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Article ; Online: Use of Point-of-Care Handheld Ultrasound for Splenomegaly in United States-Bound Refugees: A Novel Technology with Far-Reaching Implications.

Kummer, Tim / Medley, Alexandra M / Klosovsky, Alexander / Mann, Erin / Mburu, Patricia / Ekernas, Karen / Bonass, Betty / Stauffer, Jacob C / Walukaga, Stewart / Weinberg, Michelle / Dunlop, Stephen J / Stauffer, William M

The American journal of tropical medicine and hygiene

2022 Volume 108, Issue 1, Page(s) 12–14

Abstract: Ultrasound (US) is an invaluable clinical tool. New point-of-care US technology holds great promise for hard-to-reach and mobile populations such as refugees. The implementation of US in unique and challenging settings has been hindered by cost, ... ...

Abstract	Ultrasound (US) is an invaluable clinical tool. New point-of-care US technology holds great promise for hard-to-reach and mobile populations such as refugees. The implementation of US in unique and challenging settings has been hindered by cost, fragility of equipment, need for uninterrupted electricity, training, and difficulty in sharing data/image files impeding quality assurance. The recent development of more flexible, durable, high-quality, low-cost, handheld US technology has offered increased potential to address many of these barriers. We describe a pilot program using a new point-of-care US technology to identify and monitor splenomegaly in United States-bound Congolese refugees. This experience and model may hold lessons for planning and development of similar approaches in other hard-to-reach mobile populations.
MeSH term(s)	Humans ; United States ; Refugees ; Splenomegaly/diagnostic imaging ; Point-of-Care Systems
Language	English
Publishing date	2022-11-30
Publishing country	United States
Document type	Journal Article
ZDB-ID	2942-7
ISSN	1476-1645 ; 0002-9637
ISSN (online)	1476-1645
ISSN	0002-9637
DOI	10.4269/ajtmh.22-0423
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Article ; Online: Quantifying the risk of rabies in biting dogs in Haiti.

Ma, Xiaoyue / Blanton, Jesse D / Millien, Max Francois / Medley, Alexandra M / Etheart, Melissa D / Fénelon, Natael / Wallace, Ryan M

Scientific reports

2020 Volume 10, Issue 1, Page(s) 1062

Abstract: Rabies is a fatal viral disease typically transmitted through the bite of rabid animal. Domestic dogs cause over 99% of human rabies deaths. Over half of the world's population lives in a country where the canine rabies virus variant is endemic and dog ... ...

Abstract	Rabies is a fatal viral disease typically transmitted through the bite of rabid animal. Domestic dogs cause over 99% of human rabies deaths. Over half of the world's population lives in a country where the canine rabies virus variant is endemic and dog bites are common. An estimated 29 million people worldwide receive post-bite vaccination after being exposed to animals suspected of rabies. Accurate and timely risk assessment of rabies in biting dogs is critical to ensure that rabies PEP is administered to all persons with a suspected rabies exposure, while avoiding PEP administration in situations where rabies can be definitively ruled out. In this study, a logistic regression model was developed to quantify the risk of rabies in biting dogs, using data from Haiti's animal rabies surveillance program. Significant risk factors identified in the model were used to quantify the probability of rabies in biting dogs. The risk of rabies in a biting dog as assessed through Haiti's rabies surveillance program was highly elevated when the dog displayed hypersalivation (OR = 34.6, 95% CI 11.3-106.5) or paralysis (OR = 19.0, 95% CI 4.8-74.8) and when the dog was dead at the time of the assessment (OR = 20.7, 95% CI 6.7-63.7). Lack of prior rabies vaccination, biting 2 or more people, and if the dog was a puppy also increased the probability that a biting dog would have rabies. The model showed high sensitivity (100%) and specificity (97%) when examined using validation data. This model enables us to project the risk of rabies in biting dogs in Haiti shortly after the bite event and make provisional PEP recommendations prior to laboratory testing or dog quarantine results. Application of this model may improve adherence to PEP for bite victims who can be educated on the quantitative risk of the exposure event. This model can also be used to reduce unnecessary PEP costs when the risk of rabies is determined as sufficiently low and the animal is available for observation.
MeSH term(s)	Animals ; Bites and Stings/epidemiology ; Bites and Stings/virology ; Dog Diseases/epidemiology ; Dog Diseases/physiopathology ; Dog Diseases/virology ; Dogs ; Female ; Haiti/epidemiology ; Humans ; Male ; Rabies/epidemiology ; Rabies/transmission ; Rabies/veterinary ; Rabies/virology ; Rabies virus/physiology ; Risk Factors
Language	English
Publishing date	2020-01-23
Publishing country	England
Document type	Journal Article
ZDB-ID	2615211-3
ISSN	2045-2322 ; 2045-2322
ISSN (online)	2045-2322
ISSN	2045-2322
DOI	10.1038/s41598-020-57908-9
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Article ; Online: COVID-19 on the Nile: a cross-sectional investigation of COVID-19 among Nile River cruise travellers returning to the United States, February-March 2020.

