By The Washington Post · Rosalind S. Helderman, Hannah Sampson, Dalton Bennett, Andrew Ba Tran · NATIONAL, BUSINESS, FEATURES, HEALTH, US-GLOBAL-MARKETS, TRAVEL
As they stood shoulder-to-shoulder and crowded around pool chairs, the captain led the ship in a special salute to health-care workers of the world, an onboard version of the nightly applause adopted by some cities to honor medical professionals battling the novel coronavirus.
Five days later and thousands of miles away in the Atlantic, a group of British passengers aboard another ship, Coral Princess, likewise gathered elbow-to-elbow to cheer the United Kingdom's National Health Service.
The celebratory mood did not last long. Soon, passengers on both ships were contending with flu-like symptoms.
There have been 150 coronavirus cases and six deaths reported so far among passengers of the two vessels, which finally docked weeks after the virus was declared a global health crisis, according to a Washington Post tally. Two people died on the Coral Princess before passengers could even come ashore in Miami.
The Eclipse and Coral Princess were among scores of ships that continued voyages even after early outbreaks on other vessels, carrying thousands of international passengers to far-flung ports and helping seed the virus around the globe, health officials say.
A Post review of cruise line statements, government announcements and media reports found that the coronavirus infected passengers and crew on at least 55 ships that sailed in the waters off nearly every continent, about a fifth of the total global fleet.
The industry's decision to keep sailing for weeks after the coronavirus was first detected in early February on a cruise ship off the coast of Japan, despite the efforts by top U.S. health officials to curtail voyages, was among a number of decisions that health experts and passengers say contributed to the mounting toll.
At least 65 people who traveled or worked on the ships have since died, according to The Post tally, although the full scope of deaths is unknown. A similar review by the Miami Herald also identified 65 deaths linked to ships.
"We here on land, we were seeing all the news, all the ships," said Jennifer Paul-Slater, whose brother Gerald, a 72-year-old retiree from Atlanta, died of covid-19, the disease caused by the coronavirus, three days after disembarking the Celebrity Eclipse. "They could have taken more precautions."
Public health experts say that a number of factors contributed to the rapid spread of the virus around the world, predominantly air travel; an estimated 4.54 billion people flew last year, compared to the 30 million passengers who traveled on cruise ships worldwide. But with hundreds of people dining, swimming and dancing together over a sustained period of time, the ships provide unique environments for disease to spread, they say.
"People on a large ship, all together, at the same time, all the time - you couldn't ask for a better incubator for infection," Anthony Fauci, the nation's top infectious-diseases expert, said in February.
For their part, U.S. agencies struggled to manage the escalating crisis, initially deferring to the industry's own plan to manage the pandemic. Until early this month, federal health officials also allowed passengers who left infected ships but appeared healthy to board commercial airlines home.
Even as the virus exploded into a global story, cruise officials failed to immediately recognize flu-like outbreaks as possible signs of the coronavirus, passengers said. In many instances, they did not immediately isolate passengers in their cabins when sickness broke out. In some cases, such as on the Celebrity Eclipse and the Coral Princess, those aboard said they were reassured by company officials there was no coronavirus infection on their ships - even as some travelers were wracked with fevers and coughs.
David Nystrom, 75, said he spent the last four days of the Eclipse voyage with his wife, Susan, in the medical clinic, wiping her brow and watching the ship's crew administer her oxygen.
From her bedside, the Boca Raton, Florida, resident said he heard regular announcements from the ship's captain, assuring passengers that the Eclipse was a "healthy ship" with no coronavirus on board.
"If they honestly thought that all these people who were getting sick had colds and bronchitis and pneumonia, I don't know what to say," Nystrom said.
Officials with the cruise industry said they took extraordinary efforts to limit outbreaks of the new virus on ships and get tens of thousands of passengers and crew home safely as the pandemic spread, going beyond measures adopted by other industries.
Bari Golin-Blaugrund, a spokeswoman for Cruise Lines International Association, said in a statement that there is "no conclusive evidence as yet" that cruise ships were responsible for bringing the coronavirus to specific destinations, such as the Caribbean. She said that the number of cases linked to ships is a "tiny fraction" of the global total.
