A member of the media wearing a face mask walks past the Diamond Princess cruise ship at Daikoku Pier where it is being resupplied and newly diagnosed coronavirus cases taken for treatment. (Getty)
  • The Diamond Princess cruise ship went from 10 cases of the new coronavirus to more than 630 over the course of its two-week quarantine.
  • Experts and officials have critised the decision to keep people on the ship and poor hygiene practices onboard.
  • Here's how the cruise ship ended up with more than half of all novel coronavirus cases outside China.
  • For more stories, go to Business Insider's home page.

Passengers on the Diamond Princess cruise ship got their first piece of bad news on February 4: Ten people onboard had tested positive for the novel coronavirus.

It was the beginning of a two-week ordeal of quarantine orders and disease response that has been widely criticised as a failure. On Friday, Japan's Ministry of Health reported that 634 people from the ship had tested positive for the virus. The US Centers for Disease Control and Prevention (CDC) reported an additional 18 cases from the ship, with an expectation that more will arise.

Two people have died.

"The quarantine was not justified, and violated the individual rights of the passengers while allowing the virus to literally pick them off one-by-one," Dr. Amesh Adalja, who works at the Johns Hopkins Center for Health Security, told Business Insider in an email.

Adalja and other experts have criticised the decision to keep passengers and crew on the ship and said poor hygiene practices helped spread the virus.

"I'd like to sugarcoat it and try to be diplomatic about it, but it failed," Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, told USA Today. "People were getting infected on that ship. Something went awry."

Here's how it got so bad.

On February 1, a man who'd been on the Diamond Princess tested positive for the new coronavirus six days after leaving the ship. It docked in the port of Yokohama, Japan, three days later.

The man, from Hong Kong, boarded the ship in Japan and stayed on board for five days, then disembarked in his hometown.

When it docked in Yokohama, the ship had 3,711 crew members and guests.

According to The New York Times, it took Japanese officials more than 72 hours to lock down the ship after they were notified about the Hong Kong man's case.

By the following morning, 10 people on the ship had tested positive for the virus. Japan's Ministry of Health placed the entire boat under a 14-day quarantine.

Passengers had already been on the ship for two weeks, since the quarantine came at the end of their scheduled cruise.

Japanese health officials continued testing passengers and transported those who tested positive to health facilities on land.

However, testing takes a day or more, since it involves collecting and submitting spit and mucus samples.

Spencer Fehrenbacher, an American grad student on the ship, told Business Insider that he experienced a "wall for information" about test results. He said on February 6 that he'd been waiting to get his own results for two days.

Other passengers reported long delays in getting tested at all, even after they reported symptoms.

From the beginning, those quarantined on the ship reported confusion and a lack of information.

"There wasn't much information," passenger Masako Ishida told The New York Times on February 5. She said many passengers did not immediately understand that they may have been exposed to the coronavirus.

Passengers tallied the ambulances lined up on the pier, The New York Times reported, in order to get a sense of how many infections been confirmed on the ship.

Fehrenbacher told Business Insider that he stood very close to a woman who was clearly sick when he got his medical screening.

"You could hear that cough that's deep down in your lungs. I empathised with her and felt so bad," Fehrenbacher said. But he also recalled thinking to himself, "Okay, I don't want to be in this room."

Ishida also reported concerns about the screenings: "They didn't put the thermometer into our ears properly," she said.

She said her husband's first temperature measurement was about 90 degrees Fahrenheit, well below normal body temperature. When she asked for a second measurement, it was 95 degrees.

Ishida added that meals had been chaotic in the first days as well, with breakfast arriving at 2 p.m., quickly followed by lunch.

Three days into the quarantine, people on the ship began unfurling signs that read "Lack of medicine!" and "Thank you, media."

On February 11, a crew member told passengers that as many as 1,850 people on board (who had not been expecting to be stuck there for so long) had requested and been given more prescription medications.

Passengers were confined to their rooms, the least expensive of which have no windows or balcony.

At about 160 square feet (14 square-metres), the rooms are the size of a shipping container and include either two twin beds, one queen bed, or, in some cases, bunk beds.

Honeymooners Alan and Wendy Steele told The Washington Post that they were going "stir crazy" on February 5.

"We're basically being treated like we're prisoners and criminals at the moment; that's how we feel," Alan Steele said. He added that lunch on the first day had been stale bread with ham.

The next day, the ship's operator, Princess Cruises, said that it had "activated new in-room entertainment offerings," including games, trivia, arts and crafts, movies, eight new TV channels, and newspapers printed in 36 languages.

Passengers tweeted pictures of their meals and gave the room service mixed reviews.

They also received bottle water and alcohol.

In addition to food and drinks, passengers were given face masks.

The masks are not great at preventing wearers from contracting the novel coronavirus, but they may help keep sick people's germs from passing to others.

Those in the interior, windowless cabins were allowed to walk around the deck for a few minutes each day, wearing face masks.

Officials advised passengers to keep 6 feet (1 metre) apart.

Experts have criticised the decision to keep people on the ship.