Guagliardo, Sarah Anne J / Quilter, Laura A S / Uehara, Anna / White, Stefanie B / Talarico, Sarah / Tong, Suxiang / Paden, Clinton R / Zhang, Jing / Li, Yan / Pray, Ian / Novak, Ryan T / Fukunaga, Rena / Rodriguez, Andrea / Medley, Alexandra M / Wagner, Riley / Weinberg, Michelle / Brown, Clive M / Friedman, Cindy R

Journal of travel medicine

2022 Volume 30, Issue 4

Abstract: Background: Early in the pandemic, cruise travel exacerbated the global spread of SARS-CoV-2. We report epidemiologic and molecular findings from an investigation of a cluster of travellers with confirmed COVID-19 returning to the USA from Nile River ... ...

Abstract	Background: Early in the pandemic, cruise travel exacerbated the global spread of SARS-CoV-2. We report epidemiologic and molecular findings from an investigation of a cluster of travellers with confirmed COVID-19 returning to the USA from Nile River cruises in Egypt. Methods: State health departments reported data on real-time reverse transcription-polymerase chain reaction-confirmed COVID-19 cases with a history of Nile River cruise travel during February-March 2020 to the Centers for Disease Control and Prevention (CDC). Demographic and epidemiologic data were collected through routine surveillance channels. Sequences were obtained either from state health departments or from the Global Initiative on Sharing Avian Flu Data (GISAID). We conducted descriptive analyses of epidemiologic data and explored phylogenetic relationships between sequences. Results: We identified 149 Nile River cruise travellers with confirmed COVID-19 who returned to 67 different US counties in 27 states: among those with complete data, 4.7% (6/128) died and 28.1% (38/135) were hospitalized. These individuals travelled on 20 different Nile River cruise voyages (12 unique vessels). Fifteen community transmission events were identified in four states, with 73.3% (11/15) of these occurring in Wisconsin (as the result of a more detailed contact investigation in that state). Phylogenetic analyses supported the hypothesis that travellers were most likely infected in Egypt, with most sequences in Nextstrain clade 20A 93% (87/94). We observed genetic clustering by Nile River cruise voyage and vessel. Conclusions: Nile River cruise travellers with COVID-19 introduced SARS-CoV-2 over a very large geographic range, facilitating transmission across the USA early in the pandemic. Travellers who participate in cruises, even on small river vessels as investigated in this study, are at increased risk of SARS-CoV-2 exposure. Therefore, history of river cruise travel should be considered in contact tracing and outbreak investigations.
MeSH term(s)	Humans ; United States/epidemiology ; COVID-19/epidemiology ; SARS-CoV-2/genetics ; Phylogeny ; Cross-Sectional Studies ; Rivers
Language	English
Publishing date	2022-12-28
Publishing country	England
Document type	Journal Article
ZDB-ID	1212504-0
ISSN	1708-8305 ; 1195-1982
ISSN (online)	1708-8305
ISSN	1195-1982
DOI	10.1093/jtm/taac153
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Article ; Online: Retrospective Cohort Study to Assess the Risk of Rabies in Biting Dogs, 2013⁻2015, Republic of Haiti.

