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The quality of life (QOL) of the passengers and crew members on an isolated=
 ship must at least exceed the minimum to live a reasonable life. To do so,=
 the individuals must be provided with the basic medical care needed to sta=
y healthy. The quarantined Diamond Princess had already reported a shortage=
 of medicines on Day 2 of the quarantine (February 5).39 The MHLW responded=
 quickly and supplied the medications needed by patients with diabetes and =
heart disease by Day 7 of the quarantine (February 10); however, there was =
still a shortage.38 In addition, passengers and crew members on isolated ve=
ssels are subject to severe stress; therefore, mental support must also be =
provided.



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There were many difficulties in implementing quarantine, such as creating a=
 dividing traffic line between infectious and noninfectious passengers, fin=
ding hospitals and transportation providers willing to accept these patient=
s, transporting individuals, language barriers, and supporting daily life.


The structure of the cruise ship made it difficult to carry out the medical=
 services required for an outbreak of an emerging infectious disease. At qu=
arantine inception, information on the virus was very limited and practice =
had to be precautionary and developed as information emerged.


Japan implemented a large-scale quarantine on the Diamond Princess cruise s=
hip in an attempt to control the spread of the novel coronavirus severe acu=
te respiratory syndrome coronavirus 2 (SARS-CoV-2) in February 2020.


A passenger who disembarked from the ship in Hong Kong on January 25 develo=
ped a fever on January 30. This passenger was confirmed to be positive for =
COVID-19 on February 1. The ship arrived at Yokohama earlier than scheduled=
 on February 3, at which time the quarantine began.






People who had close contact with someone who got the virus may have to res=
tart the quarantine from that first date of contact. And it looks likely mo=
st or all crew will need to begin a new quarantine after the last passenger=
 leaves.


The remaining passengers who had negative SARS-CoV-2 RT-PCR test results,**=
 no respiratory symptoms, and no close contact with a person with a confirm=
ed case of COVID-19 completed a 14-day ship-based quarantine before disemba=
rkation. Those passengers who had close contact with a person with a confir=
med case completed land-based quarantine, with duration determined by date =
of last contact. After disembarkation of all passengers, crew members eithe=
r completed a 14-day ship-based quarantine, were repatriated to and managed=
 in their home country, or completed a 14-day land-based quarantine in Japa=
n.


Among 3,711 Diamond Princess passengers and crew, 712 (19.2%) had positive =
test results for SARS-CoV-2 (Figure 1). Of these, 331 (46.5%) were asymptom=
atic at the time of testing. Among 381 symptomatic patients, 37 (9.7%) requ=
ired intensive care, and nine (1.3%) died (8). Infections also occurred amo=
ng three Japanese responders, including one nurse, one quarantine officer, =
and one administrative officer (9). As of March 13, among 428 U.S. passenge=
rs and crew, 107 (25.0%) had positive test results for COVID-19; 11 U.S. pa=
ssengers remain hospitalized in Japan (median age =3D 75 years), including =
seven in serious condition (median age =3D 76 years).


Cruise ships are often settings for outbreaks of infectious diseases becaus=
e of their closed environment, contact between travelers from many countrie=
s, and crew transfers between ships. On the Diamond Princess, transmission =
largely occurred among passengers before quarantine was implemented, wherea=
s crew infections peaked after quarantine (6). On the Grand Princess, crew =
members were likely infected on voyage A and then transmitted SARS-CoV-2 to=
 passengers on voyage B. The results of testing of passengers and crew on b=
oard the Diamond Princess demonstrated a high proportion (46.5%) of asympto=
matic infections at the time of testing. Available statistical models of th=
e Diamond Princess outbreak suggest that 17.9% of infected persons never de=
veloped symptoms (9). A high proportion of asymptomatic infections could pa=
rtially explain the high attack rate among cruise ship passengers and crew.=
 SARS-CoV-2 RNA was identified on a variety of surfaces in cabins of both s=
ymptomatic and asymptomatic infected passengers up to 17 days after cabins =
were vacated on the Diamond Princess but before disinfection procedures had=
 been conducted (Takuya Yamagishi, National Institute of Infectious Disease=
s, personal communication, 2020). Although these data cannot be used to det=
ermine whether transmission occurred from contaminated surfaces, further st=
udy of fomite transmission of SARS-CoV-2 aboard cruise ships is warranted.


For more than two weeks, the passengers of the Diamond Princess have swappe=
d three-course dinners for boxed meals doled out three times a day by crew =
in masks and gloves, prepared by a temporary kitchen set up on shore by a c=
harity that normally supplies meals during natural disasters. The casino is=
 shut, but the creaky Wi-Fi remains available, and Amazon deliveries are re=
portedly making it on board, although the alcohol started to run out midway=
 through the quarantine.


