NEW YORK (NYTIMES) - The e-mail to Princess Cruises was peppered with typos and awkward grammar, but the warning was unmistakable. An 80-year-old passenger had tested positive for the new coronavirus after getting off the Diamond Princess cruise ship in Hong Kong.
"Would kindly inform the ship related parties and do the necessary disinfection," Princess' port representative wrote on Feb 1, relaying a warning from Hong Kong health officials. "Many thanks!"
Nothing happened. Princess says it believes the alert sat unread in unmonitored inboxes. Dr Grant Tarling, the company's top doctor and the person in charge of responding to outbreaks, said he had not learnt about the infection until the following day - after being alerted to a post on social media.
The fumbled alert was just the beginning of a broader breakdown by both the company and the Japanese authorities who quarantined the ship in Yokohama. Hobbled by confusion and mistakes, they played down the risk of infection, ignored best medical practice for evacuating passengers, and activated only low-level protocols for dealing with outbreaks.
Ultimately, eight people died and more than 700 were infected, including some government officials.
Now, those failures have taken on fresh urgency as Princess and Dr Tarling deal with yet another coronavirus cluster, on a cruise ship that has been turned away from port in San Francisco. A passenger who recently got off the cruise died of the virus last week, and 21 people have since tested positive.
Thousands of passengers have been told to stay in their rooms as the cruise company and the United States authorities scrambled to figure out a plan. The ship is expected to dock in Oakland, California, on Monday, and passengers will be quarantined onshore.
In conversations onboard, passengers have been asking, "Will we become another Diamond Princess?", said Mr Bill Pearce, a 54-year-old from Lafayette, California.
"Whatever's the quickest way to get home, I'm all for it. I'd rather not be on the ship," he said. "Not being able to walk more than 6 feet in any direction - it's like being in a jail cell."
The crisis on the Diamond Princess exposes the vulnerabilities in the patchwork of international agreements, national laws and corporate policies governing the health and safety of the US$150 billion (S$207 billion) cruise industry that carries 30 million passengers a year.
After the infection in Hong Kong was confirmed, company officials incorrectly assumed that the immediate risk was minimal because the sick passenger had disembarked. Health authorities recommended action immediately.
"We advise thorough environmental cleansing and disinfection of the cruise," Dr Albert Lam, an epidemiologist for the Hong Kong government, wrote to the company on Feb 2.
The company says it stepped up cleaning the next day. But it initiated only the lowest-level protocols for outbreaks.
"There's no point in going and start cleaning the ship when we really didn't know what, if any, risk there was onboard," Dr Tarling said in an interview.
When the Japanese authorities boarded the vessel, they, too, ignored medical guidelines, by leaving potentially exposed passengers on board during testing rather than taking them ashore as recommended.
The Japanese government and company still disagree on who was - or should have been - in charge. So the responsibilities for quarantining nearly 2,700 passengers fell mostly to about 1,000 low-paid ship workers who were given inadequate safety gear and guidance.
Dr Tarling, the chief medical officer for Princess' parent company, Carnival Corp, oversaw the response from California. He was unaware of the working conditions on board. He said crew members had followed the protocols for a person "in quarantine or isolation in a hospital".
In reality, a crew member often wore the same pair of gloves to deliver food to dozens of cabins at a time, door to door and face to face with passengers, a potential source of infection. They also collected dirty dishes and used linens without full protective gear.
An outbreak of a new virus aboard a crowded ship unquestionably presented high-stakes difficulties. Princess says it did the best job possible in the face of unprecedented challenges.
But in a series of interviews, company officials offered contradictory and changing accounts about their response. In the end, nearly 48 hours elapsed between the alert on Feb 1 and the captain's announcement to the ship on Feb 3 that a passenger had been infected, giving the virus time to spread.
Princess officials could not point to the social media post, or the platform, that they say tipped them off. They said it took Dr Tarling until the night of Feb 2 to confirm that a former passenger had tested positive.
