Now that cruising has recommenced – leaving aside the disastrous impact of Russia’s invasion of Ukraine on cruises to ports in the Black Sea, the Baltic and beyond – what lessons have the cruise lines and their travel insurance and medical assistance partners learned from the pandemic, and what measures have they introduced or strengthened to curb yet another Covid variant – or the seemingly inevitable ‘next pandemic’ when it breaks out?
Bound for the scrapyard?
Cruising has been one of the sectors of the tourism industry hardest hit by the Covid pandemic. Several cruise lines were forced into bankruptcy, and ships were sold for scrap. The first outbreak of Covid, onboard the Princess Cruises vessel Diamond Princess in February 2020, led to 14 deaths. Over the next year, more than 3,500 cases were reported onboard cruise ships, leading to the deaths of more than 70 passengers and crew. Most of these were during the first month of the pandemic, leading to governments quarantining and locking down vessels and closing ports of call in the world’s favourite cruise destinations. PR doesn’t get much worse than that.
The crisis has proved fatal for at least six cruise companies in Europe, the US and Asia, among them the UK’s second biggest, CMV-Cruise and Maritime Voyages (CMV), which went bust in July 2020. Other casualties attributable to the pandemic included Spain’s Pullmantur Cruceros, the Indian line Jalesh Cruises, and the US company Blount Small Ship Adventures.
CMV’s Astor and Marco Polo were sold for scrap, as were the Pullmantour vessels Monarch of the Seas and Sovereign of the Seas, and half a dozen more. Most were elderly (the venerable Marco Polo had been at sea since 1965).
The giants of the cruise sector, though, including Royal Caribbean, Carnival, and NCL, appear to have been too big (and too cash-rich) to go under.
Weathering the storm
Cruising cautiously resumed in summer 2021 as cruise lines adapted to the ‘new normal’, with measures such as mandatory masks, proof of vaccination certificates, distancing onboard and in some cases, testing for passengers boarding for the first time or re-embarking after shore excursions.
The Cruise Lines International Association (CLIA), an industry body, welcomed the US Centers for Disease Control and Prevention (CDC) decision to make its Conditional Sailing Order framework a voluntary programme. Issued in October 2020, the order replaced a ‘No Sail Order’ imposed in mid-March 2020. It was modified and updated in May 2021 and again in July 2021, when it became non-binding for cruise vessels using Florida ports.
Daniel Durazo, Director of External Communications at Allianz Travel Insurance, noted: “One sign of commitment to health and safety is the move by major lines to opt into the CDC’s voluntary Covid programme for cruise ships operating in the US to assist the industry in detecting, mitigating and controlling the spread of Covid-19 on ships.”
travellers will make their own risk assessment when choosing to travel on a cruise ship, much like they do in all other travel settings
More than 100 cruise ships returned to US waters in the second half of last year (2021), carrying more than one million passengers, according to CLIA.
In December 2021, the CDC rehiked its travel advice on cruising to its highest level, warning even the fully vaccinated against boarding a cruise. CDC director Dr Rochelle Walensky cited a 30-fold increase in cases of Covid on ships, from 162 in the first half of December to more than 5,000 in the second two weeks of the month. In January, out of more than 100 cruise vessels operating in US waters, only 11 reported no cases of Covid-19 or ‘Covid-like illness’.
As a result, many cruises were cancelled or postponed, as ports of call in the Caribbean, South America and Europe temporarily turned ships away. The German vessel AIDAnova, operated by AIDA Cruises (a Carnival brand), was briefly quarantined in Lisbon over New Year 2021/22 after more than 50 crew members and a handful of passengers tested positive. Most experienced mild symptoms or none, and on 3 January, after a five-day quarantine, passengers were allowed to fly home after testing negative.
