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THE NOROVIRUS PLAGUE SHIP

Written by Rick Archer
(Reprint from the Oslo Cruise, June 2010)

As Marla and I prepared to board the Vision of the Seas, we were handed an odd piece of paper. It was a health questionnaire asking us if we were sick. I had never been asked to sign a document like this on a previous trip, but I could see they weren't kidding. Without a signature, I would stay on shore.

Fortunately, I wasn't sick. Neither was Marla. In fact, we were both feeling pretty good.

Last year's big adventure had been our Barcelona 2009 cruise. Although that trip had been a slam dunk success, the Continental plane flight over the Atlantic had been extremely unpleasant. It was a small plane that gave a six foot man like myself no room to move. My knees felt like they were in my chest. My shoulders spilled out into the aisles. All night long, people brushed up against me as they made their way through the narrow aisles. I got no rest at all. The ten hour flight left me with more aches and pains than I have ever experienced before. I was miserable. Nor was Marla spared. She said she was just as uncomfortable the whole night long.

Live and learn. So for this 2010 flight, Marla had decided to give British Airways a first try. Good move. The plane was much more spacious. Huge difference! I was so comfortable that I slept for practically the entire flight.

Plus Marla had decided to fly us in a day early to help overcome jet lag. As a result, we were both feeling pretty good as we prepared to begin our cruise trip. We weren't sick so I signed the document without hesitation. However, I was on guard now. There had to be a reason behind this health declaration.

Sure enough, I was right. Marla and I had just climbed aboard a Plague Ship.

It didn't take us long to figure out something was wrong. The Vision of the Seas was fighting a serious outbreak of Norovirus. Our first clue was the fact that we were not allowed to go to our cabin immediately. I had never heard of this before. I had no idea what the reason was for the delay. As Marla and I strolled around, we saw Annie Fletcher and Richard Byrd at a table. We sat down to say hi. That's when Annie leaned over and whispered that she had heard a rumor of a Norovirus outbreak. They were still trying to disinfect the cabins at this very moment.

I frowned. Norovirus is often referred to as "The Cruise Disease." It is a gastrointestinal illness that usually lasts for one to two days. Apparently cruise ships are very vulnerable to outbreaks because everyone is confined to a limited space, making it easier for the virus to spread. Other environments that see Norovirus outbreaks include prisons and hospitals, but for some reason only the cruise ships get the publicity. If forced to guess, we all have sympathy for anyone who gets very sick on their vacation, no matter how brief the illness. Vacations are supposed to be immune from life's problems; otherwise they aren't a vacation.

All the unwelcome publicity aside, Norovirus is hardly limited to cruise ships. I am certainly no stranger to this disease. I was sick with the identical problem after eating tainted Mexican food a couple months back. My painful memory told me this was one illness I definitely wanted to avoid if I could. However, putting things into perspective, this was not bubonic plague, ebola or ecoli we were talking about. Noro is no picnic, but it isn't fatal and it doesn't last very long.

Once we got in our cabin, we turned on the TV. To the ship's credit, they came right out and admitted the previous trip had seen an outbreak of Noro. Using a taped message from the Captain, he explained the illness.

Symptoms typically begin between 24 and 48 hours after infection with the virus. Sudden onset of nausea is usually the first sign of infection. The first stage includes about six hours of periodic vomiting and diarrhea. Stage Two usually involves 12 to 18 hours of bed rest. The victims often experience a mild fever, aching limbs, and headaches. Symptoms typically disappear after a day or two.

The Captain recommended we wash our hands at every possible opportunity. He also said to avoid raw, unwashed foods during a norovirus outbreak which was kind of odd since someone had just delivered a plate of fruit to our cabin. How were we supposed to know if it was safe or not? The Captain concluded his message by assuring us that today's thorough ship-wide disinfection process should prevent a similar problem on this trip. I crossed my fingers and hoped that he was correct.

I had heard that Noro was a problem on some cruise ships, but I had never been on a ship with this problem before. I went to the bathroom and washed my hands, then put the problem out of my mind.

On Day Two, a day at sea, I encountered no problems with Noro.

Day Three was our trip to Paris. For some reason, Marla was mysteriously irritable. She assured me it wasn't anything I did. She just didn't feel good. We ate lunch at a lovely outdoor café. I wolfed my delicious sandwich down with a passion, but Marla said her food tasted terrible. She was so disgusted with her sandwich that she only ate half of it.