Company e-mails show that he knew by that morning. In an e-mail to a Hong Kong doctor, he listed the patient's name, his hospital wing, his travelling companions and the date of the diagnosis.
The subject line of his e-mail began: "Confirmed Coronavirus Case."
Containment procedures for an outbreak unfold on a continuum.
Basic precautions might include encouraging hand-washing, eliminating self-service at buffets and increasing cleaning. More serious matters might prompt crews to discourage handshaking, disinfect the ship or cancel social events. Outbreaks of highly infectious diseases like Ebola have their own stringent protocols.
The response aboard the Diamond Princess reflected concern, to a point. The buffets remained open as usual. Onboard celebrations, opera performances and goodbye parties continued.
"We immediately increased our already robust sanitation protocols," Mr Gennaro Arma, the ship's captain, said in response to questions submitted through Princess. He said the crew had increased the number of hand sanitisers, rotated the buffet utensils more frequently and stepped up cleaning.
Passengers aboard the Diamond Princess say they noticed few shipwide changes after the announcement of the infected passenger. But some crew members began giving out their own more cautious advice, making some passengers suspicious that the risks were higher than the company was letting on. At the end of a trivia game, for example, a worker told passengers not to hand back their pencils.
"He said, 'Hold onto your pencils and you can consider yourself a winner,'" said Ms Carol Montgomery, 67, a retired administrative assistant from San Clemente, California.
The crew member also advised them to avoid handrails.
"It was like he was trying to tell us something," Ms Montgomery said.
Underpinning the company's approach was an optimistic, but ultimately inaccurate, belief that perhaps danger had been averted.
The 80-year-old infected passenger had reported no symptoms to the medical staff while onboard. And he had disembarked more than a week earlier, along with his daughter and their two travelling companions.
"They were off the ship," Dr Tarling said. "There's nothing to believe that we have to put face masks on every single guest."
Dr Tarling also did not order the crew to begin what is known as contact-tracing, the painstaking task of questioning everybody and identifying who had been in contact with the infected passenger. Infectious disease experts say that the process should begin immediately and that anyone who was in close contact should be isolated.
Dr Tarling said Japanese health officials planned to do the contact tracing in a matter of hours, when the ship arrived in Yokohama on Feb 3. Until then, he said, he considered only the elderly man and his travelling party to be "close contacts".
That is a narrow interpretation. The World Health Organisation's (WHO) definition covers dining partners, anyone who had face-to-face contact with the patient - and certainly passengers who had shared a tour bus with him days earlier.
No restrictions were placed on passengers until around 11pm, when Japanese medical teams boarded the ship and ordered everyone to their cabins.
Two days later, when the first lab results came back, Japan reported that 10 people had tested positive.
"We were as surprised as the Japanese were that actually there were more positive samples on the ship," Dr Tarling said.
Halfway around the world, in the Greek port city of Volos, an epidemiologist named Christos Hadjichristodoulou has been studying cruise ship outbreaks for nearly two decades. He served as a science adviser in the lead-up to the 2004 Summer Olympics in Athens, which used a fleet of ships to ease the hotel crunch.
By happenstance, on the very day that the Diamond Princess pulled into Yokohama, Dr Hadjichristodoulou and a team of European experts released new recommendations for cruise ships.
The guidelines did not have the force of law. But experts said they were among the first protocols - if not the first - written specifically for the industry about the new coronavirus.
Those guidelines said that close contacts of a confirmed case should be evacuated and quarantined on shore, a step that is now supposed to happen with the ship off California's coast after several days of waiting. On the Diamond Princess, that would have meant removing many, if not all, of the 273 people selected for the first round of testing.
Instead, the Japanese government asked them to stay in their rooms while awaiting test results. In practice, passengers still moved about and ate at buffets.
When the first batch of positive results were reported on the morning of Feb 5, the Japanese authorities ordered a shipwide quarantine. Confirmed cases would be evacuated to hospitals, but everyone else would remain aboard, isolated in their cabins.
