[Bookmark] A Tale of Two Ships: How the Grand Princess Tackled the COVID-19 Outbreak

Bookmark is a new JAPAN Forward feature that gives you long reads for the weekend. Each edition introduces one overarching thought that branches off to a wide variety of themes. Our hope is for readers to find new depths and perspectives on the issues we explore here.

Last of Two Parts

Part 1: A Tale of Two Ships: How the Diamond Princess Tackled the COVID-19 Outbreak

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The Grand Princess (GP) sailed from San Francisco for Mexico on February 11, eight days after the arrival of the Diamond Princess (DP) in Yokohama. Onboard was a California resident who apparently had become infected before he embarked.

The infected passenger traveled on the ship to Mexico and then back to San Francisco, becoming ill on the return leg and showing respiratory issues while onboard. He was taken to the Kaiser Permanente Hospital in Roseville, California, on February 27, diagnosed with COVID-19 on March 2, and died on March 4. A second passenger on the GP’s Mexico cruise passed away on March 5.

The GP arrived back in San Francisco on February 21 ― or 18 days after the DP arrived in Yokohama ― and immediately allowed over 2,000 passengers and crew to return to their homes with no testing.

Hours after it had arrived and disembarked most passengers, the GP boarded new passengers in San Francisco and set out to sea again on the same day. Sixty-two passengers from the Mexico leg of the cruise, a large portion of the crew, along with over 2,361 new passengers, then went on to Hawaii.

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The GP’s Coronavirus Containment Plan

After Hawaii, the GP had planned to stop in Mexico before returning to San Francisco on March 7. However, as the GP approached U.S. waters, several passengers and crew members began showing flu-like symptoms. That triggered the order for the GP to cancel the planned Mexico stops, and to stand off San Francisco.

On March 3 (GP Day 1), the ship was ordered into quarantine, with passengers required to remain in their cabins and minimum movement by the crew.

A few dozen polymerase chain reaction (PCR) test kits were dispatched by helicopter to the vessel, and after two days a number of the tests came back positive. As 19 of the first 21 confirmed cases were crew members, there was a high risk that the virus had spread over the 22 days from the combined two voyages, first among the crew, and then to the passengers.

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On March 8 (GP Day 6), the GP was roughly 10 miles offshore, waiting for an unused area of the Port of Oakland to be prepared, including security fencing and assembling of medical personnel. After completing “health screenings,” which initially were set to require PCR tests for every passenger and crew member, the plan approved by the Centers for Disease Control and Prevention (CDC) was to begin disembarkation on March 9 (GP Day 7).

“We have developed a plan which will be implemented this weekend to bring the ship into a non-commercial port,” United States Vice President Mike Pence said. “All passengers and crew (2,421 passengers and 1,113 crew) will be tested for the coronavirus.” 

The plan anticipated starting with those people in the most need of medical care. Then, 962 California residents would disembark and be transported to Travis Air Force Base in California for a 14-day quarantine. And following those groups, the non-Californians would be disembarked and bused to Oakland Airport, from where they would be flown to other U.S. military bases in California, Texas, and Georgia for a 14-day quarantine.

However, a group of about 200 Canadians was required to depart immediately by charter flight — untested. They were flown to a military base outside of Ontario for their quarantine period. Another group of 142 British citizens were also flown out by charter — without testing — and surprisingly with no quarantine awaiting them.

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It took until March 14 (GP Day 12) to disembark all of the 2,421 passengers. The entire complement of 1,113 crew members, including those confirmed with the virus, were ordered to remain on board and immediately put to sea to be quarantined and treated aboard the vessel.

In the end, the CDC plan changed at the last minute. The “health screenings” became a health questionnaire and a temperature reading. Surprisingly, no passenger underwent PCR testing before disembarkation.

One couple described the disembarkation to Reuters, which reported it as follows:

Having packed, as instructed, just enough clothes and toiletries for 24 hours, Don and Laura Davis and his elderly parents shuttled on buses to Oakland International Airport. They ended up among 480 people flown to Miramar, near San Diego.

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Laura Davis said it appeared that personnel working under the auspices of HHS and escorting them from the ship to the base were poorly trained and ill-equipped….”

As of Friday, she said that “passengers were still wearing ‘the same dirty, contaminated’ surgical-style face masks they were issued aboard the ship nine days earlier, noting that as an ICU nurse she changes face masks every 30 minutes while on duty.

At Travis Air Force Base in California, the quarantine ended early for hundreds of people without explanation. While over half of the GP passengers quarantined in California refused to be PCR-tested, 103 of those tested were positive. Over 200 were tested but left before getting the results, and over 300 results were left pending.

CDC has refused to disclose the number of cases on the GP, stating that they provide the results to the health department of the state where each individual’s quarantine took place.

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Differences in the Handling of the DP and GP

One critical difference between the ships was the timing. The GP came one month after the DP, so much about the experience of the Diamond Princess was public knowledge. Likewise, by then, more facts about the infection incubation period, symptoms, and transmission routes were coming into focus. The U.S. had four more weeks to prepare test kits and set up remote quarantine areas for the returnees from the DP at facilities which had been used earlier by the U.S. Wuhan evacuees.

What is most striking is that there was no significant difference in the handling of the two ships for the first nine days, from when the virus was initially confirmed to when onboard cabin quarantine began. And there was no difference in the handling of the two ships concerning the crew who were required to stay on board and quarantine there, except that Japan disembarked infected crew members for treatment in Japanese hospitals, while the U.S. kept the infected crew members on board.

From Day 10, the cases on the two ships began to diverge.