Medley, Alexandra M / Millien, Max Francois / Blanton, Jesse D / Ma, Xiaoyue / Augustin, Pierre / Crowdis, Kelly / Wallace, Ryan M

Tropical medicine and infectious disease

2017 Volume 2, Issue 2

Abstract: Background: In canine rabies endemic countries the World Health Organization recommends post-exposure prophylaxis (PEP) be initiated immediately after exposure to an animal suspected to have rabies. Limited capacity in low and middle income countries to ...

Abstract	Background: In canine rabies endemic countries the World Health Organization recommends post-exposure prophylaxis (PEP) be initiated immediately after exposure to an animal suspected to have rabies. Limited capacity in low and middle income countries to assess biting animals for rabies may result in the over prescription of rabies biologics. Few guidelines exist to determine the risk of whether a dog that has bitten someone is rabid. Given PEP cost and access limitations in many countries, accurate and timely assessment of dogs that have bitten people may reduce unwarranted PEP use and improve healthcare seeking behaviors. Methods: Haiti's animal rabies surveillance program utilizes veterinary professionals to conduct rabies assessments on reported biting dogs and records characteristics of the dog, health outcomes, and laboratory results in a national database. Characteristics of rabid dogs were assessed through a retrospective cohort study of biting dogs investigated during the period from January 2013⁻December 2015. 1409 biting dogs were analyzed; 1361 dogs that were determined to not have rabies were compared to 48 laboratory-confirmed rabid dogs. Rate ratios, sensitivity, specificity, positive predictive values, negative predictive values, likelihood ratios, quarantine survival of biting dogs, and a risk matrix were developed. Findings: The assessor's determination that the animal likely had rabies was the most significant predictive factor for a rabid dog (RR = 413.4, 95% CI 57.33⁻2985, Sn = 79.17, Sp = 91.92). Clinical factors significantly associated with rabid dogs included hypersalivation, paralysis, and lethargy (RR = 31.2, 19.7, 15.4, respectively). Rabid dogs were 23.2 times more likely to be found dead at the time of the investigation compared to case negative dogs (95% CI 14.0⁻38.6). Rabid dogs were also significantly more likely to lack a history of rabies vaccination or be unowned (RR = 10.3 95% CI 2.5⁻42.3 and RR = 4.5 95% CI 2.0⁻10.1, respectively). Rabid dogs were four times more likely to have bitten multiple people (RR = 4.0 95% CI 1.9⁻8.3). Most rabid dogs died or were killed before quarantine (75%) and all died by day 3 of quarantine, compared to <1% of quarantined case-negatives. The greatest risk of death was predicted to be for persons bitten on the head or neck from symptomatic dogs. Bites from dogs deemed healthy by veterinary assessors and which were available for quarantine presented less than a 0.05% risk of rabies death to the victim. Conclusions: Vaccination of all persons exposed to a suspected rabid dog is a highly effective approach to minimize human rabies deaths. However, this may place undue financial burden on bite victims that have had a low-risk exposure and over-prescription may contribute to regional supply shortages. The results here indicate that in a low-resource country such as Haiti, a well-trained veterinary assessor can provide an accurate risk assessment of biting dogs based on a standard case investigation protocol. In canine rabies endemic countries with limited access to PEP, or where PEP costs may cause undue burden on bite victims, structured risk assessments by trained professionals may be a reliable method of triaging PEP for bite victims. Evaluating rabies risk through a matrix of bite location and risk factor in the dog presents a clear delineation of high and low risk encounters and should be used to develop data-derived PEP recommendations.
Language	English
Publishing date	2017-06-12
Publishing country	Switzerland
Document type	Journal Article
ISSN	2414-6366
ISSN (online)	2414-6366
DOI	10.3390/tropicalmed2020014
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Article ; Online: Use of US Public Health Travel Restrictions during COVID-19 Outbreak on Diamond Princess Ship, Japan, February-April 2020.

