key: cord-1052227-03jk3tjg
authors: Lin, Yung-Ching; Chen, Meng-Yu; Liu, Ming-Ching; Lin, Yu-Ju; Lin, Yu-Hsuan; Kuo, Jiun-Shian; Wang, Pi-Sheng; Shih, Chung-Liang
title: Quarantine Measures for Coronavirus Disease 2019 on a Cruise Ship, Taiwan, February 2020
date: 2020-08-07
journal: Int J Infect Dis
DOI: 10.1016/j.ijid.2020.08.011
sha: 482350153a82d7d0f91fc04ed153f95627dfcf24
doc_id: 1052227
cord_uid: 03jk3tjg

To early detect and prevent coronavirus disease 2019 from spreading via international cruise ships, Taiwan Central Epidemic Command Center implemented on-board quarantine measures on a cruise ship at Port of Keelung, Taiwan, on February 8, 2020. Quarantine officers, medical professionals and administrative staff of competent authorities conducted fever screening, investigated present illness and travel history of 1,738 passengers and 776 crew members on the ship. Throat swabs were collected from 128 (5.1%) passengers and crew members with fever or respiratory symptoms in the past 14 days or travel history to China, Hong Kong or Macao within 30 days. All swabs tested negative for severe acute respiratory syndrome coronavirus 2 by the national reference laboratory. The whole process, from on-board preparation to completion of testing, took 9 hours. All passengers and crew were permitted to disembark and were required to take mandatory 14-day self-health management measures. No cases were reported by the end of self-health management period.

 Throat swabs were collected based on specific recent symptoms or travel histories among passengers and crew.  Passengers and crew with negative tests disembarked and took 14-day self-health management measures.

To early detect and prevent coronavirus disease 2019 from spreading via international cruise ships, Taiwan Central Epidemic Command Center implemented on-board quarantine measures on a cruise ship at Port of Keelung, Taiwan, on February 8, 2020. Quarantine officers, medical professionals and administrative staff of competent authorities conducted fever screening, investigated present illness and travel history of 1,738 passengers and 776 crew members on the ship. Throat swabs were collected from 128 (5.1%) passengers and crew members with fever or respiratory symptoms in the past 14 days or travel history to China, Hong Kong or Macao within 30 days. All swabs tested negative for severe acute respiratory syndrome coronavirus 2 by the national reference laboratory. The whole process, from on-board preparation to completion of testing, took 9 hours. All passengers and crew were permitted to disembark and were required to take mandatory 14-day self-health management measures. No cases were reported by the end of self-health management period. Center (CECC) in Taiwan announced that international cruise ships were banned from calling at ports of Taiwan since February 6, 2020 (Wang et al., 2020) . Meanwhile, another cruise ship (Cruise A), carrying 1,738 passengers (98% from Taiwan; 1.6% from Southeast Asia) and 776 crew members (48% from Southeast Asia; 31% from China), departed Port of Keelung, Taiwan, on February 4, called at Naha, Japan on February 5 and 6, and requested for berthing permit at Keelung. The CECC issued a special permit on condition that all passengers and crew should undertake entry screening. Persons who meet specific criteria should test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

A total of 49 staff conducted the on-board quarantine, including 10 J o u r n a l P r e -p r o o f quarantine officers, 16 medical professionals, and 23 administrative staff.

Personal protective equipment for medical professionals included N95 respirators, face shields, gloves, coveralls and gowns. Other staff without close contact with passengers and crew wore face masks and gloves.

Cruise A arrived Keelung on February 8. All passengers completed health declaration forms in their cabins, reporting if they had fever, respiratory symptoms (cough, rhinorrhea or shortness of breath) or had been to China, Hong Kong or Macao recently (US CDC, 2020). Quarantine officers screened body temperature of all passengers and crew by infrared thermometers initially and by ear thermometers for confirmation. Fever was defined as ear temperature >38°C.