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For the Diamond Princess, large groups began leaving DP on Day 15, but it took until Day 17 for all passengers to depart. Every passenger and crew member first cleared PCR testing before disembarking. From Day 19, the 700 remaining DP passengers were transported by bus to a dozen Tokyo-area hotels and similar facilities to begin their quarantine.

For the Grand Princess, even with no PCR testing, it took three days until GP Day 12 to disembark all passengers. The GP passengers were required to remain in their cabins for up to 10 days, but then found themselves crowded together as they were departing the ship, and again as they traveled by bus and plane to over two dozen locations. 

With no PCR testing conducted (in the interest of speed), U.S. authorities assumed the risk that DP passengers, medical, and transport staff would become infected during the transport phase and accepted the risk of contagious individuals spreading it to the quarantine locations and beyond, to their homes across the U.S., Canada, and the U.K.

The decision by U.S. authorities at the last minute to forego PCR testing before disembarking the GP passengers was shocking. It implied a willingness to assume risks with far-reaching consequences. The heavily U.S.-based cruise line industry was under extreme scrutiny for operating petri dishes for infectious disease and death ships. They were desperate that the GP did not begin a new cycle of 24x7 worldwide media attention, as had happened with the DP.

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A quick resolution was desired for the GP situation, and PCR testing would have added three to four days to the disembarkation process. It was also well-known in the U.S. that the cruise line industry had been generous contributors to President Donald Trump’s campaigns.

The Ruby Princess

Although beyond the scope of this article, I must note the history of another Princess Line ship, the Ruby Princess. After having 158 confirmed COVID-19 cases on its previous voyage, it sailed from Sydney on March 8 (GP Day 6) for an 11-day round trip to New Zealand, inexplicably without notifying the passengers of the risk.

There are currently 852 additional cases and at least 23 deaths recorded separately in Australia, the U.S., and New Zealand, all attributed to the Ruby Princess. Other cases were confirmed in Canada and the U.K. A criminal probe for suspected homicide is under investigation by Australian police, where over 700 cases and 21 deaths have been attributed to this ship.

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A wrongful death action is pending in the U.S. and a class action lawsuit has been brought in Australia for anyone on the Sydney-to-New Zealand cruise.

Two Princess Ships - The Final Numbers

For the Diamond Princess, PCR tests eventually confirmed 712 of the 3,711 passengers and crew, including the 14 Ministry of Health officials, had contracted the virus. Of those, more than 50% were asymptomatic. All cases underwent medical treatment, some cases for over three months ― all expenses paid by Japan. Of the cases, 698 fully recovered. Japan never charged the passengers or crew of the DP for their extensive medical treatment and related quarantine expenses in Japan.

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Sadly, there have been 13 recorded deaths to date in Japan, and one additional death in Australia, after the former DP passenger returned home and had a relapse. As of July 3, only one passenger from the DP was in serious condition and still undergoing medical treatment in Japan. (In a July 22 update, this last patient was discharged from the hospital in Japan on July 14. There are no remaining active cases from this ship.)

For the Grand Princess, it has been far more challenging to piece together the final number of cases and deaths related to its Mexico and Hawaii cruises. There were no PCR tests to confirm the number of infections contracted aboard the GP. All subsequent cases and deaths were independently reported by jurisdictions where the individuals were under quarantine or resided. There was no compilation of data linked to the ship, as was done with the DP.

The problem goes beyond the absence of PCR tests at the disembarkation. According to the Washington Post:

The exact number of people from the ship who contracted the virus will probably remain unknown because hundreds of passengers declined to be tested. The passengers taken to bases — nearly 2,000 initially, though hundreds later returned to their home states early for quarantines there — were told that testing was optional and discouraged for those without symptoms, they said.

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The California Health and Human Services later announced that, beyond the first 21 onboard cases, over 103 passengers tested positive after arriving at California quarantine bases, with the results of hundreds of tests still pending. Surprisingly, no other updates were issued. No announcements of cases or deaths were made by Texas or Georgia.

Based on what has been published so far, there have been no fewer than 250 cases and no fewer than seven deaths. Also, unlike the DP, there are over a dozen wrongful death and negligence actions filed by GP passengers pending in courts in the U.S. against Princess Lines for the GP cruises.

Conclusion

One month after the DP quarantine began, the handling of Grand Princess passengers in the midst of an onboard infection did not improve on Japan’s experience. Instead, the U.S. merely asked the passengers to fill in a health questionnaire, took their temperatures, and, for the vast majority of those not showing any symptoms, sent them on their way. For passengers of other countries like Canada and the U.K. with large groups onboard, the U.S. asked their governments to send planes immediately and pick up their citizens.

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Japan exhibited a sincere humanitarian response in how it provided world-class medical treatment to all passengers and crew members alike. Even though PCR test kits were extremely scarce in early February, what tests Japan had were made available as a priority to the DP passengers and crew ahead of Japanese citizens. Moreover, Japan’s handling of the DP prevented the seeding of the virus across over 50 countries weeks before the virus appeared in most of those countries, and before most of them were prepared.

Here is the bottom line: the DP quarantine worked far better than anyone could have reasonably expected in stopping or slowing new transmissions among the passengers and crew. Masks, physical distancing, avoiding crowding in poorly ventilated areas are at the root of the 3 C’s that are part of the “Japan Model,” and could provide valuable lessons for the rest of the world still struggling to deal with the virus at the root of this pandemic.

Author: Edo Naito 

Edo Naito is a retired international business attorney. He has held senior executive positions, leading major business units in Japan, the Indo-Pacific region, and globally at several U.S. and Japanese multinational companies. He naturalized as Japanese in 2015 after living and working in Japan for over 40 years.    

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