Emerging infectious diseases

2021 Volume 27, Issue 3, Page(s) 710–718

Abstract: Public health travel restrictions (PHTR) are crucial measures during communicable disease outbreaks to prevent transmission during commercial airline travel and mitigate cross-border importation and spread. We evaluated PHTR implementation for US ... ...

Abstract	Public health travel restrictions (PHTR) are crucial measures during communicable disease outbreaks to prevent transmission during commercial airline travel and mitigate cross-border importation and spread. We evaluated PHTR implementation for US citizens on the Diamond Princess during its coronavirus disease (COVID-19) outbreak in Japan in February 2020 to explore how PHTR reduced importation of COVID-19 to the United States during the early phase of disease containment. Using PHTR required substantial collaboration among the US Centers for Disease Control and Prevention, other US government agencies, the cruise line, and public health authorities in Japan. Original US PHTR removal criteria were modified to reflect international testing protocols and enable removal of PHTR for persons who recovered from illness. The impact of PHTR on epidemic trajectory depends on the risk for transmission during travel and geographic spread of disease. Lessons learned from the Diamond Princess outbreak provide critical information for future PHTR use.
MeSH term(s)	Adolescent ; Adult ; Aged ; Aged, 80 and over ; COVID-19/transmission ; Child ; Child, Preschool ; Communicable Diseases, Imported/prevention & control ; Disease Outbreaks/prevention & control ; Female ; Government ; Humans ; Male ; Middle Aged ; Quarantine ; Risk Factors ; Ships ; Travel ; United States/epidemiology ; Young Adult
Language	English
Publishing date	2021-01-29
Publishing country	United States
Document type	Journal Article ; Research Support, Non-U.S. Gov't ; Review
ZDB-ID	1380686-5
ISSN	1080-6059 ; 1080-6040
ISSN (online)	1080-6059
ISSN	1080-6040
DOI	10.3201/eid2703.203820
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Article: Low SARS-CoV-2 Seroprevalence and No Active Infections among Dogs and Cats in Animal Shelters with Laboratory-Confirmed COVID-19 Human Cases among Employees

Cossaboom, Caitlin M. / Medley, Alexandra M. / Spengler, Jessica R. / Kukielka, Esther A. / Goryoka, Grace W. / Baird, Tiffany / Bhavsar, Swity / Campbell, Stefanie / Campbell, Thomas S. / Christensen, Daniel / Condrey, Jillian A. / Dawson, Patrick / Doty, Jeffrey B. / Feldpausch, Amanda / Gabel, Julie / Jones, Dee / Lim, Ailam / Loiacono, Christina M. / Jenkins-Moore, Melinda /

Moore, Andrea / Noureddine, Clarissa / Ortega, Jorge / Poulsen, Keith / Rooney, Jane A. / Rossow, John / Sheppard, Karen / Sweet, Emma / Stoddard, Robyn / Tell, Rachel M. / Wallace, Ryan M. / Williams, Carl / Barton Behravesh, Casey

Biology. 2021 Sept. 11, v. 10, no. 9

2021

Abstract: Human-to-animal and animal-to-animal transmission of SARS-CoV-2 has been documented; however, investigations into SARS-CoV-2 transmission in congregate animal settings are lacking. We investigated four animal shelters in the United States that had ... ...