Two days later, the number of infected had risen to 41, but the Japanese Mi=
nistry of Health believed at the time no further tests were required. The r=
emaining passengers were asked to quarantine on board, with the cruise comp=
any offering free internet access, switching on additional satellite TV cha=
nnels, and offering those in rooms without any windows a chance to get a br=
eath of fresh air on deck now and then. Passengers tweeted photos of flower=
s, chocolates and other gifts handed out by staff, including games and card=
s for children.


In total, 542 people have been infected with the illness, despite the lockd=
own on-board. Does that mean the quarantine didn't work? "The primary reaso=
n for the quarantine was to stop potentially infectious people then spreadi=
ng infection further around the world as they continued their holidays or r=
eturned home. In this regard it would appear that the quarantine has so far=
 been successful," says Paul Hunter, professor in medicine at the Universit=
y of East Anglia, in a statement provided by the Science Media Centre.




HIGHLIGHTSInfection rate in cabins with previous case was not statistically=
 different than those without.Age of subject was found not to be a confound=
ing factor.Conflicting results from previous studies of this outbreak are l=
argely explainable.Airborne transmission through the HVAC system could expl=
ain the virus spread on the ship.Recirculated air and inadequate air filtra=
tion likely increased airborne transmission.=20

ABSTRACT The Diamond Princess cruise ship is a unique COVID-19 transmission=
 case because of the high testing capacity and the confined environment. Th=
is exploratory study aims to raise the hypothesis regarding the role of poo=
r ventilation systems in the spread of COVID-19 by analysing count data col=
lected by the onboard clinic during the outbreak, and considering the deck =
plan and design of the air conditioning system of the ship. Observed sympto=
matic infection rate after day 5 (incubation period median day) of the quar=
antine, in cabins without previous confirmed cases are compared to that in =
cabins with previous confirmed cases. Accordingly, the observed symptomatic=
 infection rate in cabins without a previously confirmed case (1.2%) was hi=
gher than for cabins with a previously confirmed case (0.8%); however, the =
difference was not statistically significant. In addition, age did not appe=
ar to be a confounding variable. Airborne transmission of COVID-19 through =
the ventilation system onboard could explain the higher than expected virus=
 spread into cabins without previously confirmed cases during the quarantin=
e period; thus, this study provides further potential evidence of coronavir=
us transmission by aerosols. Conflicting results from other studies involvi=
ng the Diamond Princess outbreak are also discussed in light of our results=
.


By the 20th of Feb, 619 COVID-19 positive cases were confirmed. Out of thes=
e cases, a total of 301 (49%) cases were symptomatic. Among these cases, th=
ere were 163 cases with recorded symptom onset dates during the quarantine =
period (NIID, 2020). Among these 163 cases, 115 were passengers, and 48 wer=
e crew. From the 20th Feb, over 1600 non-case, mainly passengers began to d=
isembark the Diamond Princess ship. Criteria for disembarkation of non-case=
s included, completion of a 14-day period without sharing a cabin with a co=
nfirmed case, a negative test result, and no symptoms (NIID, 2020).


The objectives of the study reported here are twofold. First, to test the n=
ull hypothesis that the observed infection rate of new confirmed cases with=
 recorded symptom onset dates in cabins without previously confirmed cases =
of COVID-19, is less than or equal to that in cabins with previously confir=
med cases. To eliminate the effect of pre-quarantine period exposure to the=
 virus as much as possible, only infection rates of new confirmed cases wit=
h recorded symptom onset after the incubation period median day (day 5 of t=
he quarantine) will be considered. We will investigate whether dissimilar a=
ge distributions among the cabins, could had been the reason for any differ=
ence. Second, to examine whether the HVAC system on the Diamond Princess cr=
uise ship could have played a role in the spread of the infection to the ca=
bins with no previous confirmed cases during the quarantine period.


where QPM is the quarantine period after the incubation median day (day 5 o=
f the quarantine period), and CCs are the confirmed cases. After calculatin=
g SIRRQPM in cabins with previous confirmed cases and in cabins without pre=
vious confirmed cases (Tables S1 and S2). Two-proportions z-test (one-taile=
d) was used to compare these infection rates, in which the null hypothesis =
was:


The number of new symptomatic confirmed cases in all cabins continued to de=
cline as the quarantine continued (Table 1, Fig. 1). This may have been due=
 to the strict infection prevention and control measures that were put in p=
lace during the quarantine period onboard the ship (Mizumoto and Chowell, 2=
020; Zhang et al., 2020) resulting in a substantial decline of the dominant=
 transmission mode onboard, i.e., passenger-to-passenger transmission, as a=
 result of passengers staying inside their cabins (Mizumoto and Chowell, 20=
20). Alternatively, a large proportion of asymptomatic cases may have remai=
ned undetected (Plucinski et al., 2002; Emery et al., 2020).

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