Lessons from the Roosevelt: A Call for Improving the U. S. Navy’s Preparedness for Biological Threats
The evening sick call aboard USS Theodore Roosevelt unfolded on the night of March 23, 2020 in much the same way that it had for the past two weeks since the COVID-19 surveillance unit had arrived on board. In short, it had been largely uneventful. That changed when the night’s last batch of test results appeared on the laptop that the surveillance unit had brought with them. There, on the screen, were the unmistakable analytical curves of a positive COVID-19 result. It was just after 11:00 p.m. Recognizing the potential implications of a positive result and fearing a mistake had been made, the team lead for the surveillance unit insisted that the test be repeated, start to finish, a process that would take approximately two hours. As the results of the repeat test appeared on the laptop in the early morning hours of March 24, it was clear. There had not been a mistake. The novel coronavirus had snuck aboard USS Theodore Roosevelt as a microscopic stowaway. Although it wasn’t known at the time how many sailors were already infected, it was clear that keeping the outbreak contained on an aircraft carrier the size of a small city would be a challenge.
There are important lessons to be learned from the outbreak of COVID-19 aboard USS Theodore Roosevelt that should inform the U.S. Navy’s preparedness for and response to future biological threats. For weeks before the outbreak aboard USS Theodore Roosevelt, the world watched as the novel coronavirus spread around the globe. As individual countries struggled to contain the contagion, the World Health Organization, U.S. Centers for Disease Control and Prevention, and independent researchers issued a stream of dire projections. And, perhaps most relevant to the U.S. Navy, news outlets shared troubling reports of cruise ships left hobbled by the virus, with hundreds of infected passengers trapped onboard and the ships themselves unable to enter port. Fearing a worst-case scenario of its own shipboard outbreak, the Navy prudently deployed specialized disease surveillance units to a limited number of ships in the Pacific in the interest of detecting an outbreak early, should one occur. These units, rapidly assembled from available assets within the Navy’s own Bureau of Medicine and Surgery, were composed of active duty medical professionals and equipped with tools specifically calibrated to conduct surveillance for the COVID-19 virus.
One such unit landed aboard USS Theodore Roosevelt on March 11, two days after the ship’s port visit to Da Nang, Vietnam. It was this unit that detected the ship’s first cases of COVID-19, which set into motion a series of public health measures including flying infected sailors off of the ship for medical attention; tracing the contacts of the infected sailors and quarantining them; implementing additional disinfection procedures and social distancing efforts; and, ultimately, docking the ship in Guam so the crew could be disembarked and the ship could be disinfected. In the extraordinary circumstances of the global pandemic, it seemed that the Navy’s foresight in sending a specialized disease surveillance unit to USS Theodore Roosevelt paid off. The presence of this unit aboard the ship meant that the outbreak was detected days, if not weeks, earlier than it might have been otherwise. In contrast, the French Navy did not begin testing the crew of its nuclear-powered aircraft carrier Charles de Gaulle until almost a week after the first symptoms were reported, by which time 40 sailors had fallen sick. As a result, the carrier returned to port where testing revealed that almost two-thirds of the crew, 1,046 out of 1,760 sailors, had contracted COVID-19.
Military threats, however, are rarely communicated so clearly or so far in advance as that of COVID-19. The next biological threat to a U.S. Navy ship, be it a pandemic or an intentional biological attack, may not provide the kind of advanced warning needed to deploy the specialized disease surveillance units and capabilities necessary for early detection. This reality speaks to the need for enhanced biological detection capabilities that may be practically deployed across the fleet. It also raises the question of whether, and to what extent, technical experts in detection and surveillance need to be deployed.
To start, what the outbreak on USS Theodore Roosevelt makes clear is that such enhanced detection capabilities should include the ability to monitor crew health. The first sign of the outbreak aboard USS Theodore Roosevelt came when a sailor tested positive for COVID-19 after presenting to the ship’s sick call with symptoms on the evening of March 23, a full 14 days after the ship left Vietnam. In other words, the virus was spreading amongst the ship’s crew for two weeks before it was detected. Future capability development efforts should anticipate similar scenarios in which the first signs of a biological threat manifest as symptoms, not necessarily as alerts from environmental sensors. In the absence of a technical solution for enhanced health monitoring, or until such technology matures, strengthening epidemiology-based shipboard surveillance may provide a partial solution to the early discovery of a biological agent that is able to otherwise avoid detection. This may require increased manning for personnel with technical backgrounds in disease surveillance or specialized training of existing personnel. Either way, identifying and interpreting physiological changes among a ship’s crew may be the difference between success and failure in combating a future biological threat.