Abstract	Human-to-animal and animal-to-animal transmission of SARS-CoV-2 has been documented; however, investigations into SARS-CoV-2 transmission in congregate animal settings are lacking. We investigated four animal shelters in the United States that had identified animals with exposure to shelter employees with laboratory-confirmed COVID-19. Of the 96 cats and dogs with specimens collected, only one dog had detectable SARS-CoV-2 neutralizing antibodies; no animal specimens had detectable viral RNA. These data indicate a low probability of human-to-animal transmission events in cats and dogs in shelter settings with early implementation of infection prevention interventions.
Keywords	COVID-19 infection ; RNA ; Severe acute respiratory syndrome coronavirus 2 ; dogs ; humans ; probability ; seroprevalence
Language	English
Dates of publication	2021-0911
Publishing place	Multidisciplinary Digital Publishing Institute
Document type	Article
ZDB-ID	2661517-4
ISSN	2079-7737
ISSN	2079-7737
DOI	10.3390/biology10090898
Database	NAL-Catalogue (AGRICOLA)

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Article ; Online: Case Definitions Used During the First 6 Months of the 10th Ebola Virus Disease Outbreak in the Democratic Republic of the Congo - Four Neighboring Countries, August 2018-February 2019.

Medley, Alexandra M / Mavila, Oscar / Makumbi, Issa / Nizeyemana, Felicien / Umutoni, Angela / Balisanga, Hélène / Manoah, Yona Kenyi / Geissler, Aimee / Bunga, Sudhir / MacDonald, Gene / Homsy, Jaco / Ojwang, Joseph / Ewetola, Raimi / Raghunathan, Pratima L / MacGurn, Amanda / Singler, Kimberly / Ward, Sarah / Roohi, Shahrokh / Brown, Vance /

Shoemaker, Trevor / Lako, Richard / Kabeja, Adeline / Muruta, Allan / Lubula, Leopold / Merrill, Rebecca

MMWR. Morbidity and mortality weekly report

2020 Volume 69, Issue 1, Page(s) 14–19

Abstract: On August 1, 2018, the Democratic Republic of the Congo (DRC) declared its 10th Ebola virus disease (Ebola) outbreak in an area with a high volume of cross-border population movement to and from neighboring countries. The World Health Organization (WHO) ... ...

Abstract	On August 1, 2018, the Democratic Republic of the Congo (DRC) declared its 10th Ebola virus disease (Ebola) outbreak in an area with a high volume of cross-border population movement to and from neighboring countries. The World Health Organization (WHO) designated Rwanda, South Sudan, and Uganda as the highest priority countries for Ebola preparedness because of the high risk for cross-border spread from DRC (1). Countries might base their disease case definitions on global standards; however, historical context and perceived risk often affect why countries modify and adapt definitions over time, moving toward or away from regional harmonization. Discordance in case definitions among countries might reduce the effectiveness of cross-border initiatives during outbreaks with high risk for regional spread. CDC worked with the ministries of health (MOHs) in DRC, Rwanda, South Sudan, and Uganda to collect MOH-approved Ebola case definitions used during the first 6 months of the outbreak to assess concordance (i.e., commonality in category case definitions) among countries. Changes in MOH-approved Ebola case definitions were analyzed, referencing the WHO standard case definition, and concordance among the four countries for Ebola case categories (i.e., community alert, suspected, probable, confirmed, and case contact) was assessed at three dates (2). The number of country-level revisions ranged from two to four, with all countries revising Ebola definitions by February 2019 after a December 2018 peak in incidence in DRC. Case definition complexity increased over time; all countries included more criteria per category than the WHO standard definition did, except for the "case contact" and "confirmed" categories. Low case definition concordance and lack of awareness of regional differences by national-level health officials could reduce effectiveness of cross-border communication and collaboration. Working toward regional harmonization or considering systematic approaches to addressing country-level differences might increase efficiency in cross-border information sharing.
MeSH term(s)	Democratic Republic of the Congo/epidemiology ; Disease Outbreaks ; Hemorrhagic Fever, Ebola/diagnosis ; Hemorrhagic Fever, Ebola/epidemiology ; Humans ; Public Health Surveillance/methods ; Rwanda/epidemiology ; South Sudan/epidemiology ; Time Factors ; Uganda/epidemiology
Language	English
Publishing date	2020-01-10
Publishing country	United States
Document type	Journal Article
ZDB-ID	412775-4
ISSN	1545-861X ; 0149-2195
ISSN (online)	1545-861X
ISSN	0149-2195
DOI	10.15585/mmwr.mm6901a4
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Article: Low SARS-CoV-2 Seroprevalence and No Active Infections among Dogs and Cats in Animal Shelters with Laboratory-Confirmed COVID-19 Human Cases among Employees.