"From a virologist's perspective, a cruise ship with a large number of persons on board is more an incubator for viruses rather than a good place for quarantine," Dr. Anne Gatignol, a microbiologist who studies viruses at McGill University, told the Montreal Gazette.

Keeping people in a confined space may have helped the virus spread.

"They've basically trapped a bunch of people in a large container with [the] virus," David Fisman, an epidemiology professor at University of Toronto, told Vox. "So [I'm] assuming 'quarantine' is generating active transmission."

"Cruise ships are made of surfaces that are really sticky for viruses," Kelly Hills, a bioethicist and Rogue Bioethics co-founder, told Business Insider.

"Lots of chrome and polished metal, things with grooves and nicks and scratches. It just makes a good home," she said.

Infectious-diseases expert Kentaro Iwata said poor hygiene practices on the ship made him "so scared" of contracting the virus when he visited.

"The cruise ship was completely inadequate in terms of the infection control," Iwata said in a Youtube video. "There was no distinction between the green zone, which is free of infection, and the red zone, which is potentially contaminated by the virus."

As the case count continued to rise, some Indian crew members begged their government to rescue them.

The group shared a series of videos on Facebook. One of them, Binay Kumar Sarkar, told Business Insider that the situation on the ship was "out of control."

"There are lot of people who don't have coronavirus so why are we all being confined here?" he said. "Please save at least those of us who are healthy."

Crew members brought meals to passengers' rooms, but the workers continued to eat together in the ship's mess hall.

According to a New York Times report, infected crew members had eaten in the mess hall alongside their coworkers.

"We all are really scared and tense," Sonali Thakkar, a worker on the cruise ship, told CNN.

The New York Times reported that 85 crew members tested positive for the virus.

"There are many places where we all are together, not separated from each other," Thakkar told CNN. "Especially when we sit in the same mess hall and eat together, the place where it can spread very fast."

As the case count rose past 200, passengers expressed fear.

"I can't wrap my head around the fact that I could die from this cruise," Gay Courter, a 75-year-old novelist confined to a cabin on the ship with her husband, told The Wall Street Journal.

"The 14-day stipulation was meaningless in a context with new infections and new transmission episodes," Adalja said.

"The whole idea of the cruise ship quarantine was ill-conceived, and the resultant slew of infections it spawned was completely predictable," he added.

On February 12, the Japanese Ministry of Health announced that some passengers over 80 years old could finish their quarantine on land.

The offer applied to passengers over 80 who had windowless cabin rooms or pre-existing medical conditions. They had to test negative for the virus before they could leave the ship.

On Valentine's Day, passengers were gifted roses, chocolates, and (courtesy of the Japanese Health Ministry) new iPhones featuring a special app for medical support.

Crew members danced below deck and children drew pictures. The first group of healthy people was also allowed to leave the ship that day: 11 passengers older than 80.

After nearly a month on board, the remaining passengers finally began to leave the ship after the quarantine ended on February 19.

Officials in Canada, Australia, Hong Kong, and the US are requiring their residents to undergo an additional 14-day quarantine once they return.

By then, the number of people infected with coronavirus on the ship had skyrocketed to 621 — more than half of all cases outside China.

More than half of the infected people (322) showed no symptoms at all, which suggests that some coronavirus carriers in China could be going undetected.

Researchers still aren't sure to what extent people can spread the virus when they have no symptoms, though a report published Friday documented a case in which a woman who was asymptomatic passed the coronavirus to five family members.

Fourteen US citizens who tested positive for the virus flew home in an isolation box on the back of the plane with other Americans from the ship.

Their tests came back positive after they had left the ship and were traveling to their plane home, the State Department and Department of Health and Human Services said in a joint statement on Monday.

The agencies also said the passengers had been evaluated, and "all were deemed asymptomatic and fit to fly before being processed for evacuation."

But on Thursday, the CDC said 22 of the other US evacuees who had been on the flight had either tested positive for the coronavirus or shown symptoms.

Those people had sat in the two evacuation planes' main cabins.

The CDC reported on Friday that a total of 18 people had tested positive, though that number could grow.

"We do think based on epidemiology and risk assessment that there may be additional cases," Dr. Nancy Messonnier, director of the CDC's respiratory diseases center, said in a press conference on Friday.

"We don't want to take [the tests done in Japan] at face value," CDC spokesperson Scott Pauley told The San Francisco Chronicle.

CDC officials had argued against the decision to have sick and healthy people fly on the same plane.

The Washington Post reported that CDC officials lost the argument on the tarmac, then insisted they be left out of the news release announcing that 14 infected Americans had shared a plane with more than 300 others.

Two people who were on the cruise ship — an 87-year-old Japanese man and an 84-year-old Japanese woman — died on Tuesday, Japanese officials said.

The passengers were taken to local hospitals on February 11 and 12, and both had underlying health issues, The New York Times reported, citing the Japanese broadcaster NHK.

Princess Cruises is preparing the ship to set sail again on April 29.

"The expectation is that the ship would be fully sanitised and then taken into dry dock for a period of time," Negin Kamali, public-relations director for Princess Cruises, told The Wall Street Journal.

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