"Everybody, including cruise lines, had to make difficult decisions based on the information that was available at the time, which was admittedly limited given the fact that the world was dealing with a brand new virus," she said. "Still, cruise lines took immediate and aggressive action in response to this crisis."
Carnival Corp., the world's largest cruise company and the parent company of Princess Cruises, noted that federal health officials initially issued limited warnings about the risks of cruises and that the company voluntarily paused new voyages in mid-March.
Officials with Royal Caribbean Cruises, parent company of Eclipse operator Celebrity Cruises, said the ship did not have an unusual number of passengers with flu-like symptoms, and the crew did not believe there was an outbreak on board.
Despite high-profile outbreaks on several ships, industry leaders have insisted cruise ships are not more susceptible to the coronavirus than other places.
Arnold Donald, the chief executive of Carnival, said in an interview on "Axios on HBO" in mid-March that ships provided a "less risky environment" than being on shore and compared ships to Central Park, saying there is "a lot of natural social distancing."
He insisted that cruise ships are not to blame for spreading the coronavirus.
"The illnesses aren't created by the ship, they come from people coming from communities," he told reporters April 16, noting that the "vast majority" of ships around the world remained coronavirus-free.
But top U.S. health officials said there is evidence that cruise ships have been a factor in the spread of the coronavirus, both aboard ships and through their travel.
A no-sail order extended for at least 100 days this month by Robert Redfield, the director of the Centers for Disease Control and Prevention, found "cruise-ship travel exacerbates the global spread of covid-19″ and "has not been controlled sufficiently by the cruise ship industry or individual state or local health authorities."
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One of the world's first indications of the wild infectiousness of the coronavirus came in February, when it whipped through the Diamond Princess, a 2,666-passenger ship docked at a port in Japan.
A study published in March by the CDC found that the coronavirus was brought aboard by a passenger but quickly jumped to crew, including those responsible for preparing food, and spread quickly among ship workers from there.
More than 700 passengers and crew members ultimately tested positive and 13 died. Some Americans tested positive for the coronavirus only after they were aboard buses headed to government-chartered airplanes to be flown back to the United States.
James Lawler, an infectious disease expert at the University of Nebraska Medical Center who traveled to Japan to help evacuate Americans, said the Diamond Princess demonstrated the difficulty of attempting to discern sick from healthy people in a closed environment like a cruise ship.
"You just have to treat everybody like they're infected," he said.
It was a lesson that the cruise industry and government agencies took weeks to absorb.
In late January, cruise lines started to step up health screenings and deny boarding to people who had recently been in China. Cruise officials assured passengers that they had increased cleanings on ships. More hand sanitizer became available as the crisis went on, passengers said. On some ships, buffet meals became plated affairs.
But top U.S. health officials did not view the measures as sufficient. On March 8, Fauci warned older people and those with underlying health issues to avoid cruise ships.
The following day, another coronavirus-stricken cruise ship docked in Oakland, California. The Grand Princess, which had left San Francisco on Feb. 21 for a cruise to Hawaii, had idled for days before officials decided to send many of its American passengers to military bases across the country for quarantine.
Ultimately, more than 130 people from the ship tested positive, and at least six have died, including five passengers and one crew member, according to authorities and the cruise line.
Health experts noted that the ships' tight quarters, their communal eating and entertainment and older passenger demographics made them especially vulnerable.
"This is not to point blame," said Marty Cetron, director of the CDC's Division of Global Migration and Quarantine, in an interview earlier this month. "But we have to be honest about the science and the evidence."
He said widespread testing of passengers on the Diamond Princess and the Grand Princess showed that the "attack rate" of the coronavirus on board was especially high.
"We don't see those kinds of attack rates in other settings - even in household settings," he said. "Even in cities experiencing outbreaks, this is pretty dramatic."
Grand Princess travelers - who had been locked in their rooms, then held on military bases and confined to their homes - were stunned to watch people continue to board ships amid their saga.
"I'm shocked that they were still cruising out there," said Jackie Eilers, a 72-year-old retiree in Castle Rock, Colorado, who tested positive but had only mild symptoms.
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Tensions were running high as top officials from the Jamaican government squared off against top cruise executives in Florida for an emergency summit on March 6.
The coronavirus was spreading, and Caribbean countries worried about their citizens' exposure began to impose new rules on ships and limit access to their ports.
