Medical Examiner

“They Can Lock You in a Room”

A cruise-ship doctor explains all the ways ocean liners could contain a coronavirus on board.

A passenger on the balcony of a ship, wearing a face mask and waving
A passenger is seen on a balconies of the Diamond Princess cruise ship, where around 3,600 people are quarantined onboard due to fears of the new coronavirus. Kazuhiro Nogi/Getty Images

It’s no wonder that cruise ships have become a B-plot in the coronavirus outbreak: Nothing stands to help germs spread quite like hundreds and hundreds of people stuck together on a boat, then being released, possibly while drunk, onto the beaches of one country after another. In January, thousands of people aboard Carnival’s Costa Smeralda were quarantined in an Italian port after a passenger came down with a fever (it turned out to be the flu). Holland America’s Westerdam roamed the coast of East Asia for nearly two weeks, turned away from ports over fears that people on board were sick (there were no confirmed cases of the virus) before finally being allowed to dock Thursday morning in Cambodia. It’s not all unwarranted panic: Excluding places in China, the most coronavirus cases per capita can be found on the Diamond Princess (218 so far, among 3,700 passengers), which is currently quarantined in a harbor in Japan.

How do you care for people when a virus is spreading, no one can leave, and all of the dining venues are communal? To get a sense, I recently spoke with Phil Brewer, currently the University Medical Director at Quinnipiac University, and a former cruise-ship doctor who has done more than 50 stints sailing in Alaska, the Caribbean, and Europe. In our interview, which has been condensed and edited for clarity, Brewer explained how to tell if a ship is actually clean, how cruises are handling suspected cases of the new coronavirus, and the surprising way that cruises figure out which passengers have diarrhea.

Shannon Palus: What does a day look like on a ship?

Phil Brewer: On a typical day you spend about four hours in the clinic seeing patients. You’ll typically have around 30 to 60 minutes of administrative things to do. The rest of the day you’re pretty much free to do what you want. You can get off the ship for three or four hours at a time. I’ve got a folding bicycle small enough I can fit it inside a full-size suitcase. I would pack my bicycle, when the ship was at port I would ride around and find stuff randomly. Once, I got chased by a brown bear in Alaska. If you’re having a very rough passage and there’s a lot of people getting seasick, or if there’s an intestinal virus, you can be extremely busy and pretty much work around the clock and catch little naps here and there. That’s pretty infrequent. I’ve been through that a couple times.

What would you do if you were a cruise doctor now, and it seemed like someone might have the new coronavirus?

Anybody with a fever may be refused boarding if there is any suspicion they’ve been in contact with the virus. During the cruise, let’s say somebody calls the medical center from their cabin. They have a fever and they’re coughing a lot, maybe they’re short of breath. You would ask questions on the phone, then you would send somebody up to the room with isolation gear on, an N95 mask. If they do have a fever, if they’re stable to stay in their room, that’s what they do. You also would have to isolate the other people that they are rooming with. This is routine for all sorts of contagious things. In one case this 5-year-old girl I diagnosed with chicken pox, for the entire rest of the cruise she had to stay in her room. She was going stir-crazy.

For the older people who have medical conditions, they can take a nosedive when they come down with an illness. If you’re in a position to get them off the ship, you may try to do that. It depends on how sick they are. The most dramatic but kind of routine thing you do is have somebody taken off the ship by helicopter.

How do you stop panic from spreading?

What hurts you more than anything is when people don’t know what to expect. On Princess, until two weeks have passed with no new coronavirus cases, nobody is leaving the ship. They don’t know how long the incubation period is but it’s no more than two weeks. That should be clearly communicated that to all the passengers hoping that will incentivize them to obey the rules, because everybody wants to get off. They’re stuck there. There’s no other way to do it.

How do you know if people who are who are supposed to be isolated actually stay in their cabins?

Random phone calls. Surveillance cameras. All of the hallways on the ship have cameras. When you’re on a cruise there will be a cabin attendant assigned to your cabin. They recognize you on sight. They’re always around. If you leave your cabin, they will immediately inform the officers on the ship. If you’re sick and you keep leaving your cabin, they can lock you in a room that people can be detained in. It’s certainly not something that they advertise.

Did you ever get sick yourself?

Not that I recall. It’s always a lot of luck, but it’s also really being a stickler about hygienic precautions. For instance, we’re currently having a norovirus outbreak at school. I’ve probably washed my hands 60 times today. Before seeing every patient, after seeing every patient, before and after the bathroom, before and after eating. I did miss the boat once, in Estonia. They moved the all-aboard time up by an hour and a half and I didn’t notice. That was a disaster. They had to sail with only one doctor on board. Luckily it wasn’t busy.

How could I tell ahead of time which ships will be sticklers for handwashing?

Google “CDC Vessel Sanitation Program.” Any ship that picks up or discharges passengers in any U.S. port by law has to submit to inspections at least twice a year by the U.S. Coast Guard and the CDC. They have very, very, very detailed standards for what constitutes acceptable conditions. When they do these inspections, each ship starts with 100 points. With every deficiency, they deduct points depending on how serious it is. They consider a passing score to be 86, but frankly I would never take my family on any ship that has a score of less than 96. There’s just no reason to do it.

What are common reasons cruise ships lose points?

Most of them have to do with food. For instance, chicken is considered to always be contaminated by salmonella. It should be on the lowest shelf possible, so if it drips it doesn’t drip onto anything else. If you have chicken that’s being stored higher than beef, or anything else for that matter, that will be a point off. If you have a dirty surface anywhere, that’s a point off. If they test temperatures of the food in the food line, it’s supposed to be a certain temperature to prevent bacteria growth. There’s a lot that has to do with the swimming pools, and the Jacuzzis—that’s a major source of contamination.

I pulled up a report for the ship that was stranded, the Westerdam. In July it got a 98. One of the problems is the surveillance log wasn’t filled out correctly in a couple instances.

Every ship has to keep a GI surveillance log. They have to log in every passenger they see with either vomiting or diarrhea or both. With vomit there’s a little bit of leeway because people get seasick. It’s a little on the honors system. With diarrhea there’s no leeway at all. That also included people who go to the gift shop and buy anti-diarrheal medication, even if they don’t go to the medical center. Because all these transactions are done with your ship card, they know who they sold it to, and what cabin they’re in.

Whenever the number of people on that log exceeds 2 percent of the total number of people on the ship, that has to be reported. When the ship docks it cannot clear customs and allow people to get off until a group, usually it’s sanitation inspectors from the CDC, comes on board and determines whether this represents a threat to the health and safety to the population of the port itself. All of the people who are signed up for various excursions are stuck.

Anything else we should know?

Don’t eat the shrimp in the buffet line.