"The approach they followed is not recommended for many reasons," Dr Hadjichristodoulou said. He would not criticise decisions made under pressure but said it was clear the virus would spread. "We expected this," he said.
Japanese health officials say that some local authorities feared allowing potentially infected passengers ashore. And the country could not immediately quarantine a large number of people.
"It's easy to say that they should be moved to an onshore facility," said Dr Yasuyuki Sahara, a senior assistant minister in Japan's Health Ministry. "But in reality it is not so easy."
Dr Hadjichristodoulou, who also leads a team of WHO advisers, said he had contacted the agency's offices in Lyon, France, and offered to organise a group of experts to board the ship to advise. He said the offer was declined.
A WHO spokesman said he would not discuss the group's internal discussions. Dr Sahara said the Japanese ministry had no record of the offer.
One WHO consultant from the Manila office provided advice in the Health Ministry's Tokyo office but never boarded the ship.
'NO DRILLING FOR SOMETHING LIKE THIS'
Quarantining thousands of people is a huge operation requiring far more gear and supplies than any cruise ship carries. Confining people in shared rooms has its own challenges, as does feeding them and keeping them entertained so they won't be tempted to leave their cabins.
Japan's foreign minister, Mr Toshimitsu Motegi, said in a parliamentary session that the responsibility should not have fallen solely on Japan.
"Japan is not the only state that is obliged to conduct measures to prevent the expansion of infection," Mr Motegi said. He suggested international law was unclear as to whether both the country where the ship was officially licensed - Britain - and the cruise operator should share the burden.
Princess said it had followed Japan's lead from the moment its health officials boarded the ship.
"When we have other outbreaks like norovirus, we send our teams to the ship," Dr Tarling said. "Here, we're sort of taking direction and seeing how we can best make it work."
That responsibility fell to the crew. Cruise jobs are notorious for long hours and low pay. A supervisory kitchen worker for Princess, for example, made US$1,949 a month and was expected to work up to 13 hours a day, seven days a week, for six months straight, according to a 2017 contract.
Those crew members drill for many eventualities, said Mr Iain Hay, whose company, Anchor Hygiene, conducts training for cruise companies.
"But," he said, "there was no drilling for something like this."
On the Diamond Princess, crew members delivered three meals a day to close to 1,500 staterooms. Early in the quarantine, they served food on china. While crew members wore masks and gloves, they risked spreading - or contracting - the virus whenever they opened stateroom doors and passed in trays of food.
"I'd give them a coffee cup and they'd give me back an apple," said Ms Melanie Haering, 58, whose husband, John, was hospitalised with the virus. "It was an exchange like that - even though your hand is gloved, your hand has still been soiled from the cabin next door."
Even after switching to paper and plastic, crew members still delivered meals into rooms rather than leaving them on the floor outside, as Dr Tarling believed happened. Passengers who were evacuated to military bases in California and Texas said workers there left food outside.
Experts say the crew was not equipped to carry out the quarantine, so lapses were inevitable.
"Look at how infectious-disease teams operate anywhere in the world. That is their job," said Dr Kate Bunyan, a former medical director for Carnival. "They are not waiters in their day jobs."
But if anyone from Princess objected to the quarantine, nobody is saying so. Dr Tarling said it was the best option available.
The concern now is focused on the other Princess cruise thousands of miles away. On Wednesday, a passenger in California died from the coronavirus after completing a 10-day cruise to Mexico aboard that ship, the Grand Princess.
For days, the ship has idled off the coast as Princess and US officials have tried to figure out what to do. After shifting plans and significant uncertainty, they have decided to dock in Oakland, where sick passengers will be taken to hospitals in the state and others will be sent to quarantine facilities around the country.
Once again, Dr Tarling is helping manage the crisis. Asked whether he wished he had done anything differently to contain the outbreak on the Diamond Princess, he could not point to a single decision that he would change.
"I believe our initial response was actually pretty good," he said.