Its been a tough month for Royal Caribbean. More than 200 passengers became ill and five had to be hospitalized after an outbreak on the Ovation of the Seas during a two-week cruise between Sydney and Singapore, according to the Washington Post.

Local newspapers in South Florida are reporting today that the Independence of the Seas which left Port Everglades on Monday, for a Caribbean cruise, and returned to Fort Lauderdale this morning with at least 332 passengers sickened by a norovirus outbreak.

A cruise travel writer, @CruiseNiche, was on the cruise and posted photos on Twitter about the widespread gastrointestinal outbreak.

Independence of the Seas NoroNBC News reports that over 500 Royal Caribbean passengers have been sickened on these two cruises alone.

Last month, there was a gastrointestinal outbreak on the Anthem of the Seas. Royal Caribbean confirmed that “were a total of 98 reported cases of gastro-intestinal illness symptoms, which represents 1.9 percent of the 4,905 guests and crew onboard.”

The CDC’s Vessel Sanitation Plan requires cruise ships to send a separate notification when the GI illness count exceeds 2% of the total number of passengers or crew onboard. Cruise ship outbreak updates are posted on the CDC website only when 3% or more of the passengers and crew report symptoms to the ship infirmary during the cruise. Because there were less than than 2% of the passengers and crew members reported ill during the cruise, the CDC will not list the outbreak on its official cruise ship Outbreak Updates page.

There was also a norovirus outbreak on the Anthem of the Seas at the end of February and early March 2016 which was reported to the CDC.

Norovirus outbreaks are typically caused by contaminated food or water, according to the CDC and the FDA, although most cruise lines automatically blame their passengers for bringing the virus aboard the ship and/or spreading the outbreak by not washing their hands.

From my view, hand-washing can’t hurt, but it won’t help if the food is contaminated by an ill food handler or waiter. And of course, washing your hands won’t protect you if you contract norovirus via airborne transmission. Three years ago, in an article titled Norovirus Spreads by Air on Cruise Ships, I discussed that researchers have concluded that norovirus can spread by air, according to a publication in the highly respected Clinical Infectious Diseases. This is an issue which the cruise lines have never acknowledged.

As we have said in prior articles, don’t call us if you get sick on a cruise. Establishing where the virus came from, or that the cruise line was negligent, is virtually impossible to prove, especially since the CDC conducts no epidemiological analysis and sometimes can’t even figure out the source of the outbreak.

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Photo credit: @CruiseNiche

Independence of the Seas

Carnival BreezeAccording to crew members on the Carnival Breeze, the Carnival cruise ship was in Galveston Sunday  when the United States Public Health (USPH) came aboard the ship for a semi-annual sanitation inspection. According to these crew members, the USPH gave a failing score of only 77, although the Centers for Disease Control and Prevention (CDC)  has not published its official report yet. 

A score of 85 or lower is a failing grade, according to the CDC.

The low score is highly unusual for this ship, which received scores of 97, 100, 98, 100 and 97 on the last five USPH inspections over the last several years. The Breeze has not received a score less than 90 since it came in service in 2012. 

But the low score of a Carnival ship is not unprecedented. A month ago, the popular Crew Center reported that the "Carnival Triumph failed to pass the recent USPH Inspection. Centers for Disease Control and Prevention Inspectors boarded the vessel on November 11, at the port of New Orleans, Louisiana, and found multiple violations. CDC has not yet released an official report on their website, however, several crew members have reported that the final USPH score was 78." The CDC has still not published its report on the alleged failed USPH inspection.

This is not the first time that we have received a tip from a crew member of a cruise ship with a failed USPH score. In 2013, crew members on the Silver Shadow hid food, dirty pots & pans and cooking equipment from U.S. health inspectors. The Silversea cruise ship eventually received a failing score of 82. CNN aired a special on the story.

Stay tuned for the official reports.

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Photo Credit: Whiskey5jda – BY 3.0, commons / wikimedia. 

HAL VeendamA passenger sailing on a Holland America Line (HAL) cruise ship near Greece contacted me today, stating that a number of guests are experiencing gastrointestinal symptoms:

"I’m currently on MS Veendam. Left Fort Lauderdale on October 20th and due to return to Fort Lauderdale on December 8th. Currently docked in Souda, Greece. Leaving at 5:00 pm less than an hour from now. Souda port terminal has WiFi.

