Public Health Responses to COVID-19 Outbreaks on Cruise Ships — Worldwide, February–March 2020

Leah F. Moriarty, MPH; Mateusz M. Plucinski, PhD; Barbara J. Marston, MD; Ekaterina V. Kurbatova, MD, PhD; Barbara Knust, DVM; Erin L. Murray, PhD; Nicki Pesik, MD; Dale Rose, PhD; David Fitter, MD; Miwako Kobayashi, MD, PhD; Mitsuru Toda, PhD; Paul T. Canty, MD; Tara Scheuer, MPH; Eric S. Halsey, MD; Nicole J. Cohen, MD; Lauren Stockman, MPH; Debra A. Wadford, PhD; Alexandra M. Medley, DVM; Gary Green, MD; Joanna J. Regan, MD; Kara Tardivel, MD; Stefanie White, MPH; Clive Brown, MD; Christina Morales, PhD; Cynthia Yen, MPH; Beth Wittry, MPH; Amy Freeland, PhD; Sara Naramore, MPH; Ryan T. Novak, PhD; David Daigle, MPH; Michelle Weinberg, MD; Anna Acosta, MD; Carolyn Herzig, PhD; Bryan K Kapella, MD; Kathleen R. Jacobson, MD; Katherine Lamba, MPH; Atsuyoshi Ishizumi, MPH, MSc; John Sarisky, MPH; Erik Svendsen, PhD; Tricia Blocher, MS; Christine Wu, MD; Julia Charles, JD; Riley Wagner, MPH; Andrea Stewart, PhD; Paul S. Mead, MD; Elizabeth Kurylo, MCM; Stefanie Campbell, DVM; Rachel Murray, MPH; Paul Weidle, PharmD; Martin Cetron, MD; Cindy R. Friedman, MD

Disclosures

Morbidity and Mortality Weekly Report. 2020;69(12):347-352.

Abstract and Introduction

Introduction

An estimated 30 million passengers are transported on 272 cruise ships worldwide each year*.^[1] Cruise ships bring diverse populations into proximity for many days, facilitating transmission of respiratory illness.^[2] SARS-CoV-2, the virus that causes coronavirus disease (COVID-19) was first identified in Wuhan, China, in December 2019 and has since spread worldwide to at least 187 countries and territories. Widespread COVID-19 transmission on cruise ships has been reported as well.^[3] Passengers on certain cruise ship voyages might be aged ≥65 years, which places them at greater risk for severe consequences of SARS-CoV-2 infection.^[4] During February–March 2020, COVID-19 outbreaks associated with three cruise ship voyages have caused more than 800 laboratory-confirmed cases among passengers and crew, including 10 deaths. Transmission occurred across multiple voyages of several ships. This report describes public health responses to COVID-19 outbreaks on these ships. COVID-19 on cruise ships poses a risk for rapid spread of disease, causing outbreaks in a vulnerable population, and aggressive efforts are required to contain spread. All persons should defer all cruise travel worldwide during the COVID-19 pandemic.

During February 7–23, 2020, the largest cluster of COVID-19 cases outside mainland China occurred on the Diamond Princess cruise ship, which was quarantined in the port of Yokohama, Japan, on February 3.^[3] On March 6, cases of COVID-19 were identified in persons on the Grand Princess cruise ship off the coast of California; that ship was subsequently quarantined. By March 17, confirmed cases of COVID-19 had been associated with at least 25 additional cruise ship voyages. On February 21, CDC recommended avoiding travel on cruise ships in Southeast Asia; on March 8, this recommendation was broadened to include deferring all cruise ship travel worldwide for those with underlying health conditions and for persons aged ≥65 years. On March 13, the Cruise Lines International Association announced a 30-day voluntary suspension of cruise operations in the United States.^[5] CDC issued a level 3 travel warning on March 17, recommending that all cruise travel be deferred worldwide.^†

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*Not including river cruises.
^†Warning level 3: avoid non-essential travel due to widespread ongoing transmission: https://wwwnc.cdc.gov/travel/notices/warning/novel-coronavirus-china.

Table. Demographic characteristics of passengers and crew members on board two cruise ships with COVID-19 outbreaks January 20– March 8, 2020
Characteristic	Diamond Princess (total 3,711 persons)		Grand Princess, voyage B (total 3,571 persons)
Characteristic	Crew	Passengers	Crew	Passengers
Total no.	1,045	2,666	1,111	2,460
Age median (interquartile range), yrs	36 (29–43)	69 (62–73)	36 (30–43)	68 (61–74)
Total nations represented	48	36	44	24
Country of residence of passengers, no. (%)
Japan	N/A	1,281 (48)	N/A	3 (1)
United States	N/A	416 (16)	N/A	2,008 (82)
Hong Kong	N/A	260 (10)	N/A	0 (0)
Canada	N/A	251 (9)	N/A	231 (9)
Australia	N/A	223 (8)	N/A	1 (0)
United Kingdom	N/A	57 (2)	N/A	113 (4)
Other countries or unknown	N/A	178 (7)	N/A	104 (4)
Country of residence of crew members, no. (%)
Philippines	531 (51)	N/A	529 (48)	N/A
India	132 (13)	N/A	131 (12)	N/A
Indonesia	78 (7)	N/A	57 (5)	N/A
Other countries or unknown	304 (29)	N/A	394 (35)	N/A
Sex, no. (%)
Male	843 (81)	1,189 (45)	928 (84)	1,120 (46)
Female	202 (19)	1,477 (55)	183 (16)	1,340 (54)
No. of persons per cabin, mean (range)	1.73 (1–3)	1.98 (1–4)	1.75 (1–4)	1.95 (1–4)

Abbreviation: N/A = not applicable.

