News analysis: Are insurance and assistance providers prepared for infectious disease outbreaks?

The identification of hantavirus cases linked to passengers on the MV Hondius cruise ship has drawn attention across the travel risk and assistance sector – not because of scale, but because of what it reveals about managing infectious disease events in highly mobile environments.

The incident is unfolding against a wider backdrop of global infectious disease pressure. Recent Ebola cases in eastern Democratic Republic of the Congo (DRC) have renewed international focus on outbreak containment capacity and cross-border coordination, underscoring the continued strain placed on public health and emergency response systems. It highlights the same structural challenge now facing insurers: managing events that do not respect jurisdictional boundaries.

Elsewhere, just days after the hantavirus outbreak drew international attention, nearly 150 passengers aboard the Caribbean Princess were affected by a norovirus outbreak, according to the US Centers for Disease Control and Prevention (CDC).

Additional gastrointestinal outbreaks have been reported this year aboard vessels including the Star Princess, Oceania Cruises’ Insignia, and Regent Seven Seas’ Seven Seas Mariner. In mid-May, passengers aboard an Ambassador Cruise Line vessel were detained following its arrival in the French city of Bordeaux amid concerns linked to a suspected norovirus outbreak.

Individually, these events differ in severity. Collectively, they reinforce a persistent challenge: infectious disease exposure in cruise environments is difficult to predict, contain, and price across globally mobile populations.

The key issue is not the pathogen itself, but how quickly a contained medical incident becomes a multi-jurisdictional insurance and assistance event once it enters a cruise operating system.

Lessons learned from Covid-19 – but operational constraints remain

The post-pandemic environment has significantly improved outbreak response capability across the sector, particularly in evacuation coordination and medical escalation pathways.

Abasse Asgaraly, Founder and Principal Consultant at KMB Consulting, said the industry was now fundamentally better prepared to manage infectious disease incidents.

“Travel insurers and emergency assistance providers are now well aware and prepared to deal with efficient evacuation or repatriation of infected or potentially infected patients,” he noted. “Very detailed protocols are in place and have been tested during the Covid outbreaks.”

Crystol Lasley, Director of Maritime Medical Operations at AP Companies, said the operational lessons learned during the pandemic continued to shape outbreak response today.

“What the industry learned during Covid – and what remains highly relevant today – is that successful outbreak response depends heavily on operational flexibility, strong local networks, rapid information flow, and the ability to coordinate care across borders under constantly changing conditions.”

What the industry learned during Covid – and what remains highly relevant today – is that successful outbreak response depends heavily on operational flexibility, strong local networks, rapid information flow, and the ability to coordinate care across borders under constantly changing conditions

However, Asgaraly warned that structural vulnerabilities remained in certain transport environments.

“Some industries, such as airlines or cruise liners, are highly vulnerable and exposed to rapid changes in outbreaks because of their confined spaces and lack of adequate onsite medical resources.”

This gap between preparedness and execution is particularly evident at sea, where geography, fragmented regulation, and limited medical infrastructure continue to shape response capability – especially on expedition itineraries operating far from established healthcare networks.

Asgaraly added that Covid-19 permanently reshaped how the sector approaches infectious disease risk, elevating it from a secondary exposure to a core underwriting consideration.

“Before Covid, infectious disease was not always viewed as a core operational threat in the same way it is now,” he said. “Since then, we’ve seen major changes across underwriting, medical assistance, cruise operations, and telemedicine.”

Telemedicine has become increasingly embedded within assistance models, while cruise operators have strengthened onboard protocols, including pre-boarding screening, isolation procedures, and faster escalation pathways, alongside closer coordination with assistance providers and improved remote clinical support.

“Policies now include much more detailed communicable disease wording, destination-based risk scoring, and more sophisticated modelling around evacuation costs and outbreak exposure,” Asgaraly said. “After Covid, insurers faced enormous losses from trip cancellation and curtailment claims, so the sector has become far more cautious and analytical in how it assesses risk.”

Cruise ships as a concentrated risk environment

Cruise vessels operating across remote or multi-jurisdictional itineraries sit at the centre of this challenge. They represent one of the most complex accumulation risk environments in travel insurance portfolios, characterised by high-density passenger occupancy, shared air and living spaces, limited isolation capacity and medical supplies, and an often-older traveller demographic.