Nor was her complaining limited just to this café. All year long Marla had talked about French croissants. However, the croissants she purchased today did nothing for her. In fact, she said she had no appetite at all.

That night at dinner Marla barely touched her food. Then she looked at me and said she needed to go back to the cabin. I nodded and said I would catch up to her in a moment.

Sure enough, as I entered the room, the festivities had just begun. Marla was very sick; she definitely had Noro. Yuck. I can't say for sure, but for the rest of the night Marla seemed to make about one trip to the restroom every hour. She was in a lot of pain during these episodes, but the pain would soon subside after the deed was done. Mostly Marla was exhausted and full of aches.

On Day Four, we were scheduled to go visit Omaha Beach, the site of the most difficult D-Day Landing. Marla told me she wanted me to go, but that she preferred to stay in the cabin and rest. The worst was over. If necessary, she could make it to the phone. Besides, my trip was only half a day. Marla figured she could spare me that long.

What do I tell our friends? Marla said for now it would be easier if I told them she had a headache. That would buy her some time to see how this illness progressed.

Marla's biggest fear was being quarantined and forced to stay in the ship's hospital for several days. If she was going to be sick, she preferred to at least be sick in her own room. In her experience, it was much easier to get the needed rest in her quiet cabin than having hospital people bugging you all day long. I said I completely agreed.

When I returned that afternoon from my trip, Marla was feeling much better. In fact, she was ready for her first big meal of the day. Marla wanted a smoothie. I laughed and immediately went about procuring one for her. Marla absolutely loved her smoothie. She took little sips all day long. Marla was so cute about that drink; for the rest of the trip she complimented me on being kind enough to go get the smoothie for her the moment she asked. Good grief.

Personally, I felt guilty throughout the previous night because I didn't know enough about medicine to alleviate her pain. It is very difficult to see a loved one suffer, even when you know it isn't that serious.

For the rest of the afternoon, I quietly laid on the cabin couch reading a book on D-Day while Marla slept. I wondered how long it would be before it was my turn.

When dinnertime came along, Marla said she was strong enough to join me, but preferred not to go lest she infect someone else. Besides, all she really wanted to eat was soup. Room service could handle that.

What should I tell our friends? Marla smiled. Tell them the truth. No point in hiding it. I nodded. I agreed with her.  Of course everyone was worried about Marla. They were all sympathetic. They were also clearly worried. Marla was the first person from our group to drop. Would there be more?

Yes, there would be more. By the time the trip ended, Marla speculated that seven different people out of 36 had fallen prey to the Norovirus. In addition there were several more people who had experienced problems, but preferred to blame their woes on seasickness, not the virus.

As it turned out, the Norovirus was a frequent topic of conversation for the rest of the trip. Every night as our group ate dinner, we would compare notes. We would share what we had learned that day and idly speculate what was really causing this outbreak. In a way, it was kind of funny to be talking about such a disgusting topic right in the middle of dinner. On the other hand, we were all so comfortable with each other that no one seemed to mind. We also looked around to see who was missing.  Every empty seat signaled an 'uh oh'.

I have to be honest. As grim as it was to learn that my friends had gotten sick, I was fascinated by the medical aspects. It was a huge mystery. We all wanted to be the ones to discover what was causing so many people to get sick.

This was probably the first time in my life where I could see why the practice of medicine could be so fascinating... and frustrating too. This event was occurring right in front of my eyes. Maybe if I paid close attention, I could figure it out.

In fact, my own wife had gotten it. I had been right at her side the entire trip before she got sick. Why did she get it, but not me? Right from the start, Marla had announced she was determined not to get sick. She washed her hands constantly. In addition, she refused to use the public toilets. When she walked the stairs, Marla held her hands in the air lest she touch something.

As the days passed, I was baffled by the fact that Marla had gotten it and I hadn't. I wracked my brains to retrace our steps in Day One and Day Two. What had Marla done that I hadn't? Had she eaten something different?

Looking for more clues, I started to make friends among the ship's crew. They were more than willing to discuss the problem. At every opportunity, I would pump them with questions about the virus. To my surprise, they said very few of the crew got sick.

I thought that was an odd thing to say since Jasmina, our group liaison, had been sick with it on the second day of our trip. Obviously the ship's staff wasn't invulnerable.