Authors and Disclosures

Leah F. Moriarty, MPH¹, Mateusz M. Plucinski, PhD¹, Barbara J. Marston, MD¹, Ekaterina V. Kurbatova, MD, PhD¹, Barbara Knust, DVM¹, Erin L. Murray, PhD², Nicki Pesik, MD¹, Dale Rose, PhD¹, David Fitter, MD¹, Miwako Kobayashi, MD, PhD¹, Mitsuru Toda, PhD¹, Paul T. Canty, MD¹, Tara Scheuer, MPH³, Eric S. Halsey, MD¹, Nicole J. Cohen, MD¹, Lauren Stockman, MPH², Debra A. Wadford, PhD², Alexandra M. Medley, DVM^1,4, Gary Green, MD⁵, Joanna J. Regan, MD¹, Kara Tardivel, MD¹, Stefanie White, MPH¹, Clive Brown, MD¹, Christina Morales, PhD², Cynthia Yen, MPH², Beth Wittry, MPH¹, Amy Freeland, PhD¹, Sara Naramore, MPH³, Ryan T. Novak, PhD¹, David Daigle, MPH¹, Michelle Weinberg, MD¹, Anna Acosta, MD¹, Carolyn Herzig, PhD¹, Bryan K Kapella, MD¹, Kathleen R. Jacobson, MD², Katherine Lamba, MPH², Atsuyoshi Ishizumi, MPH, MSc¹, John Sarisky, MPH¹, Erik Svendsen, PhD¹, Tricia Blocher, MS², Christine Wu, MD³, Julia Charles, JD¹, Riley Wagner, MPH¹, Andrea Stewart, PhD¹, Paul S. Mead, MD¹, Elizabeth Kurylo, MCM¹, Stefanie Campbell, DVM¹, Rachel Murray, MPH¹, Paul Weidle, PharmD¹, Martin Cetron, MD¹ and Cindy R. Friedman, MD¹, CDC Cruise Ship Response Team, California Department of Public Health COVID-19 Team, Solano County COVID-19 Team

¹CDC COVID-19 Response Team; ²California Department of Public Health; ³Solano Public Health, Fairfield, California; ⁴Epidemic Intelligence Service, CDC; ⁵Sutter Medical Group of the Redwoods, Santa Rosa, California.

Corresponding author
Leah F. Moriarty, eocevent294@cdc.gov, 770-488-7100.

All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

CDC Cruise Ship Response Team
Casey Barton Behravesh, CDC; Adam Bjork, CDC; William Bower, CDC; Catherine Bozio, CDC; Zachary Braden, CDC; Mary Catherine Bertulfo, CDC; Kevin Chatham-Stephens, CDC; Victoria Chu, CDC; Barbara Cooper, CDC; Kathleen Dooling, CDC; Christine Dubray, CDC; Emily Curren, CDC; Margaret A. Honein, CDC; Kathryn Ivey, CDC; Jefferson Jones, CDC; Melissa Kadzik, CDC; Nancy Knight, CDC; Mariel Marlow, CDC; Audrey McColloch, CDC; Robert McDonald, CDC; Andrew Klevos, CDC; Sarah Poser, CDC; Robin A. Rinker, CDC; Troy Ritter, CDC; Luis Rodriguez, CDC; Matthew Ryan, CDC; Zachary Schneider, CDC; Caitlin Shockey, CDC; Jill Shugart, CDC; Margaret Silver, CDC; Paul W. Smith, CDC; Farrell Tobolowsky, CDC; Aimee Treffiletti, CDC; Megan Wallace, CDC; Jonathan Yoder, CDC.

California Department of Public Health COVID-19 Team
Pennan Barry, California Department of Public Health; Ricardo Berumen, III, California Department of Public Health; Brooke Bregman, California Department of Public Health; Kevin Campos, California Department of Public Health; Shua Chai, California Department of Public Health; Rosie Glenn-Finer, California Department of Public Health; Hugo Guevara, California Department of Public Health; Jill Hacker, California Department of Public Health; Kristina Hsieh, California Department of Public Health; Mary Kate Morris, California Department of Public Health; Ryan Murphy, California Department of Public Health; Jennifer F. Myers, California Department of Public Health; Tasha Padilla, California Department of Public Health; Chao-Yang Pan, California Department of Public Health; Adam Readhead, California Department of Public Health; Estela Saguar, California Department of Public Health; Maria Salas, California Department of Public Health; Robert E. Snyder, California Department of Public Health; Duc Vugia, California Department of Public Health; James Watt, California Department of Public Health; Cindy Wong, California Department of Public Health.

Solano County COVID-19 Team
Meileen Acosta, Solano County Department of Public Health; Shai Davis, Solano County Department of Public Health; Beatrix Kapuszinsky, Solano County Department of Public Health; Bela Matyas, Solano County Department of Public Health; Glen Miller, Solano County Department of Public Health; Asundep Ntui, Solano County Department of Public Health; Jayleen Richards, Solano County Department of Public Health.