Asgaraly highlighted that once an outbreak occurs, "even a relatively rare disease can escalate very quickly into a complex multinational event”.

Cruise ships also face inherent operational constraints that amplify insurance exposure.

The industry needs more advanced outbreak preparedness, stronger telemedicine integration, and more dynamic underwriting approaches

“Diagnostic capacity on board is limited, containment can be difficult, and evacuation logistics become extremely complicated depending on the vessel’s location,” he explained. “This creates downstream risk across multiple cost centres, including emergency evacuation, repatriation, quarantine accommodation, and liability exposure.

“The industry, therefore, needs more advanced outbreak preparedness, stronger telemedicine integration, and more dynamic underwriting approaches moving forward.”

Mark Barton, a cruise expert working with Avanti Travel Insurance, said the underlying nature of cruise outbreak risk had not fundamentally changed – but the visibility and complexity surrounding those incidents had intensified considerably in recent years.

“Outbreaks haven’t necessarily become more frequent; they’ve become more visible and more complex to manage,” he said.

According to Barton, public scrutiny and reputational exposure are now playing a much larger role in how cruise-related incidents unfold operationally.

“Infectious disease outbreaks on cruise ships have become more visible in recent years, particularly following the Covid-19 pandemic,” he explained. “However, this heightened profile may be largely driven by growing public awareness and easier access to news online, rather than a definitive increase in virus outbreaks.

“What has evolved is the scale of scrutiny and complexity around managing reputational and regulatory risks. Modern cruise itineraries often span multiple jurisdictions within a single voyage, which introduces layers of legal and logistical exposure when medical incidents occur.”

Beyond the vessel: When claims become complicated

The MV Hondius outbreak demonstrated how quickly a contained onboard medical incident could evolve into a cross-border insurance and assistance event.

Multiple passengers became seriously ill, with fatalities reported. Governments subsequently initiated multinational repatriation operations, while specialist quarantine facilities were activated across several jurisdictions. In parallel, military medical teams were deployed to support evacuation from remote locations.

At the same time, public health authorities undertook cross-border contact tracing spanning multiple countries and continents, reflecting how cruise-related exposure extends well beyond the vessel once passengers disembark internationally.

For insurers and assistance providers, this significantly expands the claims perimeter. Exposure is no longer limited to immediate treatment costs but extends across evacuation logistics, international medical transfers, quarantine accommodation, multi-jurisdictional coordination, and prolonged monitoring obligations.

Effective management relies on close coordination between onboard medical teams, cruise line shoreside operations, specialist maritime medical assistance providers, port authorities, and international public health agencies

Stuart Phillips, Chief Operating Officer at Medresq, said early escalation was often the most critical variable. “The greatest challenge is often early recognition rather than treatment capability itself,” he told ITIJ. “In maritime environments, evolving infectious disease presentations are not always straightforward.”

In addition, the World Health Organization (WHO) has indicated that additional hantavirus cases may still emerge due to the incubation period and the level of passenger interaction prior to confirmation of the outbreak.

WHO Director-General Dr Tedros Adhanom Ghebreyesus said further hantavirus cases were inevitable given the timing of exposure and transmission window. “We would expect more cases because the first case was on 6 April, and until the outbreak was confirmed in late April, there was significant interaction among passengers,” he said. “As you know, the incubation period is six to eight weeks. Because of this interaction, even with preventative measures in place, we would expect more cases.”

Phillips added that effective response depends on coordination across multiple actors. “Effective management relies on close coordination between onboard medical teams, cruise line shoreside operations, specialist maritime medical assistance providers, port authorities, and international public health agencies.”

This underlines a structural reality: cruise outbreaks are not discrete clinical events, but distributed operational crises that ripple across medical, logistical, and regulatory systems simultaneously.

Rising cruise demand adds pressure to claims exposure

Cruise demand continues to strengthen globally, even among younger demographics. According to the Cruise Lines International Association (CLIA), 37.2 million passengers sailed in 2025, with numbers expected to reach 42 million by 2028.

At the same time, rising aviation costs and ongoing airline disruption are pushing more travellers toward cruise products, particularly remote, luxury, and expedition-style itineraries.