On 15 January – after no deaths or cases of serious illness among cruise passengers had been reported – the CDC finally downgraded its Conditional Sailing Order from mandatory to voluntary, while urging cruise lines to continue to follow all CDC health measures, including reporting, testing, and infection prevention and control. The move was greeted by a collective sigh of relief from the cruise industry. And in March, the CDC removed its Covid-19 risk warning completely for cruises. While the move doesn’t mean there is no risk of Covid-19 transmission on cruises, ‘travellers will make their own risk assessment when choosing to travel on a cruise ship, much like they do in all other travel settings’, the CDC said in a statement.
Being responsible for their own future
CLIA insists that cruise industry protocols – including testing, vaccination, screening, sanitation, mask-wearing and ‘other science-backed measures’ – are ‘unique in their approach to effectively monitor, detect, and respond to potential cases of Covid-19’. The cruise industry is the only part of the US travel and tourism sector that is requiring both vaccinations and testing for crew and guests, CLIA claims. Vaccination rates onboard a cruise ship are typically above 95 per cent, the association states.
Dr Geoff Tothill, Chief Medical Officer of IMG, tends to agree with CLIA. Cruise lines, he says, have always expended a great deal of effort in their attempt to ensure that infectious diseases do not arise and spread onboard. Earlier, less lethal disease outbreaks have taught them hard but valuable lessons: “Norovirus outbreaks spread extremely rapidly on ships and have proven very expensive for operators, resulting in damaging publicity when not handled sensitively,” Dr Tothill points out. “For these reasons, most large cruise operators had rigorous disinfection procedures and customer-facing hygiene campaigns in place even before the pandemic.”
“When the cruise lines finally restarted their operations they set up a set of comprehensive anti-Covid measures and restrictions,” concurs Elena Donina Glukhman, Project Manager, Development and Co-operation Worldwide, AP Companies Global Solutions.
A vaccination certificate is still required, all the rest is optional and depends on each cruise line and destination
“The majority of cruise lines established a solid anti-Covid protocol, where all people onboard (both passengers and crew) were fully vaccinated and regularly tested. Passengers onboard were tested prior to embarkation, in the middle of the trip and at the end of the trip.
“Now, when in the majority of the countries anti-Covid measures and restrictions have been relieved or taken away, the same has happened onboard cruise ships. A vaccination certificate is still required, all the rest is optional and depends on each cruise line and destination.”
Cruise lines and assistance companies are now less likely to be called on to manage disembarkation and isolation of Covid cases. The early response of cruise operators was to reduce passenger numbers and implement social distancing, mandatory mask wearing, and hand cleaning, Dr Tothill notes.
“Unfortunately, before there was consensus on management [of the disease], there was a number of high-profile outbreaks on large ships that generated a great deal of adverse publicity, largely focusing on conditions on the vessel and the willingness of healthcare providers around the ports to accept offloaded patients.
“Two years later, we are in a significantly different position. Effective vaccination is available and, in those who are fully vaccinated and boosted, the Omicron variant tends to produce mild disease, which has allowed cruise operators to mandate vaccines for passengers.
“This dramatically reduces the risk that anyone contracting Covid would need to be offloaded. In addition, it reduces spread and makes brief periods of in-cabin isolation more effective, in a way not seen in 2020,” he told ITIJ.
Assistance remains steadfast
“Assistance companies are adept at supporting their members, regardless of their chosen travels, and this has continued to be the case throughout the pandemic,” said Dr Tothill.
Although many Covid-related travel requirements have been and are being lifted, the complexity of seemingly ever-changing requirements reduce traveller confidence and generate stress, he notes: “Particularly for those embarking on complex or expensive vacations, the predominant concern is not being able to complete a trip because of failing to satisfy Covid-related travel requirements,” Dr Tothill said. “In response to these concerns, some assistance companies may offer pre-travel advice, often delivered by health professionals.”
In pre-pandemic times, he points out, IMG’s advice would focus on the recommended (or required) vaccinations, common sense precautions whilst travelling and specific risks associated with each location. “This emphasis on travel health provided a good foundation upon which to build Covid-specific advice. The extent of these services varies by plan and agreement, but almost all provide entry requirements for visited countries, advice on vaccination and testing, and what to do if anyone in the party becomes Covid positive,” Dr Tothill concluded.