If the Navy’s response to a future threat rests partly on identifying physiological changes amongst a ship’s crew or enhanced epidemiologic surveillance, having the ability detect a biological agent without any prior knowledge of the agent itself is equally important. The disease surveillance unit that was deployed to USS Theodore Roosevelt was armed with a polymerase-chain reaction-based detection capability specifically designed to detect COVID-19. However, tailoring a detection capability to the moment was only possible because of the advanced warning that the emerging pandemic provided. Efforts to develop detection capabilities that do not require an a priori knowledge of the threat should continue. While advanced technologies (e.g., high throughput sequencing) have begun to close this capability gap, work remains in lowering barriers for end-users and delivering such capabilities to each of the military services. As in the case of conducting surveillance for physiological changes among a ship’s crew, until such detection capabilities are more broadly available and distributed, there may be a need to increase the number of deployed technical experts, armed with existing technologies, to mitigate any detection gaps that may currently exist.
While enhanced detection capabilities are needed, they are also not sufficient. The best detection capabilities are only as good as the ability to synthesize the data they generate into actionable information for commanders. The integration of data from sensors, biomedical samples, environmental samples, and epidemiological investigations will be necessary to ensure that commanders have the situational awareness necessary to respond effectively to any outbreak affecting their command. Detecting an outbreak, especially one involving a virus as stealthy as COVID-19, is akin to hunting a submarine in the depths of the ocean and requires the same types of data fusion and command and control capabilities to fully support decisions regarding force protection, contamination avoidance, and contamination mitigation and response.
If the outbreak aboard USS Theodore Roosevelt highlights the need for improved detection capabilities, it also demands that the Navy assess its plans and preparedness for responding to a biological threat at sea. As the publicly released report on the investigation into the outbreak aboard the ship makes clear, the contingency plans to cope with a shipboard outbreak of disease — from either a naturally circulating pathogen, as in the case of the COVID-19 virus, or from a biological attack — could be improved. Despite the success in detecting the outbreak, 25 percent of the crew was ultimately infected, one sailor died, and USS Theodore Roosevelt was forced out of operation for 10 weeks. Should the next shipboard outbreak involve a more deadly pathogen or a ship that needs to keep fighting through an outbreak of disease, the consequences of an inadequate or ill-executed contingency plan could be far worse.
With large numbers of sailors working in confined spaces, cohabitating in shared berthing, sharing meals in large dining facilities, and using communal toilets and showers, Navy ships are particularly vulnerable to the spread of disease. Fully manned warships conducting routine operations also generally lack the space to safely isolate infected sailors and quarantine large numbers of exposed ones. Thus, perhaps even more so than in the civilian world, the need to effectively respond to a biological threat at sea is crucial. These factors and USS Theodore Roosevelt’s own response to the novel coronavirus outbreak suggest that the Navy should improve upon its tactics, techniques, and procedures and increase its capabilities and resources for contending with a biological threat at sea. Are ships equipped with sufficient personal protective equipment or, alternatively, is personal protective equipment strategically stockpiled on-shore to allow for rapid deployment and resupply? Are isolation and quarantine procedures adequate? Are such procedures practiced onboard ships to the extent that they should be? To what extent should future response plans include contingencies for disembarking a large fraction of the crew, as was conducted in the case of USS Theodore Roosevelt? Are tactics, techniques, and procedures for safely evacuating sick or infected personnel sufficiently detailed? Are materiel solutions for such evacuations, like the U.S. Coast Guard-developed Portable Isolation Unit or U.S. Transportation Command’s Transport Isolation System capability, necessary and/or sufficient? Off ship, do medical treatment facilities have the capacity to diagnose and safely isolate and treat patients with highly infectious diseases? These questions and others should comprise an intensive review of the Navy’s biodefense posture with respect its ability to combat the next biological threat.
Minimizing the fleet’s vulnerabilities to biological threats of the future will mean learning from the COVID-19 outbreak aboard USS Theodore Roosevelt. Preparing for the future means acting now to enhance the Navy’s shipboard capabilities. The Navy may not be lucky enough next time to receive a warning far enough in advance of an impending threat to deploy assets that are not already organic to a ship. At the same time, any advantage gained from identifying an outbreak of disease aboard a ship is lost if the plans to contain and manage an outbreak are not fully developed or actionable. A comprehensive review of the Navy’s response procedures is an important step towards ensuring that it is prepared to mitigate future biological threats when they do appear.
Lt. Cmdr. Brian L. Pike is currently stationed at the Naval Medical Research Center in Silver Spring, Maryland and detailed to the Office of the Deputy Assistant Secretary of Defense for Chemical and Biological Defense. He also led the Navy unit that detected the first cases of COVID-19 onboard the USS Theodore Roosevelt.
Dr. Gregory D. Koblentz is an associate professor and director of the Biodefense Graduate Program at the Schar School of Policy and Government at George Mason University. He is also a member of the Scientists Working Group on Chemical and Biological Security at the Center for Arms Control and Non-Proliferation.
Disclaimer: Lt. Cmdr. Pike is an active duty member of the United States Navy. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the U.S. Government. Furthermore, this work was prepared as part of Lt. Cmdr. Pike’s official duties. Title 17, U.S.C., §105 provides that copyright protection under this title is not available for any work of the U.S. Government. Title 17, U.S.C., §101 defines a U.S. Government work as a work prepared by a military Service member or employee of the U.S. Government as part of that person’s official duties.