MILNET Brief
  Cruise Paranoia:  Are Illnesses Aboard Cruise Ships Bio-Terror?  (1/12/2005)

"It may sound like I need to straighten my tin foil hat a bit, but this could be bio-terrorism.  3 ships in about as many weeks with hundreds of sick passengers?  Plus, they all depart from Miami and we all know how much the Islamist terrorists like Florida."

-Jennie on her blog, The Greatest Jeneration, in an article "Bio-Terror Afloat", 2/3/2002.

We noted this interesting quote when perusing blogs in the past.  However, for us, the concept never got out of the interesting conversation phase. However even after decades of stories about the so called NLV (Norwalk-Like Virus or norovirus) infections aboard cruise ships, a few paranoids continue to email MILNET with questions about cruise ships being attacked by bio-terrorists.

And while we are as paranoid as just about anyone you know, this one doesn't smell right for terrorism...unless the terrorist is focusing on economic terrorism -- and even that's a stretch.  Here's our rationale for "poo-pooing" the idea (you'll see more puns like that). 

And then maybe you folks out there will stop sending us the annoying bio-terror warnings every time another cruise ship docks with 100s of sick people on board.
  1. Terrorists want death and destruction.  Maimed and bleeding corpses or burned and desiccated images for TV.  Bullet ridden, yuck, yuck, and more yuck.  Why?  It's about impact.   A ship full of diarrhea ridden passengers is almost comical (relatively speaking -- no one at MILNET wants to contract a noro-virus, believe me) as compared to what a terrorist is looking to get for his or her risk.  Think bodies not barfing.
  2. The fact that several of the ships which have had 10% of crew and passengers who've come down with the viral infection, continue to have the infection even after the CDC's Sanitary Division descend on them like flies on excrement.  The implication (and most disease experts agree) is that a) the virus is brought on board by a passenger, and b) is passed around person to person through the food supply or common things such as hand rails, toilet handles, etc. etc. and ad nauseam (Sorry for this pun it really is weak).
  3. The only death's so far are attributed to very sick people who go on a cruise and have the bad luck to be on one that has the NLV outbreak.  That also does not sound like good planning on the Terrorist's part.
  4. Anyone who has been on a cruise ship will notice that while many of the waiters, waitresses, and cook's helpers don't usually speak English all that well, they are hungrily part of the capitalistic system, not terrorists out to kill western infidels. Of course, that could be good acting on the part of one or two.
  5. The first and worst cases on cruise ships go back (according to Elaine Cramer, medical epidemiologist with the CDC's Vessel Inspection Program) to a three year period between 1975 through 1979, when there were 27 outbreaks per 100,000 passenger hours during that period.  That rate was the highest, and we've never gotten close.  So if there was a terrorist cell at work, they are certainly slacking off, or our protections have reduced the incidence by nearly a magnitude.  We've not heard of terrorists even considering bio-terror in that time frame, but that could be just a hole in our mind (B-5 speak).
  6. The biological agents in question have been identified and they are easily found ten feet off the ship.  In fact, there are more cases of NLV off ships then there are on ships. In the tens of millions of cases every year.  You would have to be a real paranoid to think that all those cases are created by a terrorist network.  You'd be more likely to point at SARs or the ever changing Flu virus with that kind of paranoia. Or AIDS for that matter.
Having said all that, we will make the following prediction.  We have not yet seen, but will most likely see, a case where real bio-terror in the transportation system is repeated (we are reminded of the Japanese terrorists who released sarin gas in a Japanese train station...and there are other cases of bio-terror against transportation systems).  We also admit that Bio-terror is "good" terror in the minds of terrorists.  It creates lots of fear -- the unknown, microscopic virus is all invasive and wholly frightening to anyone with an ounce of brains.

So yes, we have decided that the best we can say about possible bio-terror on cruise lines is that "perhaps" it is intentional.  In our heart of hearts, though, we doubt it.  Not likely with a NLV. Now if a ship load of folks comes down with small pox or anthrax, that will change our derisive tone right quick.  Those agents are a lot harder to bring aboard accidentally, and there will definitely be some deaths to count, not just a high requirement for toilet paper and a whole lot of green faces.

And just to make sure we don't get anymore of those annoying emails, here is the raw data...



