Letitia Stein, Mike Stucka and Cara Kelly

USA TODAY

Princess Cruises had a health problem long before back-to-back outbreaks of the new coronavirus on the Diamond and Grand Princess ships unmoored the entire cruise industry.

Their passengers fell sick extraordinarily often. Nearly 5,000 people onboard Princess ships in the past decade have suffered from bouts of vomiting, diarrhea – or both – in numbers widespread enough that government health officials issued alerts on 26 outbreaks.

The next-closest cruise line, Celebrity, reported one-third fewer breakouts during the same years.

Yet Princess, with 18 ships in the world's largest cruise company, Carnival Corp., consistently earned high marks on U.S. inspections that were supposed to protect 30 million people taking cruise vacations each year.

A USA TODAY investigation found the high-profile scoring of inspections administered by the Centers for Disease Control and Prevention masks how frequently ships are cited for health and sanitation violations.

The score most commonly awarded? A perfect 100.

Yet outbreaks kept occurring, even on ships with flawless inspections. USA TODAY found no instance in which a ship had failed its last inspection before a breakout of a stomach-related illness, the only type of outbreak routinely published by the CDC.

Princess ships consistently earned high ratings, including some of the best scores in the industry on disease reporting standards.

In 2017, inspectors noted multiple problems with medical records on the Coral Princess. A food service worker fell sick on the job and supposedly went into isolation, but his timecard indicated he was still working. In a separate violation, there was no documentation that the cabin mates of several sick crew members were interviewed to assess and contain the risk of possible spread.

The ship still earned a perfect inspection score. Then, on a voyage starting 10 days later, it reported a norovirus outbreak.

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Dr. Chris Taylor, a former cruise ship physician, researched five years of CDC inspections and found the scores had no value in informing the public about the risk of illness spreading on a ship.

“The proof of whether a ship has a high sanitary standard is the outcome,” Taylor said. “It is all about whether you have outbreaks.”

Cruise ship health safety failures came into glaring focus in recent weeks. The industry’s slow response to initial warnings facilitated the early global spread of the COVID-19 virus. Only after two high-profile outbreaks, and after major U.S. sporting tournaments and other events were canceled, did the industry at large decide to abandon ship for a month.

READ: CDC says because of coronavirus everyone should avoid cruise ships

Many of the health factors that fuel gastrointestinal illness outbreaks also are suspected of contributing to spread of the coronavirus, from unwashed hands to failing to separate the sick from the healthy.

During the second outbreak, people onboard the Grand Princess kept mingling even after public health authorities and ship leaders knew that passengers on the voyage immediately before had contracted the coronavirus, with some still on the ship who could have been exposed.

After being informed of the concern by loudspeaker announcement, passengers were still permitted to don formal attire for an evening meal featuring lobster tail. By morning, a letter had been pushed under their cabin doors explaining that only a few people needed to stay in their rooms, an initial isolation later expanded to all passengers.

“Zero steps were taken,” said Debi Chalik, an attorney whose parents, Ronald and Eva Weissberger of Florida, are now suing the cruise line for putting them at risk of infection.

Princess declined to answer detailed questions under deadline “due to the large volume of media inquiries we’ve received.”

The cruise line referred USA TODAY to a video posted last week when Princess Cruises announced a 60-day hiatus for its fleet. In it, President Jan Swartz noted the company’s global clientele of passengers and crew and its commitment to reporting every medical case onboard.

“We’ve been asked, and we’ve asked ourselves, why COVID-19 seems to be impacting Princess so heavily,” she said. “We don’t really know.”

Speaking in the White House Rose Garden the next day, President Donald Trump praised his administration’s response to the coronavirus outbreak on the Grand Princess. Vice President Mike Pence also pledged to work with the industry so when the pandemic passes, “cruise lines are safer than ever before.”

Contagious disease long a concern on cruise ships

In the past decade, outbreaks of stomach-related illnesses on cruise ships have sickened about 18,000 people, USA TODAY found.

In that time, more than 415 million passengers sailed on cruise ships, plus hundreds of thousands of crew, the Cruise Lines International Association said. It added that far more people get sick from norovirus each year on land.

Still, contagious disease has long been a concern on cruise ships that thrust thousands of people into close quarters for days or weeks at a time. The new coronavirus has raised similar questions in other crowded living environments, such as nursing homes, where early examples show the infection can rage rapidly, with deadly consequences.