I also learned from my chats that our current trip was the THIRD TRIP IN A ROW with the problem. I later learned that this same ship had a huge problem with the norovirus earlier in the year back when it was stationed in Brazil.

I often wondered if someone among the crew was responsible for the continued outbreaks. After all, once the passengers left the ship, they took the virus with them. So what was getting the NEXT CROP OF PASSENGERS SICK?

Once I discovered that FIVE DIFFERENT VOYAGES on this ship had experienced Noro, I began to wonder if there was a Norovirus equivalent of Typhoid Mary on board this ship. Typhoid Mary was the first person in the United States to be identified as a 'healthy carrier' of typhoid fever. In 1906, she played a big part in spreading the disease throughout New York.

Over the course of her career as a cook, Typhoid Mary was known to have infected 53 people, at least three of whom died from the disease. Her notoriety is in part due to her vehement denial of her own role in spreading the disease, together with her refusal to cease working as a cook. She was forcibly quarantined twice by public health authorities and died in quarantine. It is possible that she was born with the disease, as her mother had typhoid fever during her pregnancy.

No one on the ship believed my "Noro Mary" theory. The staff members didn't think they were responsible. The ship's personnel liked to blame the outbreak on the passengers. One person lectured us on the poor hygiene of the Scandinavian people. Yet another person said in the city of Santos, Brazil, a mediocre water supply was responsible for spreading the disease throughout the town. People from Santos then brought the disease on board. This happened back in March.

My favorite waitress was Michelle from Brazil. She said typically she was as strong as a horse. However one night in the dining room, a man stumbled trying to sit down. Just as she reached to steady him, the man coughed directly in her face. The next day she caught the Norovirus.

Although the research suggests that the virus is not transmitted by air, it is quite likely that Michelle received a droplet of infected saliva in the cough spray. Therefore her story makes complete sense.

One of my favorite people was Erik from San Diego by way of Las Vegas. Erik, age 26, was the bar manager. He was also the most informed person I talked to about the problem. Erik explained he had acquired his vast knowledge in college. He said his graduation research paper for his hotel management degree had been specifically on the topic of Norovirus.

Erik told me a bunch of good stories. He said back in the Eighties, a Norovirus outbreak had occurred among players and spectators after a football game between the University of Pennsylvania and Cornell. Researchers eventually determined everyone got sick from ice that was contaminated with norovirus.

Erik said this ice story showed just tough this virus is. It is the second most common virus after the cold virus. In fact, more dangerous viruses like hepatitis C and HIV can't survive being frozen and will die soon after they're out of the body. This explains why you are unlikely to catch the HIV or Hep C from contact with a surface touched by an infected person.

Unlike these two more dangerous viruses, the norovirus is so tough it can linger on surfaces like a hand rail for a long time waiting for an unsuspecting person to come along and inadvertently touch it.

So who puts the virus on the hand rail to begin with? Upon my questioning, Erik took a deep sigh. He didn't really want to say this out loud, but I told him to go ahead. He said the virus is contained in both fecal matter and vomit. Erik said I could only catch it through direct contact. Let's say an infected person forgets to wash their hands properly after a bout with diarrhea, then wanders out on the ship. All it would take would be just a thin film on the finger that touches a door knob or the handle on a toilet. The next person who touches that same spot can pick up the virus.

Erik wasn't finished. He said that even if a person DOES INDEED TOUCH AN INFECTED SPOT, THEY STILL MIGHT NOT GET SICK. Erik said the person would also have to then touch their mouth, their nose, or their eyes for the virus to enter the body.  That is why people should wash their hands constantly. In this way, their hands would be purified before they accidentally touched their face.

Before we finished our talk, I asked Erik point-blank if the disease was airborne. Erik shook his head no. Absolutely not. It is transmitted strictly by touch. Okay, if you say so (let me add I later found no professional article that disagreed with Erik's position).

After my conversation with Erik, I thought about what he said about not touching the face. I found myself watching everyone at dinner that night. I was amazed to see EVERYONE at the table touched their face with their hands at some point in the meal. They didn't even realize it. One person rubbed their nose. Another person touched the corner of their eye. Several people scratched their face. One person licked some spilled soup off their finger without even thinking about it.

Later that same night, I went back to the cabin. Having trouble turning a page in my book, I licked my finger in order to help turn the stubborn page. I groaned to myself. I was determined not to get sick and yet I had just violated Erik's Golden Rule #2: Don't touch your face!