Cossaboom, Caitlin M / Medley, Alexandra M / Spengler, Jessica R / Kukielka, Esther A / Goryoka, Grace W / Baird, Tiffany / Bhavsar, Swity / Campbell, Stefanie / Campbell, Thomas S / Christensen, Daniel / Condrey, Jillian A / Dawson, Patrick / Doty, Jeffrey B / Feldpausch, Amanda / Gabel, Julie / Jones, Dee / Lim, Ailam / Loiacono, Christina M / Jenkins-Moore, Melinda /

Moore, Andrea / Noureddine, Clarissa / Ortega, Jorge / Poulsen, Keith / Rooney, Jane A / Rossow, John / Sheppard, Karen / Sweet, Emma / Stoddard, Robyn / Tell, Rachel M / Wallace, Ryan M / Williams, Carl / Barton Behravesh, Casey

Biology

2021 Volume 10, Issue 9

Abstract	Human-to-animal and animal-to-animal transmission of SARS-CoV-2 has been documented; however, investigations into SARS-CoV-2 transmission in congregate animal settings are lacking. We investigated four animal shelters in the United States that had identified animals with exposure to shelter employees with laboratory-confirmed COVID-19. Of the 96 cats and dogs with specimens collected, only one dog had detectable SARS-CoV-2 neutralizing antibodies; no animal specimens had detectable viral RNA. These data indicate a low probability of human-to-animal transmission events in cats and dogs in shelter settings with early implementation of infection prevention interventions.
Language	English
Publishing date	2021-09-11
Publishing country	Switzerland
Document type	Journal Article
ZDB-ID	2661517-4
ISSN	2079-7737
ISSN	2079-7737
DOI	10.3390/biology10090898
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Article ; Online: Coronavirus Disease 2019 (COVID-19) in Americans Aboard the Diamond Princess Cruise Ship.

Plucinski, Mateusz M / Wallace, Megan / Uehara, Anna / Kurbatova, Ekaterina V / Tobolowsky, Farrell A / Schneider, Zachary D / Ishizumi, Atsuyoshi / Bozio, Catherine H / Kobayashi, Miwako / Toda, Mitsuru / Stewart, Andrea / Wagner, Riley L / Moriarty, Leah F / Murray, Rachel / Queen, Krista / Tao, Ying / Paden, Clinton / Mauldin, Matthew R / Zhang, Jing /

Li, Yan / Elkins, Christopher A / Lu, Xiaoyan / Herzig, Carolyn T A / Novak, Ryan / Bower, William / Medley, Alexandra M / Acosta, Anna M / Knust, Barbara / Cantey, Paul T / Pesik, Nicki T / Halsey, Eric S / Cetron, Martin S / Tong, Suxiang / Marston, Barbara J / Friedman, Cindy R

Clinical infectious diseases : an official publication of the Infectious Diseases Society of America

2020 Volume 72, Issue 10, Page(s) e448–e457

Abstract: Background: The Diamond Princess cruise ship was the site of a large outbreak of coronavirus disease 2019 (COVID-19). Of 437 Americans and their travel companions on the ship, 114 (26%) tested positive for severe acute respiratory syndrome coronavirus 2 ...