The current system of cruise safety inspections is aimed at preventing stomach bugs rather than an influenza-like illness like the new coronavirus, which is suspected of spreading widely by air. But many of the preventive measures are the same, such as scrupulous hand cleaning and tracing the contacts of anyone sickened.

No agency regulates medical practices on cruise ships. Instead, the CDC sends inspectors twice a year to conduct sanitation inspections on ships sailing internationally with visits to U.S. ports. The comprehensive reviews can last eight to 10 hours.

Deficiencies cited based on those visits can attest to the broader health and safety culture on the ship, said Ross Klein, an academic in Newfoundland who tracks cruise ship outbreaks and has spent two decades researching and studying the industry.

“If their attentiveness is lower with known viruses, what can we expect about the viruses that are not known?” he said.

USA TODAY reviewed about 4,100 inspections conducted across the cruise industry through the so-called Vessel Sanitation Program since 2010, looking at both the scores behind the ship’s overall passing score and details of cited deficiencies.

Almost every ship inspected – 92% of them – has been flagged for problems with medical records maintained onboard, a standard intended to help control the spread of disease and track outbreaks when they do occur.

Sailing into a coronavirus outbreak

On a crisp Friday last month in San Francisco, Greg and Cathy Rafanelli of Seattle boarded the Grand Princess for their 21st Princess line cruise. They were handed a questionnaire to report any recent travel abroad to countries of concern or symptoms of the new coronavirus.

“We said, ‘no, no, no, no, no,’” Greg Rafanelli said, “and happily sailed away.”

Judy and Garth LaPar of Florida got the same form before the ship departed on Feb. 21. Later, they wondered why no one from the ship had interviewed them in person or checked their temperature, a more rigorous approach to coronavirus screening.

Three weeks before, another of the company’s ships, the Diamond Princess, had been the site of an early coronavirus outbreak that ultimately would infect about 700 passengers and crew.

Investigators now believe that outbreak started with a passenger and spread to the crew – who continued to work unless they had symptoms – especially food service workers working closely together and living in cabins on the same deck, the CDC said in a report released this week.

The Grand Princess was similarly vulnerable as it sailed away for 13 days, making four stops on islands in Hawaii. The Rafanellis recalled rough seas as the ship turned toward Ensenada, Mexico, with less experienced cruisers vomiting in public and crew scurrying to clean up.

By then, U.S. health authorities were aware of a problem not yet announced to passengers: Authorities in California were tracking several coronavirus cases involving passengers on the previous Grand Princess voyage – with exposure to some still onboard. They reported an elderly man’s death on Wednesday.

The captain shared the news over the loudspeaker that afternoon and canceled a reception that night for VIP cruisers. A planned music and dance show was instead piped into the rooms, where the Rafanellis watched it.

The formal dress dinner still carried on that night, though, featuring a “surf and turf” menu. The crew now wore gloves and served the food rather than allowing passengers to help themselves from the buffet.

Rafanelli, 73, recognized the protocol from a previous cruise with a norovirus outbreak. That night, he was not allowed to touch common utensils. “The gloved wait staff had to put on your salt and pepper,” he said.

In a ship cafe after dinner, Michelle Saunders, 23, sipped hot cocoa with her grandmother. She had been impressed throughout the cruise by how attentively the crew were wiping down handrails and elevator buttons.

Still, she wondered whether crowds should be mingling. “The thought crossed my mind,” she said.

A letter delivered overnight to passengers' rooms offered details. Princess Cruises’ chief medical officer, Grant Tarling, explained that the CDC was investigating a “small cluster” of coronavirus cases connected to the previous voyage. Out of an abundance of caution, he wrote, the CDC was requiring passengers who had sailed on both trips to stay in their rooms until medically cleared.

All were advised to practice proper hand washing and sneeze etiquette.

It was not until later Thursday that passengers received instructions to isolate themselves in their rooms. Before retreating, Cathy Rafanelli, 67, darted back to the buffet line, which was still open despite the new guidance, to stock up on cookies and fruit.

Gloved and masked crew deposited meals at cabin doors for the next week as authorities scrambled to arrange for the disembarkment and quarantine of the ship’s passengers. Clean linens arrived in bags. Rafanelli and her husband left their cabin only once for an organized deck walk, with protective masks provided.