Noro started about four days ago. We did pick up passengers in Barcelona and some of them are sick now and seem to have gotten sick shortly after boarding from what I understand. One day there were 29 passengers and two crew sick . . .  Yesterday …  only four new cases and no crew sick anymore. 

Ship is cleaning, isolating and taking precautions including not allowing passengers to handle food which is good."

It is currently unknown whether the gastrointestinal outbreak is in fact due to norovirus (or-coli or some other more exotic virus) because there will be no testing of the affected passenger’s stools. 

In the last week, we have written about GI outbreaks which included the Crown Princess, which called on a U.S. port and had to report the outbreak to the U.S. Centers for Disease Control and Prevention (CDC). The Anthem of the Seas was experienced a similar outbreak affected many dozens of guests (around 100 people). The Anthem did not meet the percentage of guests who reported their symptoms to the ship infirmary, and therefore there is no official CDC report.  The Celebrity Solstice was also reportedly hit with an aggressive GI outbreak while sailing around Australia, according to news accounts. 

Holland America Line experienced 18 cases of GI sicknesses reported to the CDC since 2010. Only Princess Cruises suffered more norovirus/GI cases which were reported to the CDC during this time period. HAL suffered norovirus outbreaks on the Nieuw Amsterdam, and two outbreaks each on the Volendam and the Noordam this year.

Cruise ships on non-U.S. itineraries do not have to report GI outbreaks. 

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Photo credit: Fletcher6 – CC BY 3.0, commons / wikimedia.

A local news station in Philadelphia reports on a recent gastrointestinal outbreak on the Royal Caribbean Anthem of the Seas.

ABC-6 reports that a family from Philadelphia returned from a 7-night cruise aboar the Anthem which departed Cape Liberty, New Jersey on Saturday, November 4th. The news stations reports that on the second day of the seven day cruise, "rumors of the virus started circulating . . . and started to spread fast. Workers could be seen spraying the narrow hallways, but it was apparently spreading like wildfire." 

A newlywed woman and her husband and several of her family members became ill with symptoms of a gastrointestinal virus. 

The family complained to the news stations that "some hand sanitizing stations … didn’t have any Royal Caribbean Norovirussanitizer available to us, there were out of soap at certain sinks, there were no sanitizing stations at the elevators . . the ship’s managers (didn’t take) enough measures to stop the spread of the virus, which is not airborne but rather comes from personal touch with others or germs left on surfaces."

Royal Caribbeaan confirmed that "were a total of 98 reported cases of gastro-intestinal illness symptoms, which represents 1.9 percent of the 4,905 guests and crew onboard." 

The CDC’s Vessel Sanitation Plan requires cruise ships to send a separate notification when the GI illness count exceeds 2% of the total number of passengers or crew onboard. Cruise ship outbreak updates are posted on the CDC website only when 3% or more of the passengers and crew report symptoms to the ship informary during the cruise.

Because there were less than than 2% of the passengers and crew members reported ill during the cruise, the CDC will not list the outbreak on its official cruise ship Outbreak Updates page.

A couple of take-aways from this article. First, how many passengers did not dislose their symptoms to the ship doctor?

Secondly, there is no indication that the outbreak is related to norovirus, which cannot be confirmed until there is scientific analysis of the infected passengers’ stool samples, which will not be done because the CDC is not involved.

Thirdly, the local news station is wrong that GI virus outbreaks can’t occur through airborne transmission. Two years ago, in an article titled Norovirus Spreads by Air on Cruise Ships, I discussed that researchers have concluded that norovirus can spread by air, according to a publication in the highly respected Clinical Infectious Diseases.

Finally, don’t call us if you get sick on a cruise. Establising where the virus came from, or that the cruise line was negligent, is virtually impossible to prove, especially since the CDC conducts no epidemiological analysis and sometimes can’t even figure out the source of the outbreak

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Read: Gastrointestinal Outbreak on the Crown Princess, Again.

http://6abc.com/video/embed/?pid=2643100

Coral PrincessThe Coral Princess arrived in Fort Lauderdale this weekend with 157 of 2,016 cruise passengers aboard the Princess Cruises’ ship stricken with nausea/vomiting and diarrhea which the Centers for Disease Control and Prevention (CDC) suspect are symptoms related to norovirus.