Abstract	Background: The Diamond Princess cruise ship was the site of a large outbreak of coronavirus disease 2019 (COVID-19). Of 437 Americans and their travel companions on the ship, 114 (26%) tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Methods: We interviewed 229 American passengers and crew after disembarkation following a ship-based quarantine to identify risk factors for infection and characterize transmission onboard the ship. Results: The attack rate for passengers in single-person cabins or without infected cabinmates was 18% (58/329), compared with 63% (27/43) for those sharing a cabin with an asymptomatic infected cabinmate, and 81% (25/31) for those with a symptomatic infected cabinmate. Whole genome sequences from specimens from passengers who shared cabins clustered together. Of 66 SARS-CoV-2-positive American travelers with complete symptom information, 14 (21%) were asymptomatic while on the ship. Among SARS-CoV-2-positive Americans, 10 (9%) required intensive care, of whom 7 were ≥70 years. Conclusions: Our findings highlight the high risk of SARS-CoV-2 transmission on cruise ships. High rates of SARS-CoV-2 positivity in cabinmates of individuals with asymptomatic infections suggest that triage by symptom status in shared quarters is insufficient to halt transmission. A high rate of intensive care unit admission among older individuals complicates the prospect of future cruise travel during the pandemic, given typical cruise passenger demographics. The magnitude and severe outcomes of this outbreak were major factors contributing to the Centers for Disease Control and Prevention's decision to halt cruise ship travel in US waters in March 2020.
MeSH term(s)	COVID-19 ; Diamond ; Disease Outbreaks ; Humans ; Quarantine ; SARS-CoV-2 ; Ships ; Travel ; United States/epidemiology
Chemical Substances	Diamond (7782-40-3)
Keywords	covid19
Language	English
Publishing date	2020-08-07
Publishing country	United States
Document type	Journal Article
ZDB-ID	1099781-7
ISSN	1537-6591 ; 1058-4838
ISSN (online)	1537-6591
ISSN	1058-4838
DOI	10.1093/cid/ciaa1180
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Article: COVID-19 in Americans aboard the Diamond Princess cruise ship

Clin. infect. dis

Abstract: BACKGROUND: The Diamond Princess cruise ship was the site of a large outbreak of coronavirus disease 2019 (COVID-19). Of 437 Americans and their travel companions on the ship, 114 (26%) tested positive for severe acute respiratory syndrome coronavirus 2 ( ...

Abstract	BACKGROUND: The Diamond Princess cruise ship was the site of a large outbreak of coronavirus disease 2019 (COVID-19). Of 437 Americans and their travel companions on the ship, 114 (26%) tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). METHODS: We interviewed 229 American passengers and crew after disembarkation following a ship-based quarantine to identify risk factors for infection and characterize transmission onboard the ship. RESULTS: The attack rate for passengers in single-person cabins or without infected cabinmates was 18% (58/329), compared with 63% (27/43) for those sharing a cabin with an asymptomatic infected cabinmate, and 81% (25/31) for those with a symptomatic infected cabinmate. Whole genome sequences from specimens from passengers who shared cabins clustered together. Of 66 SARS-CoV-2-positive American travelers with complete symptom information, 14 (21%) were asymptomatic while on the ship. Among SARS-CoV-2-positive Americans, 10 (9%) required intensive care, of whom 7 were ≥70 years. CONCLUSION: Our findings highlight the high risk of SARS-CoV-2 transmission on cruise ships. High rates of SARS-CoV-2 positivity in cabinmates of individuals with asymptomatic infections suggest that triage by symptom status in shared quarters is insufficient to halt transmission. A high rate of intensive care unit admission among older individuals complicates the prospect of future cruise travel during the pandemic, given typical cruise passenger demographics. The magnitude and severe outcomes of this outbreak were major factors contributing to the Centers for Disease Control and Prevention's decision to halt cruise ship travel in U.S. waters in March 2020.
Keywords	covid19
Publisher	WHO
Document type	Article
Note	WHO #Covidence: #714056
Database	COVID19

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