I didn't catch the Norovirus, but it wasn't because I was tougher or smarter than anyone else. I made the same mistakes as everyone else. Apparently I was just lucky not to have touched an infected hot spot shortly before touching my own face.

There are certain universal precautions that are even more important when you're aboard a ship. As important as washing your hands, you have to learn to KEEP YOUR HANDS AWAY FROM YOUR EYES, NOSE AND MOUTH. This is a normal human condition to touch your face. If you sit at a restaurant and watch people eat for five minutes, you will see what I mean.

Many people think that shaking hands is the problem. Erik said this is a misconception. Most viruses are not spread by hand to hand contact alone. They are spread by hand to hand to mouth (or eyes or nose). If you had the virus ONLY on your hands, you wouldn't get sick. You still have to touch your face before you wash your hands to complete the nasty transaction.

I might add as I reread my text on this part of the story, I just caught myself with my fingers touching my mouth. It seems impossible not to touch our own face. We touch our faces all the time before we can even think about it! Habits of a lifetime cannot be changed overnight, which explains why this nasty little virus keeps finding new hosts.

Speaking of finding new hosts, as the cruise progressed, people were dropping like flies. One night at dinner we heard 'Alpha Alpha Alpha west corner of the dining room'. Someone had a virus-related accident right at the dinner table somewhere else in the room. Yuck.
On another night, I looked around and wondered where everyone was. I realized the room was only half-full. Did this mean what I thought it meant?

Rumors pegged the total number of cases around 300 passengers. Now before you get too alarmed, remember that I have been on eighteen cruises and this was the FIRST TIME I have ever encountered Noro. In addition, I have the same chance of the getting the virus at various Houston restaurants. As long as we wash our hands before and after dinner and don't touch our faces between hand washing, theoretically we are safe.

On the other hand, 300 is an awfully high number. Out of the total ship population of 2000, I would speculate that several hundred more people who caught it didn't report it. I mean, Marla caught it and she is not part of that total because she didn't report it. A couple other people in our group didn't report it either. So maybe 500 people caught Noro ... one in four.

They said it was not spread through the air. Are we to believe that all 500 people simply failed to wash their hands? Marla for one washed her hands constantly and she still got it. That is why I wondered if there was a better explanation, perhaps something in the food and water.

When I returned home, I reviewed several articles on Norovirus.

I thought this blog was interesting:

"Firstly, I think a cruise ship is a prime location for any type of contagious illness to spread - so many people in a confined space!
Air-conditioning has to take its share of the blame - all that recirculated air, recirculating all the germs too just in case they passed you by the first time round. And if it's not the air-conditioning, then it must be the heat in the general areas. That is bound to cultivate bugs.
My main suspicions though lie with the passengers (yes, I do include myself in that category!).

If these ships are scrupulously cleaned and they certainly appear to be, then somebody must be taking this bug on board. We are all asked at embarkation whether we feel/have been unwell etc. Now can you tell me hand on heart that if you had booked a cruise and been looking forward to it for six, twelve or eighteen months, would you honestly answer 'yes' to those questions and risk being turned away, just because your tummy felt a bit icky? Maybe therein lies your answer - human selfishness. But how the cruise lines ever stop people from lying - well, I can't answer that!"

Then I ran across an Internet article that stated the Food and Drug Administration points to contaminated water as one of the most likely causes of norovirus. I couldn't help but think of Erik's frozen ice story when I saw this.

The FDA report said that "water is the most common source of outbreaks and may include water from municipal supplies, wells, recreational lakes, swimming pools, as well as contaminated water stored aboard cruise ships".

Well, I drank the ship's water throughout the trip. So did Marla. She got sick; I didn't. One woman at our table who purchased bottled water every night got sick. Draw your own conclusions, but I don't think it was the water… at least not on this trip.

Another weird feature is that within our group, only two men got sick while 7 to 10 women got sick. Everyone thought this was significant, but no one had a theory to explain the disparity. I didn't dare suggest my secret makeup theory.

Besides the water, I wondered if perhaps the food supplies might be contaminated. The same FDA report suggested that "shellfish and salad ingredients are the foods most often implicated in norovirus outbreaks. Ingestion of raw or insufficiently steamed clams and oysters poses a high risk for infection with Norwalk virus. Foods other than shellfish are contaminated by ill food handlers."