The noro-infected passengers comprise 7.79% of the total passenger population on the ship. 25 of 881 (2.84%) crew members are also infected.

The CDC was unable to conclude where the norovirus came from. I am not aware of a single instance when the CDC has pinpointed the cause of a cruise ship disease outbreak. Unfortunately, the public is often left with the "blame game" of wondering whether the cruise ship food or water was contaminated (which the CDC and FDA generally say are the most likely causes of gastrointestinal outbreaks), or the outbreak was caused by a sick galley worker, or was brought aboard by sick passengers, and then spread because of inadequate hygiene and poor cleaning procedures.

Several years ago, Time magazine published an article titled 13 Worst Norovirus Outbreaks on Cruise Ships. The overall winner of Time’s top 13 list was Princess Cruises which had five outbreaks on its brand alone: Crown Princess (January 2010) with 396 ill; Crown Princess (February 2012) – 363; Ruby Princess (March 2013) – 276; Coral Princess (February 2009) – 271; and Sun Princess (July 2012) – 216.

The last norovirus outbreak involving the Coral Princess was in April 2015.

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Photo credit: Roy Luck – CC BY 2.0, commons / wikimedia.

Hat tip to the popular Crew Center blog which first covered the outbreak. 

HAL's OosterdamPassengers aboard a Holland America Line (HAL) cruise ship have fallen ill with symptoms consistent with norovirus on an approximately two week trans-Atlantic cruise that departed from Civitevecchia, Italy on November 3rd and arrived today in Tampa, Florida.  

According to the Centers for Disease Control and Prevention (CDC), the November 3 – 18 cruise aboard the Oosterdam sickened 86 of 1,843 passengers (4.67%) and 18 of 796 crew members (2.26%) who exhibited symptoms of vomiting and diarrhea. 

The link to the CDC about this outbreak is here. There has been no official determination of the cause of the outbreak although norovirus is suspected.

According to the CDC and the FDA, the most common cause of norovirus is contaminated food or water. Of course, like land-based restaurants, ill food handlers often transmit the virus. Passengers can also obviously bring the disease aboard which can spread due to unhygienic conditions caused either by the passengers and/or the cruise line.

Before there can be a scientific determination as to the actual cause of the outbreak, there must first be a serious epidemiology assessment of the ship which the CDC rarely performs due to the quick turn-around of the cruise ship. Unfortunately, in this case HAL immediately argued that norovirus is allegedly "circulating throughout North America and can be easily transmitted if personal hygiene is not maintained," according to a statement that it released to the Tampa Bay Times.

The CDC says that there have been 13 GI outbreaks this year, mostly involving norovirus with two e-coli outbreaks. 

The cruise ship says that it performed enhanced cleaning and left today for the Caribbean.

Photo credit: Sebastian Wessels wikipedia / commons, CC BY 2.5.

Majesty of the SeasA passenger from Ohio who sailed aboard the Majesty of the Seas last November and developed Legionnaires’ disease has filed suit against Royal Caribbean. The passenger alleges that only after he boarded the cruise ship in Miami, and the ship had set sail, did the cruise line notify him, via a notice placed under his door, that Legionella had been discovered in the ship’s water system on prior cruises.

Legionnaires’ disease is one of the most serious diseases a passenger can contract on a cruise ship. Legionnaires’ disease is a severe pneumonia caused by inhalation or possibly aspiration of warm, aerosolized water containing Legionella organisms. According to the Centers for Disease Control (CDC), contaminated ships’ whirlpool spas and potable water supply systems are the most commonly implicated sources of shipboard Legionella outbreaks. Symptoms include a cough, shortness of breath, high fever, muscle aches and headache. Although prompt antibiotic treatment can kill the bacteria, 5% to 30% of people infected with Legionella will die from the infection.