They were pleased with the measures taken to protect their health, even after the captain informed passengers over the speaker system that coronavirus tests given to 45 of the 3,533 people onboard turned up 21 cases – two in passengers and 19 among the crew.

But in an interior cabin with no windows, the LaPars worried about air circulating between rooms and how sanitary it was to sleep on the same sheets night after night. On their lone trip out for fresh air, they saw passengers violating the recommendation to stay 6 feet apart.

“For six to seven days, our room wasn’t clean,” said Judy LaPar, 73.

Perfect inspections downplay problems

The Grand Princess had never failed a CDC inspection. Nor had any Princess ship on its last inspection before an outbreak.

Yet in 2012 alone, five outbreaks occurred on three Princess Cruises ships with recent flawless 100-point inspections: the Emerald Princess, the Crown Princess and the Ruby Princess.

The CDC’s outbreak reports offer limited insight beyond the numbers and pathogens involved.

An attorney in Australia has been collecting detailed accounts from passengers on the Sun Princess, which in 2017 experienced norovirus outbreaks on back-to-back cruises, one to Papua New Guinea, the other to New Zealand. Concerns include contamination in the buffet areas, public restrooms, swimming pools and casinos.

One passenger smelled vomit in a cabin upon arrival for the second trip, raising questions about how well cabins were sanitized, according to Vicky Antzoulatos, who is investigating for a potential lawsuit over the outbreaks that sickened 230 passengers in all.

“They basically didn’t take adequate steps,” she said.

Industry experts say cruise lines take their inspection scores very seriously. The CDC posts the ratings online, and findings of unsanitary conditions can be public relations nightmares.

Some caution, however, that the vessels prepare for the unannounced exams. They can anticipate at times when a ship visit is likely in the rotation from the timing of passenger disembarkation or boarding, for example, or if there is just one U.S. docking in an itinerary.

They add that cruise lines have little control over passengers who board knowing that they are sick.

“Once someone made their final payment, if they can go from toilet to toilet, they are going to go on their cruise ship,” said Andrew Coggins Jr., a professor in the business school at Pace University in New York who specializes in the cruise industry.

'Nothing happened' until sickness broke out

For weeks, the cruise industry gradually stepped up protocols around the new coronavirus threat, gradually restricting passengers who had traveled to certain international countries from boarding.

As of March 9, when the Grand Princess was finally able to dock in Oakland, California, cruise ships had begun rolling out temperature screenings before boarding.

As U.S. health officials started cautioning against cruise travel, the industry proposed requiring a doctor’s note for anyone over 70 and at higher risk of coronavirus complication. Finally, late last week, the major cruise lines all canceled voyages from U.S. ports for a month.

New Orleans attorney and maritime law expert Paul Sterbcow, who testified about cruise safety before Congress last fall, told USA TODAY the industry should have responded to the emerging public health threat far sooner.

“Nothing happened until people started getting sick on their boats,” he said. “And then the reaction is, ‘We’ll just stay out here and let them get sick.’ ”

Experts say any return to the high seas will require a complete review of infection control practices and should include not only stomach bugs but also respiratory illness like the new coronavirus.

“What the cruise ship industry has to do is really critically assess their infection prevention and control,” said Connie Steed, a frequent cruiser and president of the Association for Professionals in Infection Control and Epidemiology.

Meanwhile, knowledge – and questions – about the impact of the Princess line’s role in the pandemic’s early stages are still expanding: A Chicago teacher exposed on the earlier Grand Princess cruise tested positive, prompting one of the nation’s early school closures.

READ:Coronavirus closed this school.

Crew with potential exposure on that voyage also ended up on three other ships – the Caribbean Princess, Royal Princess and the Regal Princess – sailing out of Los Angeles and Port Everglades in Florida.

The CDC then asserted its rarely used authority to issue “no sail” orders until that crew tested negative. But soon after, three workers at a company that greets cruise passengers at Port Everglades tested positive.

The South Florida region is now the leading hot spot for infection in the state.

Letitia Stein is a reporter on the USA TODAY investigations team, focusing primarily on health and medicine. Contact her at lstein@usatoday.com, @LetitiaStein, by phone or Signal at 813-524-0673.

Contributing: Morgan Hines and David Oliver, USA TODAY