For insurers, this increases both exposure volume and complexity.

Expedition cruising, in particular, is reshaping risk dynamics. These itineraries operate far from established healthcare infrastructure, coastguard support or viable aeromedical evacuation corridors, making response times longer and coordination more complex.

In the MV Hondius case, several patients required multi-stage medical transfers across jurisdictions, while one suspected British case triggered the deployment of UK military medical personnel to Tristan da Cunha – one of the world’s most remote inhabited islands.

Expedition cruising, in particular, is reshaping risk dynamics

Aeromedical evacuation alone can rapidly escalate into six-figure territory, particularly where biocontainment transfer, specialist isolation facilities, or multi-stage transport coordination is required.

At the same time, traveller behaviour is evolving. Industry data suggests passengers are becoming increasingly risk-aware when booking remote travel, with stronger demand for cancel-for-any-reason (CFAR) cover, higher medical evacuation limits, and specialist expedition protection policies.

This is also driving a more granular approach to underwriting, particularly around age profiles and pre-existing medical conditions. As cruise and expedition travel expands, insurers are under increasing pressure to price and structure cover around individual health risk, rather than treating passengers as a single uniform cohort.

For Asgaraly, it is only a matter of time before more “personalised, tailored insurance products begin to emerge, shaped more closely around individual risk profiles, age and pre-existing medical conditions, and specific itinerary exposure”.

Operational reality versus medical reality

Medical assistance providers are increasingly required to operate within constraints where clinical need and operational feasibility diverge.

This introduces additional uncertainty for insurers, where outcomes depend not only on clinical severity, but also on port acceptance, local regulation, and geopolitical conditions at the point of intervention.

Lasley said this variability was no longer exceptional, but embedded in modern cruise response scenarios.

“One of the biggest challenges in international medical assistance is that healthcare decisions are not made in isolation from politics, border regulations, and local operational realities,” she explained. “What is medically possible and what is operationally permitted are not always the same thing.”

She added that managing suspected infectious disease cases at sea increasingly depended on real-time coordination with local systems, which could vary significantly between jurisdictions.

What is medically possible and what is operationally permitted are not always the same thing

“Some ports may become extremely cautious about accepting potentially infectious patients, while others may have stronger infrastructure and more established isolation capabilities. Our role is to help clients navigate those realities in real time.”

Lasley emphasised that this complexity placed greater emphasis on communication throughout the assistance chain, particularly where decisions must be made quickly among multiple stakeholders.

“Transparency and real-time communication are essential in managing client expectations, particularly when medical decisions are being made in rapidly changing operational environments.”

This dynamic is not unique to cruise travel. The recent Ebola cases in Africa have similarly highlighted how outbreak response is shaped by fragmented health systems, cross-border coordination challenges, and variable national capacity for containment and treatment.

While clinically distinct, both scenarios underscore the same structural issue facing insurers and assistance providers: medical decisions increasingly sit within politically and operationally constrained environments.

The shift towards adaptive risk

Asgaraly also pointed to a broader structural shift within the travel insurance and assistance sector, arguing that while operational capability had improved significantly since the pandemic, commercial and underwriting behaviours had become increasingly “cautious, conservative, and constrained”.

He told ITIJ: “There is a tendency towards rigidity and slower decision-making, with too much emphasis on exclusions rather than adaptive risk management.”

This has particular relevance in complex operating environments such as cruise and expedition travel, where incidents can escalate rapidly and require flexible, real-time coordination across multiple jurisdictions and providers.

There is a tendency towards rigidity and slower decision-making, with too much emphasis on exclusions rather than adaptive risk management

Looking ahead, Asgaraly argued that the sector’s next phase of evolution would depend on moving away from static policy structures towards more adaptive, intelligence-led models of protection.

“Insurers need to adopt the new predictive tools combined with AI,” he said. “They would allow them to better understand and capture the emerging risks to travellers, such as political instability, disease outbreaks, and weather-related events, that are becoming increasingly common. They have at their disposal new technologies that allow them to push in real-time relevant alerts, or information.”

The question now is not just how quickly insurers can respond – but whether their systems are built to move fast enough when everything else already is.