Table of selected cruise ship illness stats

Date Ship Ship Line Headed To # Ill % Typical Symptoms Intentional?
11/03/03 Aurora P&O Greece 500+ 28% Nausea,Vomiting, Diarrhea Perhaps
10/16/03 Holiday Carnival E.Caribbean 120 7.10% Vomiting, Diarrhea Perhaps
08/18/03 RegalPrinc. Princess Iceland 346 15.40% Vomiting, Diarrhea Perhaps
07/20/03 Rhapsody Roy.Cari.. E.Caribbean 72 3.10% Vomiting, Diarrhea Perhaps
05/20/03 Norw.Sky Norw.C.L. Alaska 55 2.50% Vomiting, Diarrhea Perhaps
02/12/03 SunPrinc. Princess Hawaii 300 15% Vomiting, Diarrhea Perhaps
12/16/02 Conquest Carnival E.Caribbean 229 7.20% Vomiting, Diarrhea Perhaps
12/12/02 U.K.Oceana P&O E.Caribbean 393 10.90% Vomiting, Diarrhea, Fever Perhaps
12/04/02 Magic Disney ? 60 1.70% Vomiting, Diarrhea Perhaps
12/03/03 Statendam Roy.Cari. Mex.River. 12 0.90% Flu-likesymptoms Perhaps
12/02/02 U.K.Oceana P&O ? 212 7.90% Vomiting, Diarrhea Perhaps
12/02/02 Fascination Carnival ? 203 6.00% Vomiting, Diarrhea Perhaps
11/22/02 Amsterdam Holl-Amer ? 125 9.00% Vomiting, Diarrhea Perhaps
11/14/02 Statendam Roy.Cari. Mex.River. 42 3.20% Vomiting, Diarrhea Perhaps
11/01/02 Magic Disney ? 275 7.80% Vomiting, Diarrhea Perhaps
11/01/02 Mariner SevenSeas ? 20 2.50% Salmonella Poisoning Perhaps
06/01/02 Ryandam Holl-Amer. Alaska 388 ? Vomiting, Diarrhea Perhaps

Note:  number ill and percentages reflect both crew and passengers when both counts are available
Also, every ship listed is from one or more of the news reports cited in the Sources section below. 
Don't sue us, sue the publication who maintains that archived story online!

For a comprehensive listing (not confirmed) of cruise ship illnesses occuring from 2002 through 2004, see the Cruise Junkie's list  2



Below are our notes compiled after looking at over 200 news stories from 2002 through 2004.  Also we've cataloged some of the more insteresting stories at the end of the page in our usual "Sources" section.

Gary Barnas, MD, Associate Professor of Medicine (General Internal Medicine) at the Medical College of Wisconsin, gave us some facts about the viruses. “The original Norwalk virus was named for its first occurrence in Norwalk, Ohio,” he says. “All other similar outbreaks are now called ‘Norwalk-like.’” Symptoms of illness from Norwalk-like viruses include nausea, vomiting, abdominal cramping and diarrhea. “The entire GI tract can be affected,” reports Dr. Barnas, “but fortunately, these illnesses usually run their course in two to three days.” The Norwalk-like viruses are among the most common causes of diarrhea, especially in travelers. They affect many confined sites on land as well, such as schools and nursing homes. (Healthline, Dec 13, 2002)  15


Dave Forney, Chief of Centers for Disease Control and Preventions Ship Sanitation Department says there have been 23 outbreaks of gastrointestinal illness aboard 19 ships so far this year  (Oct 16 2003), Forney said. Eleven were confirmed norovirus  [Norwalk-like virus - MILNET]. 6


In all, 21 outbreaks of stomach sickness have occurred on 17 cruise ships this year, federal scientists said Thursday (Dec 12, 2002).  16


"Elaine Cramer, medical epidemiologist with the CDC's Vessel Inspection Program, gave these statistics:

• From 1975 to 1979, there were 27 outbreaks per 100,000 passenger days.

• From 1980 to 1985, there were eight outbreaks of illness per 100,000 passenger days.

• From 1986 to 1993, there were six outbreaks of illness per 100,000 passenger days.

• From 1990 to 1995, there were four outbreaks of illness per 100,000 passenger days.

• From 1996 to 2000, the most recent year for which data have been calculated, there were 3.5 outbreaks of illness per 100,000 passenger days.

Last year, just seven outbreaks were detected aboard ships, one-third the number reported so far this year, but officials said that does not necessarily mean the incidence of illness aboard ships has risen this year.

"It looks as though there's been a change, but two points do not make a trend," Forney said. "We will have to calculate rates, using 100,000 passenger days, in order to really effect a comparison. We will be doing that." (CNN, Dec 12, 2002) 16


From October to late December, more than 1,500 passengers from over 24 outbreaks on cruise ships leaving US Ports were logged, over three times the total for 2001 (seven) and greater than the last four years combined. (Hilltop, Jan 14, 2003)  12


Recent outbreaks
Nov. 25, 2004: Up to 100 students and five teachers at a public school in Hamilton, Ont., become sick with Norwalk virus.

Nov. 9, 2004: Health officials confirm that Norwalk virus is responsible for illnesses at a homeless shelter in Calgary.

June 11, 2004: Ten patients at St. Paul's Hospital in Vancouver become infected with a Norwalk-like virus. Three staff members are sent home sick.

May 31, 2004: About 180 people become sick with Norwalk virus after visiting Emerald Lake Lodge in Alberta's Yoho National Park.

Oct. 11, 2003: More than 60 people at an RCMP training facility in Regina are treated for symptoms of a Norwalk-like virus. Most of the patients are RCMP cadets.

Dec. 16, 2002: A Norwalk-like virus strikes more than 200 passengers on the cruise ship Carnival Conquest.