It would be interesting to determine the job positions of the crew members infected with norovirus. For example, I read a CDC report that sixty-nine crew members were reported ill on another recent cruise with a large outbreak. How many of these crewmembers were cooks, waiters or food handlers?

On the other hand, there are experts who discount the food and water theory. One article I read said this:

"Health experts confirm that norovirus on cruise ships is not generally sourced from food or water, but rather from direct contact with a person with the "stomach bug." It is also passed along indirectly on objects or surfaces previously touched by someone with norovirus, such as handrails or elevator buttons."

Personally, I don't agree. Assuming that this virus cannot be transmitted via the air - the most common method of spreading disease - then I lean towards the contaminated water and food theory. I doubt seriously there are enough contaminated surfaces on that ship to explain the large number of sick people. You have no idea how hard the ship's personnel worked throughout this cruise. Every day I saw dozens and dozens of crew members spraying disinfectant on every possible public surface in sight.

Those people worked themselves to the bone trying to rid the ship of this virus. For example, my Brazilian friend Michelle the waitress and her partner Caroline both told me they were required to come to their station an hour earlier than usual every morning to scrub down their dining room area of responsibility.

The ship was trying as hard as it could. For example, the day Marla got sick, I asked for a refund on her trip to Omaha Beach. The ticket clearly said "No Refund". Nevertheless, when I explained to the man how sick she was, he gave us a credit with no further questions asked. I was impressed.

Another woman in our group got sick about the same time as Marla. However, unlike Marla, she bravely trudged down to the ship's hospital. They gave her a free shot and some free medication, sent her back to her room and told her to rest. The lady reported almost instant relief from her problems. When Marla and I heard this story, we both looked at each other. Too bad we were so suspicious. Marla might have cut her suffering in half.

In my opinion, the ship was bending over backwards trying to alleviate the suffering.

I realize there is a natural tendency to blame the ship, but after watching the superhuman efforts to clean the bathrooms and cabins on this infected cruise ship, I have to say the ship personnel were doing everything they had any control over.

Let me add that my Internet research revealed that norovirus happens to every single cruise line.

So rather than blame the ship, Marla and I both adopted the attitude that we were all in this virus problem together. I talked with every staff member I met hoping to come up with the key to the puzzle, but in the end I came up empty. My first case as medical detective was a failure.

When I got home, my daughter asked me if my fear of this illness would stop me from taking more cruises. I told her no.

I said that even though I had my first cruise experience with the virus, I also know that very few ships actually have the problem. In my case, only one trip in 18 has had the problem. Those are pretty good odds.

Besides, every time I go to a restaurant in my hometown I am taking the same risk. Do these people practice safe hygiene? Do they wash their food properly? What about their silverware? How am I supposed to know the truth about this restaurant until it is too late?

Usually when these problems occur, our only remedy is to say, "I'm never going back there again." But in the case of a cruise ship, after watching how hard they fight the problem, I would give them another chance.

Even if I do run into another situation like this, I also know that if I am careful, I have a good chance of not catching it. And if I do catch it, I am comforted by the fact that Marla survived and was still able to have a great trip. I would do the same if I am ever as equally unlucky as my wife.

Besides that, even in the presence of three straight outbreaks, the ship's crew didn't seem worried or in any way panicked. That Captain was still shaking every hand in sight the last time I looked.  So when I compare the slight chance of catching the illness and weigh this against the benefits of having a wonderful time and sharing experiences with family and friends, I have no fear.

If I had one suggestion, I think if I ran across another Noro problem in the future on a cruise ship, I would wear gloves.

Although I am sure I would get disapproving looks or at least teased, this simple precaution might not be such a bad idea. I would simply explain to people I am wearing the gloves to remind me not to touch my face. I might add the gloves would also help prevent touching an infect surface.

Although I am sure the cruise ships wish to avoid the stigma of posted pictures of travelers wearing gloves, there might be some interesting benefits. What if everyone on board wore gloves and people STILL GOT SICK? Then at least the medical people could discard the Touch Theory and concentrate their attention elsewhere.

And what if everyone wore gloves and the problem went away? Once you have three trips in a row with the same problem, you would think they would consider a different approach towards solving the problem.

In summary, I realize this has not been the most pleasant story I have written, but I am sure you understand the purpose of sharing this story is simple - forewarned is forearmed.