Yaffe-Bellany
Photographs by: Jim Wilson
© 2020 THE NEW YORK TIMES