When the Dominican Republic turned away a ship after reports of passengers with flu-like symptoms in late February, the ship's operator, U.K.-based Fred. Olsen Cruise Lines, issued a statement calling the government's move an "overreaction."
Jamaica barred port entry Feb. 27 to people traveling from areas with known covid-19 outbreaks, such as Italy, and the following day denied entry to all Italian passengers who arrived on the Costa Luminosa ship. A few days later, officials put out interim guidelines that also required ships to document illness on board and conduct temperature checks.
The cruise industry expressed concern about the new rules, which upended scheduled stops for its vacationing guests, according to one Jamaican official involved in the negotiations with the cruise lines, who was not authorized to talk to the media and spoke on the condition of anonymity.
"I think cruise lines in general were challenging the whole process of the elevated protocols that were being forwarded by all destinations," Edmund Bartlett, Jamaica's minister of tourism, told The Post.
Roger Frizzell, chief communications officer at Carnival, which owns the operator of the Costa Luminosa, said the company was "looking for additional understanding and clarity tied to the new process, so we could plan and make decisions for our ships, guests and crew."
Jamaican officials agreed to travel to Florida - the industry's home turf - for negotiations. There, they met with several Carnival executives at the company's headquarters in Miami, where the walls are lined with glass cases filled with intricate models of the cruise operator's fleet. Later, the Jamaicans visited the Fort Lauderdale, Florida, headquarters of MSC, another cruise line with a ship that had difficulty disembarking in Jamaica because a crew member had been diagnosed with the flu at the time. (The crew member later tested negative for the coronavirus.)
"There was clearly a view we were being too hard with our requirements. We felt that the public health interests at the time trumped the interest of the cruise lines," Christopher Tufton, Jamaica's minister of health and wellness, said of the meetings, which he described as "difficult."
Frizzell described the meeting with Jamaican officials as "respectful, in the spirit of finding a mutually beneficial solution." MSC Cruises said in a statement that it was "a productive meeting between two long-term partners," adding that it never raised concerns about Jamaica's guidelines and had only requested the rules be clearly defined and that the cruise lines be given advance notice of new requirements.
The standoff threatened one of the region's biggest economic drivers. Cruise companies employ thousands of people on Caribbean islands and deliver an estimated $2.5 billion in tourism dollars, according to industry estimates.
Two days after the Florida meetings, Jamaican authorities announced that after "rigorous" discussions, the cruise lines had accepted the country's health protocols, including the submission of medical logs for review and the quarantining on board of anyone with symptoms who had visited a country with covid-19.
The announcement made no mention of barring visitors who had been in a country with a known coronavirus outbreak during the previous two weeks. But Jamaican officials told The Post that policy remained in place. Cruise vessels continued to visit Jamaica after the meeting.
The clout of the industry was also apparent in the United States, where Carnival chairman Micky Arison is a personal friend of President Donald Trump.
The major cruise lines have avoided federal income taxes and labor laws by incorporating overseas and flagging their ships in other countries. Even so, Trump has bemoaned the pandemic's effect on the industry.
By early March, several top health officials and members of the administration's coronavirus task force wanted to impose a temporary ban on Americans going on cruise ships, as The Post previously reported. They included Health and Human Services Secretary Alex Azar, Centers for Medicare and Medicaid Services Administrator Seema Verma and Surgeon General Jerome Adams.
Behind the scenes, the industry scrambled to head off a no-sail order.
The day after meeting with the Jamaican officials, top cruise line executives huddled in Fort Lauderdale with Vice President Mike Pence, the head of the White House coronavirus task force, arguing cruise lines could voluntarily contain the outbreak.
On March 10, the industry submitted a plan to the White House that proposed measures including stepped-up health screenings, monitoring of passengers and requiring a doctor's note for passengers older than 70. At the time, Adam Goldstein, global chair of the Cruise Lines International Association, told The Post that it was "a very practical, actionable plan that makes a difference."
Days later, under pressure from the administration, the industry abruptly went further, voluntarily suspending new voyages to and from the United States for a month.
It still wasn't enough.
On March 14, the CDC issued a no-sail order for 30 days - and noted that there were already signs of covid-19 clusters associated with cruise ships, including in communities far from the water.