After fever screening, quarantine officers reviewed health declaration forms. In addition, recent 30-day travel histories of passengers and crew were also checked by the National Immigration Agency.

A throat swab was obtained from any person with fever or respiratory symptoms during the past 14 days, or with travel histories to China, Hong Kong or Macao within 30 days, including those with unclear travel histories. All throat swabs were collected by medical professionals on the deck in open environment (jogging track), and were tested for SARS-CoV-2 on real-time J o u r n a l P r e -p r o o f reverse transcription PCR assays by the national reference laboratory (Cheng et al., 2020) . Those who did not meet criteria for testing were requested to return to their cabins or workplaces (Figure) .

A total of 26 passengers and 17 crew members, including one member who boarded an airplane in Wuhan, China on January 20, had been to China, Hong Kong or Macao within 30 days. In addition, recent travel histories of 28 foreign passengers could not be identified by the National Immigration Agency and were categorized as unclear travel history (Table) .

No passengers or crew had fever during screening. Five passengers reported that they had fever and 51 had respiratory symptoms, including cough or rhinorrhea, during the past 14 days. One crew member had fever on February 3 and was diagnosed as having tonsillitis by the doctor on board (Table) .

Eventually, 128 (5.1% overall) throat swabs were collected and all tested negative for SARS-CoV-2. The whole process of quarantine measure, including preparation, specimen collection, specimen transportation, and testing, took 9 hours (180 person-hours totally). All passengers and crew were permitted to disembark on the same day, and were required to take mandatory self-health management measures for the following 14 days, J o u r n a l P r e -p r o o f including wearing surgical masks, paying attention to respiratory hygiene and cough etiquette, checking temperature twice a day, and seeking medical attention if any respiratory symptom developed (Taiwan CDC, 2020). No suspect COVID-19 cases were reported by the end of 14-day period.

As of February 8, 18 laboratory-confirmed COVID-19 cases were identified in Taiwan, including 16 imported cases and 2 import-linked cases related to household transmission. Since no community-acquired or unknown source cases were found in Taiwan, and >99% confirmed cases globally were from China at that time (WHO, 2020), we assumed that most COVID-19 cases on board, if existed, should have contracted the disease when visiting China, Hong Kong or Macao before boarding. Therefore, we tested those who had been to China, Hong Kong or Macao within 30 days, as well as those with unclear travel histories, regardless of their health conditions. To detect cases that might contract COVID-19 elsewhere or even on board, we also tested all passengers and crew who suffered from fever or respiratory symptoms during the past 14 days regardless of their travel history. Our quarantine strategy might not be able to detect COVID-19 cases among asymptomatic individuals J o u r n a l P r e -p r o o f without relevant travel history. However, the estimated asymptomatic proportion among infected cases was 17.9%, according to a published analysis on a cruise ship (Mizumoto et al., 2020) . It was less likely that all COVID-19 cases on Cruise A were asymptomatic.

If any passenger or crew had tested positive for SARS-CoV-2, the confirmed cases would have been transferred to a designated hospital for isolation, and their close contacts would have been quarantined in designated facilities. All other passengers and crew should also be quarantined in their cabins for 14 days. Since no COVID-19 case was detected, no further isolation and quarantine measures were implemented.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Not required. 

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Initial Investigation of Transmission of COVID-19 Among Crew Members During Quarantine of a Cruise Ship -Yokohama

Response to COVID-19 in Taiwan: Big Data Analytics, New Technology, and Proactive Testing

Interim Guidance for Ships on Managing Suspected Coronavirus Disease

Initial rapid and proactive response for the COVID-19 outbreak -Taiwan's experience

Self-Health Management Notice (Coronavirus disease 2019, COVID-19)

World Health Organization, Coronavirus disease (COVID-2019) situation reports-19

Estimating the asymptomatic proportion of coronavirus disease 2019 (COVID-19) cases on board the Diamond Princess cruise ship

All authors have no conflict of interest to declare.J o u r n a l P r e -p r o o f