After the cruise ended on November 13, 2015, Royal Caribbean sent an email to the disembarking passengers, stating that they may have been exposed to Legionella during the cruise. It stated that if passengers become ill, they should seek medical attention and undergo testing for Legionella.

Royal Caribbean stated that two passengers had been confirmed to be infected with Legionnaires’ disease from the cruise ship, and that one person was possibly infected. One person was infected during a cruise in July 2015 and one other person was infected during a cruise in October 2015. The email stated that Royal Caribbean had shut down the whirlpools on the ship after it confirmed the first case of Legionnaires’ disease associated with the July sailing. The cruise line claimed that it treated the ship’s water supplies with extra chlorine (the email mentions “two rounds of treatment with chlorine”), but water samples taken from showers confirmed the presence of Legionella.

Royal Caribbean also sent the email to those people who had booked cruises on the Majesty on future dates, advising that the risk of illness is “low but not zero” and suggesting to future cruisers that they may want to reschedule their cruises for a later date depending on their individual risk factors.

A few days after returning home, the passenger began experiencing symptoms consistent with Legionnaires’ disease. He visited his doctor on an urgent basis and he was immediately hospitalized. His lawsuit lists kidney, heart and pulmonary failure among other complications which he suffered as a result of the disease which he contracted on the cruise ship.

The lawsuit alleges that Royal Caribbean was on actual notice of Legionella on its ship but notified the passengers only after Majesty sailed and was at sea. In addition to alleging that the cruise line was negligent, the lawsuit states that the cruise line “acted with deliberate and wanton recklessness” in refusing to advise passengers of the Legionella prior to the cruise. Royal Caribbean, the lawsuit alleges, acted in “callous disregard” of the dangers to the passenger’s health in order to promote its economic interests.

The lawsuit seeks punitive damages, in addition to compensatory damages, due to the cruise line’s intentional misconduct.

The lawsuit was filed by Miami maritime lawyer Domingo Rodriquez.

There was a discussion regarding Legionnaires’ disease and this particular cruise last year on the Cruise Critic boards. If the comments are accurate, some of the passengers apparently were not notified of the Legionella on the ship during the cruise but were notified only after the cruise was over. At least one person commenting said that he sailed on the cruise ending November 13, 2015 but never received an email from the cruise line. One poster mentioned that a family member who was on the cruise was allegedly admitted to the hospital with Legionnaires’ Disease. She stated at the time: “we did not get the email about the ship being contaminated until the afternoon of Nov. 13, after we had just gotten off the ship . . . This was very irresponsible and unethical on Royal Caribbean’s part.”

In my opinion, it is outrageous that Royal Caribbean kept sailing the Majesty if it knew that the ship’s water supply was still contaminated with Legionella after multiple “extra-chlorine” treatments. It is Legionellaprobable that some of the passengers or crew members would become sick because, obviously, passengers are going to shower during cruises. Unfortunately, we have seen this cruise line take the “show-must-go-on” attitude to extremes over the years, whether it is recklessly sailing into hurricanes or repeatedly exposing its passengers to noro virus on successive cruises.

There have been a number cases of Legionnaires’ disease on cruise ships over the years. The most infamous case involved the Horizon cruise ship operated by Royal Caribbean’s sister cruise line, Celebrity Cruises (before it was purchased by Royal Caribbean), back in 1994.

Following a deadly shipboard outbreak which caused Celebrity to cancel cruises and fly passengers back from Bermuda, passengers sued Celebrity alleging that the company defrauded them by refusing to disclose that Legionella was present on the cruise ship. An Associated Press writer wrote that: “on Saturday passengers on the cruise ship Horizon were told the risk of contracting Legionnaires’ disease on board was low. On Tuesday they were hustled off the ship in Bermuda as a precaution.” (Numerous passengers were nonetheless infected). The AP quoted passengers as saying at the time: “everyone is entitled to a worry-free vacation and this has been anything but that” and “the people who operate this line should be chastised” and “what they did to the passengers is unconscionable.”

Celebrity subsequently sued the manufacturer of the ship’s pool and whirlpool equipment, alleging that extensive press coverage of the disease outbreak stigmatized the company, thus hurting its reputation and reducing its profits. Celebrity obtained a $193 million verdict, although an appellate court subsequently reduced the verdict.