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In Iowa, state health officials found that the state's first 16 confirmed coronavirus cases were all part of a group that had recently returned from a cruise on the Nile River in Egypt. Pockets of cases were linked to the same cruise voyage in Houston and Maryland.
The March CDC study found that cruise ship-linked cases accounted for 17 percent of all known cases in the United States between the key early weeks of the spread from Feb. 3 to March 13. Those cases included passengers returning from the Diamond Princess, the site of one of the biggest outbreaks in the world in mid-February.
The biggest driver of the coronavirus cases in Australia has been an outbreak on the Ruby Princess cruise ship, which docked in Sydney on March 19. Authorities have opened a criminal investigation into the ship, which has been linked to 21 deaths and more than 600 positive cases.
And in France, authorities have grappled with a massive outbreak on a ship that had not yet carried any passengers.
There, the brand new Celebrity Apex - which boasted more than two dozen restaurants, bars and lounges and a venue towering 13 stories above sea level - had been preparing for its first sail, a four-night preview cruise scheduled to leave April 1.
By early March, 1,400 crew members were living on board the ship, preparing to welcome its first guests. A lawsuit filed by a crew member alleges that contractors continued to board the vessel, and Celebrity conducted crew drills even after signs of the coronavirus began to appear.
So far, 284 crew members have tested positive, according to French health authorities.
Rob Zeiger, global chief communications officer for Royal Caribbean Cruises, which owns Celebrity, said that the ship followed guidance from the French government and that in an effort to avoid the coronavirus, crew had been restricted from leaving the ship and their interactions with contractors were limited.
Along with airplanes, cruise ships also played a role in the spread of the virus in the Caribbean, a region with small island populations and a fragile health-care system. While air travelers brought the first cases to islands such as St. Lucia and Cuba, cruise passengers were the first confirmed coronavirus patients in places such as the Cayman Islands and Puerto Rico, according to local health officials.
A Post analysis found that five ships - the Costa Favolosa, Costa Magica, Costa Luminosa, MS Braemar and MSC Meraviglia - made 18 stops in the Caribbean between Feb. 29 and March 11 while carrying someone who later tested positive for coronavirus.
Dozens of passengers who disembarked in their native countries in the region have since tested positive. Among former passengers from the Costa Favolosa, there have been at least 52 covid-19 cases and one death in Trinidad and Tobago, 13 cases in the Dominican Republic and two cases in the French territory of Martinique, according to local health officials.
"We knew there was an epidemic with international potential," said Ted Cohen, an epidemiologist at Yale School of Public Health who examined data gathered by The Post, adding: "It was irresponsible for the industry to not be proactive in how to limit these activities in times of global crisis."
Cruise lines said they followed all international regulations to prevent the spread of disease and took voluntary measures such as temperature checks and intensive sanitation measures. And they disputed the idea that their ships brought the coronavirus into the region, saying that while Caribbean residents who sailed on their ships have tested positive, there is not proof they contracted the virus on board.
"We have no evidence of any direct link of contagion between our ships and the territories of our destinations in the Caribbean and there is no scientific or health-related evidence or background to this," Costa Cruises, which operates the three Costa ships, said in a statement.
MSC Cruises said it "has no reason to believe" that the Meraviglia contributed to any local outbreak, saying it screened the health history of its passengers and has had no known cases on any ships while sailing. After a Canadian passenger who had traveled on that ship tested positive after returning home, the ship isolated seven crew members who had contact with him, the company said.
Fred. Olsen Cruise Lines, which operates the MS Braemar, said that once it learned that two passengers from a previous Caribbean cruise had been diagnosed with covid-19, it arranged to test those currently on board who had flu-like symptoms. When six people tested positive, it barred passengers from disembarking until the ship ended its journey in Cuba.
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The emergency medical treatment of passengers placed a significant burden on the region's health-care infrastructure.
Much of a hospital in the Cayman Islands was shuttered for two weeks after a 68-year-old Italian man who suffered a stroke was evacuated from the Costa Luminosa ship on Feb. 29 and later tested positive for the coronavirus.
More than 40 health-care workers who came into contact with the man and their families were quarantined, and the nation's limited testing capabilities were used to test nurses and other patients in the hospital, according to a spokesperson for Health City Cayman Islands, where the passenger was treated. The hospital reported six positive cases connected to the passenger, including four health-care workers.
