The hantavirus-stricken cruise ship MV Hondius arrived at its last stop Monday. Now the waiting begins.
The diagnosis of a strain of the Andes strain of hantavirus — an infection that’s fatal in about 40 percent of cases — on a ship carrying people from roughly two dozen countries has given public health officials around the globe their first major test in controlling contagion since the Covid-19 pandemic. Countries are choosing different strategies to monitor potentially exposed passengers and stop the spread of the disease and to communicate with a nervous public anxious that the virus may have come closer to home.
Passengers on board the ship since early May are now entering the window when they will be most likely to develop symptoms, according to infectious disease experts.
Indeed, a Hondius passenger who had been quarantined in Canada and developed symptoms has been confirmed to be positive for the Andes strain of the hantavirus, according to the Public Health Agency of Canada.
“No one would be surprised if there are others that test positive this upcoming week,” said Dr. Isaac Bogoch, an infectious disease specialist and professor at the University of Toronto.
Bogoch recently partnered with Dr. Jason Andrews, an infectious disease epidemiologist at Stanford University, to model the incubation periods and secondary spread in two past outbreaks of this virus in Argentina: one from 1996 and one from 2018, which were both well-documented. Their work was recently posted as a preprint, ahead of peer review.
Their analysis found that the average incubation period for the virus — the time between when a person is infected and when they develop symptoms — is roughly three weeks.
The last person to fall ill on the ship was a German passenger who died May 2, the same day researchers identified the cause of the infections. Until then, passengers had not known they needed to take precautions.
Though not everyone on board may have been exposed – or exposed at the same time – the May 2 date is a rough marker for the edge of the danger zone. It can take as long as six weeks for symptoms to appear, which is why most countries are monitoring passengers for a minimum of 42 days counted from the day they got off the ship, May 10.
‘Relying on everyone doing the right thing’
In the past, Bogoch notes, Argentina has stopped the spread of Andes hantavirus through tried-and-true public health measures such as regular testing and quarantines.
“So now you’re relying on everyone doing the right thing, rather than just one country doing the right thing, and I think that just adds an element where error could be introduced more readily,” Bogoch said.
Different countries are using a variety of approaches to monitor returned passengers.
Mandatory quarantines are in place in Spain and France, whereas Great Britain and the United States are asking passengers to voluntarily isolate themselves, with regular check-ins with public health authorities.
Some passengers are spending quarantine in a hospital, while others are being monitored at home.
Several countries are testing passengers at regular intervals to spot the first signs of infection. US officials have said they don’t recommend testing until a person shows symptoms, however.
Bogoch thinks that approach may prove inadequate. His study found that people may shed virus several days before symptoms appear.
“Relying on symptoms alone, you’re going to miss people,” he said. His study found that those infected can shed virus five to 10 days before symptoms start.
“In a perfect setting, you would actually test them with some degree of frequency to be able to detect the infection” before symptoms show, he added.
There are several reasons to do that. If a person is at home, a positive test before symptoms would signal the need to move to hospital for both a higher level of care and to protect anyone else living with them. Although there are no medications specifically approved to treat the Andes virus, there are three approved antiviral drugs that may be effective at blunting the infection, and they’re all best used at its earliest stages, he added.
Shifting situation in the US
US officials have said the 18 passengers who returned to the US on last week are being offered a choice to quarantine either at home or at the National Quarantine Center at the University of Nebraska Medical Center.
The New York Times reported late Monday that a passenger who had planned to leave received a federal order requiring that she stay for at least two more weeks, and that health officials said law enforcement would be contacted if she attempted to leave.
CNN has reached out to US Department of Health and Human Services and CDC about the orders.
CDC experts leading their assessments said last week that they are encouraging the cruise passengers to stay at the Quarantine Center, where they can be closely watched and promptly treated if they develop symptoms.
The CDC has also notified several states of passengers who returned before the outbreak was identified and to people who were exposed to symptomatic cruise passengers on airline flights.
The agency said Thursday that state and local health departments were monitoring a total of 41 people, including the 18 in quarantine. All have been advised to take their temperature at least once a day and report any symptoms including headache, nausea, vomiting, muscle aches, shortness of breath and cough.
Anyone exposed, including those deemed to have high-risk exposures, has the option to quarantine at home, provided their local health department determines that they will follow directions and have suitable accommodations – preferably with a private bathroom – and there’s appropriate medical care nearby, according to the CDC’s interim guidelines. Hantavirus can rapidly get worse, and patients may need advanced critical care with machines that can take over for the work of the heart and lungs.
The CDC’s guidelines specify that people with high-risk exposures get twice daily in-person visits from state or local public health departments.