Regarding the recent outbreak, if Royal Caribbean was uncertain whether the Majesty of the Seas still had Legionella in its water system, merely warning future passengers that the risk of illness was “low” but not canceling cruises was, at a minimum, irresponsible. Not informing passengers who cruised on the ship of the disease until after they sailed is truly reprehensible conduct.

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Photo credit: Top –  CC-BY-SA-3.0/Matt H. Wade at Wikipedia; bottom – By CDC (PHIL #1187) – CDC Public Health Image Library, Public Domain.

Legionella Royal Caribbean Email

Legionella Royal Caribbean Email

 

Empress of the SeasAccording to the Centers for Disease Control and Prevention (CDC), Royal Caribbean’s Empress of the Seas flunked a surprise sanitation inspection conducted in early June. The Empress of the Seas scored a failing score of only 80.  You can read the report here. A score of 85 or lower is considered a failure.

The Empress of the Seas underwent an extended period of renovations in Spain and later in Freeport, Bahamas when the ship was transferred back from Pullmantur. Royal Caribbean canceled a total of thirteen cruises scheduled for earlier this year. The first sanitation violation related to the renovation and involved a bathroom for the medical staff which could be used only for storage and was "heavily soiled." Back in April of this year, Royal Caribbean told the Miami Herald that “as work has progressed, we learned that more significant infrastructure and physical improvements across the ship’s multiple galleys and provisioning areas were needed to meet our high standards.”

I was contacted previously by crew members, during the renovation period, who complained  of unsanitary conditions on the ship. There was talk that the CDC had inspected the ship and initially had not given the ship a passing score, although there was nothing officially posted on the CDC website. Several crew members said that the ship had fallen substantially in disrepair while operated by Pullmantur and had a major problem with pests.    

It is apparent, however, that once back in the Royal Caribbean fleet, the Empress failed to meet high standards. The report regarding the June inspection details forty four CDC violations, ranging from improper procedures to monitor acute gastrointestinal illness cases to incorrect potable water and swimming pool/whirlpool testing.   

The report included numerous references to live and dead flies and cockroaches around refrigerators, buffet lines and other areas used for food storage. The ships was also in violation of the CDC’s requirement to use rat guards, and was utilizing rat guards on only one out of six mooring lines while the ship was in port.

A crew member states that the Empress was reinspected earlier this month, on July 10th, and received a score of 97.  If such an inspection took place, the CDC has not posted that inspection yet.  

Royal Caribbean, including its Celebrity brand, has failed other inspections in the past.  In 2013, the Celebrity Century scored only a 78.  The same year, the Celebrity Summit scored only a 81. The Monarch of the Seas scored a 85 in 2011. 

Two years ago, Market Watch published the 5 Most Hygienic Cruise Lines and concluded that Costa and Disney and three other smaller lines had never failed a CDC inspection. Since then, the Disney Wonder experienced a gastrointestinal outbreak in April of this year.    

We last mentioned the Empress of the Seas three weeks ago when it experienced problems with one of its engines, causing Royal Caribbean to alter the cruise ship’s itinerary.

Photo Credit: By Jsausley – Own work, CC BY-SA 4.0.

A gastrointestinal sickness outbreak on the Silver Shadow in March was found by the Centers for Disease Control and Prevention (CDC) to be caused by Enterotoxigenic E. coli (ETEC).

The outbreak occurred during a cruise from March 3 – 21, 2016. The outbreak sickened 37 people according to the CDC report on the incident. The CDC concluded that 24 of 388 (6.19%) passengers and 13 of 366 (3.55%) crew members fell ill due to the disease.

Outbreak News Today said that “according to the Centers for Disease Control and Prevention (CDC), Silver SpiritETEC is a major bacterial cause of diarrhea among travelers and children in the developing world. ETEC is increasingly recognized as an important cause of foodborne illness in developed nations, such as the United States. Infection occurs when a person eats food, or drinks water or ice contaminated with ETEC bacteria. Human or animal wastes (e.g., feces) are the ultimate source of ETEC contamination.”