On the Costa Luminosa's next sail around the Caribbean, the ship dropped off an Italian couple in Puerto Rico on March 8 after the woman was experiencing flu-like symptoms.
Carmen Cruz, who owns the ambulance company that transported her to a hospital, said the dispatcher told local medical personnel that the woman possibly had pneumonia - but that covid-19 was not suspected.
"As soon as they described the symptoms, we said, 'This is covid-19,' " Cruz said. "They described it saying 'No, that this was pneumonia, and she had a history of respiratory issues.' " At the time, Puerto Rico had no other confirmed cases of the illness.
The woman and her husband tested positive for the coronavirus on March 13. She died eight days later.
"The cruise line needed to have been more direct and transparent with us because it could put our island in danger," said Cruz, noting that the woman's symptoms were clearly consistent with the coronavirus. "A rooster could not sing more loudly."
A representative of the dispatcher said that the company facilitates communications between a ship's medical staff and the local hospital, but that those parties discuss the particulars of a medical case.
Costa Cruises disputed the idea that ship officials had dismissed the possibility of the virus, saying that before the sick woman disembarked, the ship's doctor requested that she be tested for the coronavirus in Puerto Rico, even though the hospital said it was not likely a covid-19 case, according to the company.
"Costa Cruises' main concern has always been and remains to safeguard the health and safety of our guests, our crew members and the communities in the destinations we visit," the company said.
While the woman was still in the hospital, Luminosa officials isolated those who were in close contact with her, and then took further measures when it got the results of her test, quarantining all guests and performing daily temperature checks, according to the company.
Still, signs of sickness spread as the ship traveled across the Atlantic and into the Mediterranean, where it struggled for days to find a port that would accept its passengers.
Finally, 350 Americans and Canadians disembarked March 19 in Marseille, France. The group was crowded together on buses and then an airplane to Atlanta, where the CDC allowed many to enter the terminal and then board commercial airliners home.
It would take more than two more weeks for the CDC to change its guidelines about disembarking passengers from stricken ships, barring even those without symptoms from further commercial travel.
Cetron, the CDC's head of global migration and quarantine, said the agency shifted courses after fully realizing the implications of asymptomatic transmission.
"Not only is this virus fast moving in terms of its spread and transmission and stealth, it's also teaching us every day something new," he said.
As of April 20, at least 145 crew members and 48 passengers who were aboard the Luminosa have tested positive for the coronavirus, according to Costa Cruises. Former passengers who have started a Facebook page to track their experiences have reported accounts of at least seven deaths.
Among them was Tom Sheehan, 68, who flew from Atlanta to his home in Sarasota, Fla., before being hospitalized the next day. He died March 28, his four adult children barred from his hospital room, able to say goodbye only via video.
"My dad had said multiple times if the cruise had let them know there was a possible covid case, they would have just gotten off in Puerto Rico and flown home," said Sheehan's son, Kevin. "They were more worried about keeping people on the boat and spending money."
Costa Cruises said it communicated information to passengers as soon as it received it and noted that it voluntarily paused new cruises on March 13, the same day it said it received notice that the first passenger had tested positive. At that point, the ship struggled to find a port. The company said it expressed "its deepest grief and condolences to the families of those guests who have lost their lives due to this invisible enemy."
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Aboard the Celebrity Eclipse and Coral Princess, the vicious virus seemed a world away as the ships headed in early March toward Cape Horn at the tip of South America - a bucket list trip for many cruisers.
"There were whales and penguins and glaciers. You name it, we saw it," said Tom Sachs, 66, a retired federal worker from Franconia, Va., who was on the Eclipse.
Then countries began barring ships from docking. Off the west coast of South America, Chile prohibited the Eclipse from scheduled stops there. On the other side of the continent, Uruguay and Argentina did the same to the Coral Princess.
There was confusion on both ships, where passengers initially believed their days at sea had kept them walled-off from the coronavirus.
On the Coral Princess, passengers received a letter March 20 from the senior physician assuring them that the risk of the ship's exposure was "near negligible."
"Rest assured that, relatively speaking, Coral Princess is probably one of the safest places in the world to be at this time," read the letter obtained by The Post.
Gill Morgan, 66, who works with the National Health Service in the United Kingdom, said that Coral Princess passengers continued to enjoy music, films on the deck and guest-organized tai chi classes and line dancing sessions.