Dec. 4, 2002: At least 60 passengers fall ill with the virus aboard the Disney cruise ship Magic in Florida. This comes just days after the ship was thoroughly cleaned when 275 passengers fell ill in a similar outbreak.

Nov. 28, 2002: Emergency room at Toronto's Sunnybrook Hospital is closed as officials try to contain an outbreak of the Norwalk virus.

November 2002: Holland America sanitizes the Amsterdam after more than 500 people catch the virus on four separate voyages.

July 2002: Holland America pulls the Ryndham from service to be sanitized after 388 passengers fall ill during an Alaska cruise.
(CBC News)  3


The CDC Green Sheet:
This listing shows inspection results from CDC's Vessel Inspection Program instituted in the 1970s and which continues today. The listing shows ship inspections for the year, and the score is made up various sanitary accomplishments...the higher the number, the better the ship scored and is "more clean" during the inspection than ships with lower scores.  The CDC emphasizes that a clean ship does not mean you will not contract an NLV -- the agreed pathogen source are passengers bringing it on board and then spreading it amongst themselves. Even after CDC has supervised a thorough and rigorous cleaning of a ship, that same ship will again have a virus outbreak -- typically smaller, but an outbreak never-the-less.

Ascore of 86 is considered Satisfactory, less than that, unsatisfactory.  The 1/5/2005 list indicates some 9 ships had inspected unsatisfactory with some having dates for their last inspection going back to February of 2004:

Astor 79, Carnival Victory 80, Century 79, Enchanted Capris 81, Fantasy 83, Legacy 76, Logos II 79, Nautilus Explorer 77, and Pacific Venus 77

Barely passing were Empress of the North 89, Fascination 89, Maxim Gorkiy 87, Norwegian Crown 89, Orion 88, Safari Quest 88, Spirit of Endeavor 88, Texas Treasure I 88, Vistamar, 86, and Volundam 87.  1


Death Due to Complications of NLV
Los Angeles attorney, Geoffrey P. Norton, has filed a class action lawsuit on behalf of the [Holland American - Raddison Hotels] Ryndam's sick passengers and says the passengers weren't told about the virus before they arrived for the cruise. Norton says "One of our passengers contracted the virus and died a week later without ever recovering." That passenger was 56 year old Martin Massey, who had several serious health problems including severe arthritis.  (Inside Edition, Nov. 19, 2002)  22



Sources:
  1. The CDC "Green Sheet", Ship Inspection Listing, CDC,  updated regularly
  2. Illness Outbreaks on Cruise Ships in 2004, The Cruise Junkie, 1/2005
  3. The Norwalk Virus, CBC News, 11/29/2004
  4. Illness Outbreaks on Cruise Ships in 2003, The Cruise Junkie, 1/2004
  5. Cruise Passengers Tell of Sickness Hell, The Scotsman.com, 11/03/2003
  6. Cruise Ship Outbreak Sickens 129, CNN, 10/16/2003
  7. Many Fall Ill on Cruise Ship, Forcing Trip to be Cut Short, New York Times (Found archived elsewhere online), 9/28/2003
  8. Hundreds Sickened Aboard Cruise Ship, CNN, 9/02/2003
  9. 72 Aboard Crew Ship...Report Illness, Knight Ridder Tribune, 7/20/2003
  10. 55 Sick On Cruise Ship That Docked, SeatllePI.com, 5/20/2003
  11. Princess Cruise Hit By Virus, CBS News, 2/12/2003
  12. Ocean Sickness, The Hilltop Online, Howard Univeristy, 1/14/2003
  13. Illness Outbreaks on Cruise Ships in 2002, The Cruise Junkie Online, 01/2003
  14. New Cruise Ship Illness Sickens 229, CNN, 12/16/2002
  15. Cruise Ships Trying to Prevent Further Outbreaks, Healthline, 12/13/2002
  16. CDC: Cruises Absolutely Safe, CNN, 12/12/2002
  17. Cruise Ship Outbreak Sickens 212, CNN, 12/9/2002
  18. Scope of Illness Puzzles Experts, Miami Herald's Herald.com, 12/03/2003
  19. Sailing the Sickening Seas, CNN, 12/3/2002
  20. Sea Sick:  The Norwalk Virus Strikes..., Susan Breslow Sardone, About.com, 12/03/2002
  21. Cruise Ship Illness May Leave Industry Ailing, Local 10, Miami, Ft. Lauderdale, FLA news station website, 11/22/2002
  22. Inside Editon Investigates Viruses at Sea, Inside Edion, 11/19/2002
  23. Cruise Ship Illnesses May Be Bio-Terrorism, Jack Thompson, Canada Free Press, 12/02/2002
  24. Cruise Industry Fighting Virus, Terror Outbreaks, National Geographic News, 2/11/2002
  25. Bio-Terrorism Afloat?, The Greatest Jeneration, 2/3/2002



© Copyright 2005, Michael G. Crawford for MILNET