Going viral

First published in ITIJ 131, December 2011

When marketing nerds or computer geeks talk about a concept or an application ‘going viral’ they generally mean it as a compliment. But viruses don’t just exist in cyberspace. The old fashioned kind, hungry for living human tissue, are still out there, and the implications for the travel insurance industry are immense. Scared yet? Robin Gauldie thinks you will be

Steven Soderberg’s Contagion, which premiered to considerable acclaim in October, is the latest in a long tradition that stretches all the way back from 1995’s Outbreak in which Dustin Hoffman battles against time to contain an epidemic of the outstandingly unpleasant and highly infectious Ebola virus, to the 1976 Cassandra Crossing featuring a trans-European train infected by a deadly disease. The seemingly endless public appetite for zombie chillers such as 28 Days Later, The Walking Dead, and World War Z (out in 2012) underlines our near-phobic fascination with viral infections.  

That fascination is understandable. Existing on the borderline between living and unliving, viruses can be blamed for some of the nastiest, most intractable – and most infectious – diseases that afflict the human race. It’s commonplace to point out that, while we have apparently got the measure of former viral killers such as smallpox and measles and yellow fever, there is still no cure for the common cold, nor for the herpes group, responsible for shingles (herpes zoster) and cold sores and genital herpes (herpes simplex).

Nor, of course, is there yet a cure for perhaps the most high-profile virus of all, human immunodeficiency virus (HIV), which has killed more than 30 million people since it became epidemic around 30 years ago.

It is relatively easy to prevent and avoid HIV infection, which is mainly transmitted by contaminated blood in transfusion, poorly sterilised sharps (including hypodermic needles used by drug users), and by unprotected sex (heterosexual as well as homosexual). But other viruses are much more contagious and several are of increasing concern to travel health practitioners, travel insurers and the travel industry as a whole.

Reality bites

This not just media scaremongering. The reality may be even more frightening than even the tabloid press would have us believe. In a new book, The Viral Storm: The Dawn of a New Pandemic Age, Professor Nathan Wolfe, of Stanford University and director of Global Viral Forecasting, notes that while fewer than one in a hundred victims of the H1N1 ‘swine flu’ virus will die, H1N1 will eventually infect two billion people, with a death toll of two million. The virologists’ real nightmare is not swine flu, however, but some new mutation that will combine the high infection rate of H1N1 with the much greater lethality of its cousin H5N1, or ‘bird flu’, which seems to spread less easily among humans – but kills 60 per cent of those it touches.

In August 2011, the UN Food and Agriculture Organisation (FAO) warned that H5N1, which first appeared in 1997 with further outbreaks in 2003 and 2005, has not gone away. The FAO urged ‘renewed vigilance’ after several bird flu deaths in Cambodia, and voiced concerns that migrant wild birds could spread the disease from Asia to the Middle East and Europe.

As early as 2006, the life insurance industry began to consider its ability to deal with the impact of a full-scale pandemic, with the US Insurance Information Institute warning, in a paper entitled Pandemic: Can the Life Insurance Industry survive the Avian Flu?, that the total dollar value of death claims resulting from a pandemic could be $133 billion. Has the travel insurance sector yet begun to consider its own position?

localised outbreaks of non-lethal but highly infectious diseases are a more immediate worry for the travel industry than doomsday pandemics

During the last swine flu scare, the Association of British Insurers (ABI) sought to reassure travellers. The ABI’s director of general insurance and health, Nick Starling, urged against public over-reaction. The ABI stressed that swine flu was treated no differently from any other illness by travel insurers, with insurance typically covering the cost of medical treatment abroad, rearranged flights and accommodation for the insured, while anyone diagnosed with the virus when due to travel abroad, as well as immediate family members travelling with them, would likely be covered for the cost of holiday cancellation.   

As the UK’s National Pandemic Flu Service went live in response to the 2009 outbreak, the ABI signalled a flexible response, stating that in the absence of written documentation from a qualified medical practitioner, it would accept as medical certification of swine flu diagnosis the unique ID number and label on prescribed anti-flu drugs, including an individual's name and date of issue, for purposes of validating a related travel insurance cancellation claim. In July 2009, the ABI also confirmed that its members’ policies would cover costs arising from swine flu diagnosis, including medical treatment abroad and cancelled holidays and flights. The ABI said costs of accommodation and rearranged flights for people quarantined abroad after being diagnosed with the virus and forced to stay beyond their planned departure date would be covered by travel insurance policies. However, the position of people quarantined as a precautionary measure was less certain, with insurers considering claims on an individual basis, the ABI said. At the time, Nick Starling commented: “We understand that the National Pandemic Flu Service will only authorise an anti-flu prescription to people who are genuinely displaying symptoms of swine flu. On that basis, travel insurers will accept an individual's unique ID number generated by the National Flu Service, together with the label on their anti-flu drugs which states their name and date of issue, as proof of diagnosis to validate a travel insurance cancellation claim." As of now, that is still the ABI’s position.

Media hype?

In Outbreak, Dustin Hoffman’s team battle to control the spread of a virus before the US military sterilises the entire area with a tactical nuclear strike. Travel insurers aren’t calling for such drastic action, but there is widespread agreement that more proactive strategies may be necessary to deal with virus outbreaks on cruise ships, in large hotels and in all-inclusive resorts. All of these accommodation types, despite best practice, could almost have been tailor-made for the rapid spread of infection, with a high multi-national churn-through of clients potentially carrying infections from all over the world, and a wide range of age groups, from babies and toddlers to senior citizens.