Working with assistance companies to manage disembarkation processes
Dr Lynn Gordon, Chief Medical Officer, Charles Taylor Assistance, spoke to ITIJ about the challenge of managing a medical case that is slowly moving further away on a ship in a remote region: “It’s important to bear in mind that it’s not easy for a cruise ship to divert its course; weather conditions may not be favourable, while fuel supplies and the needs of potentially thousands of passengers onboard also need to be taken into account. The logistical and financial implications of diverting a ship’s course are huge, and a diversion may not always enable a patient to reach suitable care more quickly.”
A patient in need of acute care that extends beyond first stage medical management, for instance a coronary angiogram or a stent insertion after a heart attack, will need to be disembarked from a cruise ship for further investigation and treatment – and most cruise companies will go above and beyond to disembark patients in a place that gives them access to this. Gordon continued: “Sometimes this will involve disembarkation followed by a road or air transfer elsewhere, organised by the assistance provider. At other times, an assistance company may ask a ship to delay disembarkation until the ship has reached an area with better medical facilities, if it is practical and safe to do so. Disembarkation decisions are always taken with the patient’s best interests at heart and are usually reached collaboratively by onboard doctors and assistance providers.”
One significant challenge for cruise lines is the continuing care of passengers who have disembarked due to a serious illness or injury
Durazo added that co-ordination between cruise lines, insurance providers and medical assistance companies is key to meeting the challenges posed by the pandemic. “One significant challenge for cruise lines is the continuing care of passengers who have disembarked due to a serious illness or injury,” he added.
“Allianz Partners has evacuated many cruise passengers who have been transported to local hospitals due to an acute condition. It’s important that the cruise line coordinate with us and the passenger’s family so that we may arrange the appropriate level of care.”
Cruise lines should also insist that passengers have a travel insurance policy in force to provide appropriate emergency medical coverage and arrange and pay for an evacuation if needed, Durazo added: “In addition to the substantial cost involved, there can be significant logistical challenges to overcome, especially with an evacuation in the pandemic era.”
The absence of an over-arching global protocol for Covid quarantine and hospitalisation is also something of an issue, said Glukhman: “The main challenge for this kind of cases is the fact that neither medical assistance company nor travel insurer or assistance company can take the full responsibility and complete action on such cases, as those cases are largely regulated by the state, which designates the [quarantine] hotel for non-symptomatic patients or the hospital for symptomatic patients. The rules differ from one state to the other,” Glukhman points out.
Insurance responds to customer need
Many travel insurance and international medical assistance providers have already responded to the new reality by expanding cover for cancellation due to illness and for quarantine. Last year, Allianz Partners formally added ‘epidemic coverage’ to many of its products to provide cancellation coverage for customers, close family members or travelling companions who become ill with Covid-19 before their trip begins or while they are travelling, notes Daniel Durazo.
challenges associated with Covid-19 cases onboard cruise ships have changed with the emergence of effective vaccines
Enhanced epidemic coverage also provides emergency medical cover for customers who become seriously ill on their trip. And coverage for mandatory personal quarantines and denied boarding due to suspected illness. Allianz provides a 24/7 assistance team as well as support via its TravelSmart mobile app, Durazo says.
In conclusion, Geoff Tothill says, the challenges associated with Covid-19 cases onboard cruise ships have changed with the emergence of effective vaccines, treatments, and the arrival of a less virulent variant of the disease.
“Initially, patients would often present as part of a larger outbreak and be isolated in their cabins. This often resulted in difficulty in communicating with them, a paucity of medical monitoring on the vessel, and late presentation of serious disease. When individual patients became unwell and required offloading, they found themselves in the middle of improvised local political and public health policies. Assistance companies often had to negotiate with individual hospital providers, health ministries, and border agencies to facilitate escalation of care,” he says.
These complexities have remained a theme of Covid-19 transfers, but have become easier to navigate as the various agencies involved have developed coherent policies and assistance companies have incorporated these into their case management processes. For the cruise sector, it may not all be plain sailing ahead, but useful lessons have been learned.