Silversea Cruises was last in the news several years ago when the USPH caught crew members hiding perishable food and galley equipment in crew quarters on the Silver Shadow and flunked the cruise line. CNN covered the scandal. You can see the video here.

The Silver Shadow failed another USPH inspection last year as well.

The Silver Spirit, on the other hand, has always scored highly by the USPH (93-100) in the last 6 years, and it scored a 98 during the last inspection in January. However, in a lawsuit filed by a Silversea crew member (aboard the Silver Spirit and Silver Wind) in 2011, the crew member alleged that his employment as a bartender was terminated after he complained that he was required to fill expensive, premium top-shelf brand liquor bottles with cheaper brands and to fill empty expensive French champagne bottles with cheaper Italian sparkling wines. The case is Marin Asenov v. Silversea Cruises, Ltd., Case No. 0:11 CV 62360 WJZ. You can read the allegations in the lawsuit here.

Photo credit: This image photographed by Brian Burnell with permission was uploaded to Commons by George Hutchinson. CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=15252523

P&O OceanaA month ago, a crew member aboard the P&O Oceana notified me that the cruise ship failed a sanitation inspection by the enters for Disease Control and Prevention (CDC) while the ship was in port in Charleston, South Carolina.  Oceana received a score of 82; 85 or lower is considered a failure.

I have been checking the CDC’s online inspection scores since then. I have been asking the CDC when it will release its report on the Oceana.

The report was finally released today. You can read the report here. The report indicated that several back-flow prevention devices, to prevent the contamination of potable water, did not have test results and appeared not to be tested. The ship’s Riviera swimming pool and Crystal whirlpool did not have adequate levels of chlorinated and bromine, failed to have hair and lint strainers / filters and were not disinfected. The inspector closed the recreational water facilities on the ship.

The report also revealed that a food handler had an onset of Acute Gastroenteritis (AGE) and exhibited symptoms at 9:00 A.M. in the morning but did did not report to the medical center until 11:20 A.M. A review of the crew member’s work history indicated that this crew member worked, notwithstanding his illness, from 7:30 A.M. until 10:30 A.M.

The ship’s galley appeared dirty. There were comments like “the tile grout in this area was soiled and in disrepair.”  “The deck below under counter refrigerator . . . had a significant buildup of more than a week’s accumulation of food debris, dirt, equipment parts, and what appeared to be insect remains.” Food service equipment was broken or out of service and many operational ovens and ice-makers were overflowing their drip pans and/or leaking onto the floor.

Oceana has not prepared a “corrective action report” in response to the failed score, as required by the CDC.

In an era when cruise lines are quick to blame every single norovirus outbreak on the passengers, this CDC report provides an insight into how deficient water sanitation and disgusting food handling practices by a cruise line can jeopardize the health of the traveling public.

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April 4, 2016 Update: The CDC vessel sanitation inspectors inspected the P&O Oriana in February.  Although the cruise ship passed with a score of 90, there were several significant sanitation problems including dirty and out of service galley equipment.  Also food handlers working while ill with gastrointeritis: “A Chef de Partie experienced onset of GI symptoms on 20 January 2016 at 6:45 am. This crew member worked from 7 am to 11 am, took lunch at the crew mess, then returned to work from 1 pm to 5 pm. The chef reported his symptoms to the medical center at 6 pm.”   You can read the report here.

April 5, 2016 Update:  Cruise Law News was quoted today in the Southampton’s Daily  Echo and the U.K.’s Daily Mail.

Fortune magazine also covered the story, writing that it “raises questions about the industry’s squeaky-clean image, and indeed, that there may be more unreported cases that were either ignored or dismissed by the sickened passengers or the cruise lines themselves.”

April 6, 2016 Update:  FoxNews covers the story today – Health inspectors find cockroaches, ‘potentially hazardous’ food aboard two luxury cruise ships.  The Cruise Line International Association (CLIA) interjects the blame-the-passenger-wash-your-hands excuse but ignores the fact that crew members were handling food while contagious and the ship’s galley was found to be unsanitary and potentially hazardous to the guests’ health.

Photo credit: Piergiuliano Chesi, CC BY 3.0, commons / wikimedia.