Arguably, localised outbreaks of non-lethal diseases are a more immediate concern for the travel industry and for travel insurers than a notional, future pandemic. Infections such as norovirus or E. coli are here and now, and each outbreak gives rise to a scattering of claims. One cruise line, Carnival, offers its own ‘cancel for any reason’ protection, which it claims is ‘the only money-back guarantee offered in the cruise industry’. A look at the small print, however, reveals that Carnival has hedged its bets with a number of provisos – guests wishing to disembark and ask for their money back must make their request before the ship reaches its first port of call.

“The reason you hear about norovirus on cruise ships is because they are required to report every incidence of gastrointestinal illness,” says a spokesperson for the US Centers for Disease Control (CDC), the organisation that is charged with preventing the introduction and spread of disease within the US, partly through its Vessel Sanitation Programme which monitors illness on ships carrying more than 13 passengers. “Nowhere else in the US public health system is norovirus a reportable illness. Norovirus is not a ‘cruise ship’ illness but is commonly seen in many settings in the US.”

The cruise industry has remained buoyant despite recession, but cruise lines have been under pressure to reduce prices, and to do so they have to cut costs by reducing anything from food portions, training and service levels to the variety of green vegetables offered, explains Douglas Ward, one of the world’s leading consumer experts of cruising and cruise ships and author of the new Complete Guide to Cruising and Cruise Ships. Ward, who spends up to 200 days a year aboard cruise ships, inspecting and evaluating their facilities, said to ITIJ: “Should cruise lines pay compensation? I don’t think so. After all, hospitals don’t, schools don’t, and nobody else does. When an outbreak occurs, a cruise line will immediately sanitise the whole ship and will usually confine affected passengers to their cabins to stop the condition spreading. Hand gel dispensers will be used at all restaurants and other eatery entrances. In my experience, almost all outbreaks have occurred because someone brought the condition with them from ashore. Strangely, only cruise ships must report outbreaks; which is why the media often hypes it to the max.”

Distressing though it is, norovirus is a mild and brief illness that typically occurs 24 to 48 hours after contaminated food or water has been consumed, and lasts for 24 to 72 hours. The condition itself is self-­limiting, is mild, and is characterised by nausea, vomiting, diarrhoea, and abdominal pain. It is more prevalent in adults and older children than in the very young.

The nightmare scenario is a pandemic alert causing ‘global lockdown’

Norovirus and E.coli outbreaks aboard cruise ships or in all-inclusive resorts inevitably make headlines, but such outbreaks need to be put into context. The CDC has reported nine outbreaks on cruise ships in 2011, compared with almost 40 in 2006, so there is some indication that cruise lines are getting better at prevention and control. Also, the number of people affected is generally relatively small – generally well below 10 per cent of the total number of passengers.

Tighter controls

Meanwhile, some experts argue that it is only a matter of time before governments and meta-national organisations adopt a tighter regime to limit the spread of communicable disease between countries. Tim Lynch, author of The 2009 H1N1 Outbreak: A Chaotic North American Trigger with Evolving Global Consequences, suggests that the World Health Organisation’s International Health Regulations (IHR 2005) provides a framework for such regulation. “The fact that the 2009 H1N1 outbreak was not very severe does not take away from the urgency of considering such matters,” he argues, “It is my belief that in the future, in addition to those cards we are asked to read about what to do when there is an emergency in a plane we are flying in, we shall also have a similar card telling us about the International Health Regulations and what to do if we are caught up in a pandemic outbreak.” The North American Free Trade Agreement countries, comprising the US, Canada and Mexico, could serve as a platform for promoting compliance with IHR 2005 ‘within the context of the North American tradition of voluntary accreditation, emphasising professionalism rather than authoritarianism’, Lynch speculates.

An analogy could be drawn between a governmental response to a notional, lethal pandemic and the US-driven but worldwide tightening of international security following 9/11 and subsequent terror attacks. We have grown used to a world in which we have to empty our pockets and take off our shoes before boarding; where body-scans, luggage X-rays and pat-downs for airline passengers are the norm, and where anyone objecting too strenuously to such measures is likely to be dealt with by armed security guards. It seems at least possible, then, that a serious pandemic would prompt states to react in an even more severe fashion, with wide-ranging consequences for travellers and insurers.

In many, if not most, countries, the machinery is already in place for just such measures. For example, in 2007, US national Andrew Speaker, diagnosed with ‘extremely drug resistant tuberculosis’ (XDR-TB), a contagious and potentially fatal form of the disease, returned home from his honeymoon in Italy to be met by a quarantine order served by the CDC – the first such order since the 1950s. How agencies such as the CDC might react to a full-blown pandemic is anyone’s guess, but the indications are far from encouraging. “The type of chaos that occurs upon a pandemic outbreak is different to what happens when there is an act of terrorism,” Tim Lynch states. “Pandemic outbreaks happen in a ‘knowledge vacuum’.”

While travel insurers must budget to meet the costs of hospitalisation and medical evacuation for policyholders who become infected, the cost of claims from uninfected travellers whose travel plans are disrupted by any future outbreak could be vastly greater. The nightmare scenario is a pandemic alert causing ‘global lockdown’, with governments imposing quarantine measures that could force airlines to leave multitudes stranded, resulting in vast numbers of claims covering flight delays and emergency accommodation. For example, just a one-day shutdown of London Heathrow could affect 200,000 people. Even if only half of them claimed against their travel policies for just one night’s hotel accommodation and association, that could cost insurers, conservatively, £1.5 million. Multiply that by airports around the world, and the picture become truly frightening. Unlikely? Perhaps. Impossible? No.

“This time around, we have been aided by pure good luck,” said the WHO’s director general, Dr Margaret Chan, in her report on the 2009 H1N1 outbreak, published in August 2010. Next time around, we may not be so lucky. Time, perhaps, for the insurance industry to make sure it’s prepared for the worst.