That seems like a bad idea, said Dr. Jennifer Nuzzo, who directs the Pandemic Center at Brown University.
“It seems like a lot of resources, and I’m not sure that that’s necessary,” Nuzzo said. Local health departments saw steep cuts last year when HHS rescinded $11 billion in unspent Covid-era funding that paid for things like contact tracing during outbreaks. They’re already stretched trying to manage a record surge in measles cases.
The CDC has advised people who are being monitored to stay away from others and not to travel during these six weeks.
Still, some cases have fallen through the cracks. At least two Hondius passengers from California and New York who disembarked before the source of the outbreak was known have already traveled on international flights. One left the ship and returned to California briefly before flying a second time. That person is now quarantined by British authorities on Pitcairn Island. The US government has been in touch with the person from New York, an HHS official said, though the official offered no additional information on that person’s health or location.
Mandatory quarantines
Some countries have taken a stricter approach to quarantine.
In the Netherlands, passengers are in mandatory quarantine at home, with occasional outings allowed as long as people wear masks and stay away from others. They have to check in with health authorities daily. Twenty-three quarantine cabins were being built in Rotterdam for the international crew members of the MV Hondius — 22 people disembarked Monday, including two doctors — but it’s unclear whether they’ll stay in these cabins for the entire six weeks of the monitoring period. Five crew members remain on board during disinfection.
Great Britain is allowing passengers and their contacts to return home after an initial evaluation in the hospital. As in the US, the quarantine in Britain relies on voluntary cooperation, whereas France and Spain have issued legally enforceable orders, which require mandatory reporting.
French passengers on the Hondius and others exposed on planes will have to stay in the hospital for at least 15 days.
Similarly, Spain is requiring people exposed to the Andes virus to quarantine for at least seven days. After that, health authorities are taking a stepwise approach to contact: If blood tests taken on day seven remain negative, those in quarantine can have visitors, as long as everyone wears personal protective equipment.
Two passengers from Singapore will remain isolated in the hospital for 30 days and then, following testing, must stay in phone contact with public health authorities for an additional 15 days.
Different approaches to testing
Several countries presented their monitoring strategies on a call hosted by the World Health Organization last week. The CDC did not participate, said Dr. Jeanne Marrazzo, chief executive officer of the Infectious Diseases Society of America and former director of the National Institute of Allergy and Infectious Diseases.
The call highlighted another difference between the US and other countries: Other countries are regularly testing people in quarantine, while the US is not.
In a briefing Friday, Dr. David Fitter, director of the Division of Global Migration Health at the CDC’s National Center for Emerging Zoonotic Diseases, said the agency “does not recommend testing people for Andes virus who have not experienced symptoms.”
Not doing that testing means possibly missing an early window on the infection, Marrazzo said.
That kind of testing, called polymerase chain reaction or PCR, looks for the virus in the blood, which is the first sign of an infection. Instead, the CDC’s approach recommends testing for antibodies, which appear after the body has begun to fight off the infection.
“This is an incredible opportunity to try to figure out exactly what the natural history of this virus is,” Marrazzo said.
People in protective hazmat suits leave after inspecting the MV Hondius in Rotterdam on Monday.Nicolas Tucat/AFP/Getty Images
Communicating about risk
Another striking difference has been how these plans are being communicated to the public.
The French minister of health, Stephanie Rist, who has issued a legally enforceable decree mandating quarantine and isolation for exposed passengers and their contacts, stood at a lectern Wednesday flanked by experts in virology, epidemiology and medicine, including a doctor at the hospital treating one of the passengers who has tested positive and is critically ill. All the speakers took questions from reporters during the 90-minute news conference.
On the same day, the CDC gave reporters an hour’s notice to join a telebriefing offering an update on the hantavirus response — a rare announcement during the Trump administration, when most information comes directly from HHS.
Two experts on the call, Fitter and Dr. Brendan Jackson, who are leading the CDC’s response to the hantavirus outbreak, opened by saying they were working with state and federal partners to protect public health and that the risk to the general public was low.
After that, details were scarce. Reporters asked whether the officials could share an update on the conditions of the passengers who were in quarantine at a facility in Atlanta. No, was the response.
How about the number of people being monitored nationwide, beyond the 18 cruise passengers in Nebraska and Atlanta? Out of respect for their privacy, no – although Fitter shared the number being monitored at a separate briefing the next day.
After a handful of questions, the moderator announced that there was no additional time, and the briefing was ended after 20 minutes.
The CDC has held two short subsequent briefings, but officials have still declined to share many specifics about the next steps for the cruise ship passengers.
As of Friday, two in Atlanta had been moved to the Nebraska quarantine facility. It’s not clear when any of them could leave.
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