IN THE PAST two weeks, I have been asked some version of the same question by patients, friends, and a few colleagues. Should I cancel my cruise? Is this the next COVID-19? Should I be worried?
The honest answer is more complicated than yes or no, and I think our time is better spent on the complicated version. So I am going to tell you two things in this piece. The first is what I tell people about the hantavirus outbreak on the MV Hondius, which evacuated the final passengers off the Canary Islands on May 11 with three dead and a number of confirmed cases. The second is what I tell people when they ask whether I personally go on cruises, which I do not, and which is a separate conversation from the hantavirus one.
As a physician who ran New York City’s COVID-19 medical response, and who has worked outbreaks including Ebola in sub-Saharan Africa, a few things have stood out to me about how this particular story is landing.
People Are Paying Attention to the Wrong Number
THE NUMBER THAT keeps getting reported is the case count on the ship. The number I watch is incubation. Hantavirus has a one to eight week incubation window, which means the question that actually matters is not “how many cases are there today” but “how many people who were on or near that ship will still be developing symptoms three weeks from now.” That is also why the contact tracing around the KLM flight attendant in Amsterdam is the right move, even though it sounds alarming. Public health is doing what it should be doing. The fact that we are hearing about it is a feature, not a failure.
The Fear is Reasonable. The Target is Wrong.
THE INSTINCT UNDERNEATH “should I cancel my cruise” is actually a healthy one. People learned during COVID-19 that public health risks are real, that they move fast, and that official messaging often lags the situation. That is a hard lesson, and I do not think anyone should unlearn it. The reflex to take an outbreak seriously is the reflex we want in the public.
But hantavirus is not COVID-19. It is not close to COVID-19. The Andes strain on the Hondius spreads almost exclusively through contact with infected rodents, specifically their urine, droppings, or saliva. The rare cases of person-to-person transmission that have been documented over the years have all involved close, prolonged contact with someone already very sick, usually a family member providing hands-on care. There is no airborne spread in the way we mean it with respiratory viruses. There is no community transmission chain. For someone going about their normal life in the United States, there is no risk.
Here is where I have to be honest about the part most coverage skips. When a patient asks me whether they should cancel their cruise because of this outbreak, my answer is clearly no. This outbreak is not a reason to cancel your holiday cruise in the Caribbean. When that same patient asks whether I would go on a cruise, my answer is different. I would not. Congregate settings with shared ventilation and food service have an elevated transmission risk for almost every pathogen I track, and I do not personally choose to be in that environment for a week at a time.
That is a position about cruise ships as a category, not a position about hantavirus. The two questions get conflated in the news cycle, and I think that conflation is part of why people are having such a hard time determining how worried to be. The outbreak on the Hondius is not the reason to reconsider a Caribbean cruise.
The Cruise Industry Conversation is the One Worth Having
THE HONDIUS IS a small expedition ship with one doctor on board, operating in some of the most remote waters on Earth. Its stops include Saint Helena and Ascension, islands with minimal medical infrastructure. When someone on a vessel like that becomes critically ill in the South Atlantic, the response is not a quick diversion to Miami. It is a multi-day evacuation that may not be survivable.
This is a category of cruising that has grown a lot in the past decade. Adventure cruises. Polar cruises. Small-ship expeditions to places most travelers cannot otherwise reach. The marketing is built on exclusivity and remoteness, which are real selling points. The medical reality of being seventy-two hours from a hospital deserves equal weight in the decision, and almost never gets it.
Even setting aside my broader view on cruise ships, expedition cruising involves a tradeoff that the brochures do not describe. If a traveler is going to make that tradeoff, they should make it with their eyes open. The questions to ask before booking are these:
- What can the onboard doctor actually treat, and what would require evacuation?
- How long would that evacuation take from the most remote point on the itinerary?
- Does the travel insurance cover an air ambulance from a remote location? If so, get it in writing.
- And, given your own health history, is this a trip your personal physician would recommend?
The Hondius crew, by all accounts, handled an unexpected outbreak about as well as a small expedition ship can. This is not a story about a failure on the ship. It is a story about a tradeoff that travelers are making without fully understanding it, and about a category of travel where the medical infrastructure has not caught up with the demand.
There’s A Pattern Underneath All of This
THERE IS ONE more thing worth saying, and it is the pattern I think about most. It is the same pattern I have watched across every major outbreak I have worked on. The acute event commands attention. The structural lesson does not. We watch the ship. We argue about which port should take it. Then it docks, the sick are treated or buried, and the underlying problem goes back into a drawer.
I am not speaking abstractly. In March 2020, I was part of the team that handled what turned out to be the last cruise ship on Earth still at sea, the Grand Princess. We decanted those passengers into a hotel in San Carlos, California, and ran the public health response on the ground. It was one of the more impressive operations I have ever been part of, and it was also a confession. We were improvising in real time because the public health infrastructure on and around cruise ships had never been built for what was coming.
We have not built it since. Cruise ships are floating petri dishes, or to use the public health term, congregate communities with shared ventilation, shared food service, and a closed population for a week at a time. They are also not the only example. Congregate homeless shelters are another. Jails and prisons are a third. Skilled nursing facilities are a fourth. The settings change. The structural problem does not. We move enormous numbers of people through environments where novel pathogens live, but the screening, diagnostic, and communication systems are not adequate.
The Hondius is not the next pandemic. It is a small stress test, and we will get more of them. What the cruise industry needs, and what travelers should be asking for as loudly as they ask for better wifi and bigger pools, is routine public health presence on ships. Onboard diagnostic capacity that does not depend on emergency airlifts. Mandatory pre-departure screening for itineraries that pass through endemic zones. Transparent surveillance reporting from every vessel to the public health authorities of the ports they are sailing toward. None of that is exotic. It is the kind of infrastructure we already build for airports and for hospitals. The reason it does not exist for cruise ships is that nobody has insisted on it. The reason nobody has insisted on it is that the events that would make us insist on it tend to fade from view within a news cycle.
The Hondius is in the news cycle now. So when patients ask whether they should be worried, I tell them the worry is reasonable, and the answer is usually smaller than the headlines suggest. Hantavirus is not the next pandemic. It is a tragic, contained outbreak that public health professionals around the world are working to keep contained. The instinct that made you pay attention to it in the first place is a good one. Keep it. You will need it again someday, probably for something quieter than this story, and probably for something closer to home. Until then, the day is yours.
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