By late March, both ships were headed toward the United States, where they could finally disembark - California for the Eclipse and Florida for the Coral Princess.
On March 21, Eclipse passenger Vivian Miller, 77, said the captain gathered people around the pool to celebrate health-care workers. "We cheered and applauded," she said.
Days later, hundreds partied again at a special ceremony to mark the ship's passage of the equator. The ship's theater hosted daily events. "They actually made more activities, to keep people occupied," Miller said.
On the Coral Princess, the March 26 celebration of health-care workers drew a large crowd.
"The ship is virus free, so we can move around as normal with no social isolation," British passenger Sara Roberts, who posted a video of the applause, told The Post via email on March 27.
But soon, people were getting sick on both ships. Several passengers aboard the Celebrity Eclipse, including Miller, said in interviews that they sought assistance from the onboard medical clinic for flu-like symptoms starting early in the cruise, only to be told they likely had colds or the flu.
On the Coral Princess, Long Island residents Peter and Grace Nahm went to the medical center March 28 after their health had been deteriorating. After a nose swab, both were diagnosed with the flu, said their son, Paul Nahm, 39, of Fort Lee, N.J.
Meanwhile, Coral Princess passengers continued to sunbathe, swim and socialize in what was "glorious weather," Roberts recalled later.
As the ship sailed toward Barbados on March 30, where a stop the next day was planned, the cruise line released a public statement at 6 p.m. Eastern that said in part: "There remains no known risk of COVID-19 onboard."
Nearly 19 hours later, there was suddenly a different message. After a "higher-than-normal number of people presenting influenza-like symptoms," all passengers were being confined to their rooms, the company announced March 31.
By then, those aboard had been freely socializing for 26 days.
That night, the Coral Princess stopped in Barbados, where a sick passenger was taken off the ship. There, the company also collected coronavirus test samples and sent them to the island.
Two days later, on April 2, ship officials said 13 people had been tested; 12 were positive for the coronavirus. That number included Peter Nahm, his son said.
By the time the ship finally reached land in Miami on April 4, two people aboard had died. Six were brought to hospitals in Florida the day the ship arrived, and a dozen more the next day, according to county officials.
The Nahms were hospitalized a day apart; both have tested positive for the coronavirus, Paul Nahm said. His mother has since recovered and returned to New York on a medical evacuation flight; his father remained in a Miami-area hospital.
Paul Nahm said the trip should have been canceled before it started or should have tried to find a port to disembark passengers earlier. And, he argued, the cruise line should have better managed the situation once anyone was aware of illness.
"Once people are sick on board and there's cases of flu-like symptoms, they should have immediately locked down," he said.
Princess Cruises spokeswoman Alivia Owyoung Ender did not address specific questions about how the Coral Princess handled the situation, but said in an email that the company has followed the guidance and direction of health authorities, including the CDC.
"During this entire unprecedented time, Princess has done everything possible to be open, honest and transparent, and to provide for the health and well-being of our guests and crew in the most earnest and compassionate way possible," she said.
Zeiger of Royal Caribbean Cruises said the Eclipse did not experience an abnormally high number of people with flu-like symptoms for a ship carrying more than 3,000 passengers, adding that the crew did not believe the coronavirus was aboard. He noted that the ship ultimately spent five days off the coast of Chile while trying to dock and another 10 days sailing to San Diego, keeping it out at sea longer than the virus's typical incubation period.
Still, he said of the cruise industry's experience with the coronavirus, "You don't come through something like this without learning some lessons. You better be more humble than that."
Now in San Diego, David Nystrom said he believes the Eclipse's medical staff genuinely did not believe his wife had covid-19 - they treated her for days without masks, potentially endangering their own health, he noted.
She was the first off the ship when it docked March 30, transported from the Eclipse to a hospital by ambulance, where Nystrom said she tested positive for the coronavirus within 10 hours and then spent 22 days on a ventilator before beginning a slow recovery.
"What happened was terrible and my life might be changed forever," he said in an email. "But since coronavirus was still new when we got on the cruise on March 1, did the medical staff just not realize what was happening?"
Earlier this month, after more than 14 days in quarantine, David Nystrom developed a dry cough. His test result: positive.