Interim Guidance for Cruise Ships during the 2009-10 Influenza Season
January 29, 2010 5:45 PM ET
This document provides interim guidance for crew members and passengers of cruise ships originating from or stopping in the United States during the 2009-10 influenza season. This guidance will be updated as needed. CDC recognizes that cruise ships travel worldwide, necessitating awareness of and responsiveness to local jurisdictional requirements. Cruise ship management and medical staff need to be flexible in identifying and caring for persons with influenza. The health-care provider’s assessment of a patient’s clinical presentation and underlying risk factors is always an essential part of decisions about the need for further medical evaluation or treatment.
Commercial maritime travel is characterized by the movement of large numbers of people in closed and semi-closed settings. As with other close contact environments, these settings can facilitate the transmission of influenza from person to person or through contact with contaminated environmental surfaces. The Centers for Disease Control and Prevention (CDC) recommends that persons with influenza-like illness (ILI) not travel. Efforts to reduce the spread of influenza on cruise ships should focus on early identification and isolation of ill crew members and passengers, good cough and hand hygiene etiquette, and environmental controls to encourage proper hygiene. This document provides guidance for the management of ILI during and after a voyage, including personal protective measures for the crew, and is meant to supplement CDC’s recent guidance for employers on ways to decrease the spread of seasonal and 2009 H1N1 influenza in the workplace. See CDC’s Guidance for Businesses and Employers to Plan and Respond to the 2009-10 Influenza season.
Symptoms of influenza can include some or all of these symptoms: fever, cough, sore throat, runny or stuffy nose, body aches, headache, chills, and sometimes diarrhea or vomiting. Not everyone with influenza will have a fever (a temperature of 100° F [37.8° C] or greater). Cruise ship medical personnel should consider someone to have a fever if the ill person feels warm to the touch, gives a history of feeling feverish, or has an actual measured temperature of 100° F (37.8° C) or greater. Because the symptoms of influenza are not specific and most persons who have a respiratory illness are not tested for influenza, an ILI has been defined as an illness with fever or feverishness plus either cough or sore throat.
Screening and Isolation
If a passenger has ILI at the time of embarkation, he or she should be advised against traveling until at least 24 hours after resolution of fever (100° F [37.8° C]) without the use of fever-reducing medications (e.g., aspirin, acetaminophen, ibuprofen).
Passengers with ILI who nonetheless decide to board, as well as passengers who develop ILI en route, should be medically evaluated (see next section) and remain isolated in their cabins or quarters until at least 24 hours after resolution of fever (100° F [37.8° C]) without the use of fever-reducing medications.
Crew members with ILI should take the following actions:
- Notify their supervisors.
- Report to the infirmary for medical evaluation, according to shipboard protocols.
- Remain isolated in their cabins or quarters until at least 24 hours after resolution of fever (100° F [37.8° C]) without the use of fever-reducing medications.
If a passenger or crew member with ILI is taken to a health-care facility off the ship, the facility should be informed before arrival.
While temporarily in common areas, passengers and crew members with ILI should be separated from other passengers and crew members by a distance of 6 feet or more, if possible, and should wear a facemask, if it can be tolerated.
Individuals with ILI should be advised of the importance of covering coughs and sneezes with a tissue or, in the absence of a tissue, their sleeves. Used tissues should be disposed of immediately in a disposable container (plastic bag) or a washable trash can.
Passengers and crew should also be reminded to wash their hands often with soap and water, especially after coughing or sneezing. If soap and water are not available, they can use an alcohol-based hand rub until soap and water become available.
Medical Evaluation and Management
Influenza Diagnostic Tests
Interim recommendations for the clinical use of diagnostic testing for influenza infection during the 2009-10 influenza season are available at.
Disposition of Cases upon Disembarkation
A cruise ship passenger or crew member with ILI who is symptomatic or who has had fever 24 hours prior to disembarking should be advised to wear a facemask when disembarking the ship.
Individuals with ILI should stay in home or hotel isolation in the city of disembarkation and refrain from further travel until at least 24 hours after they are free of fever (100° F [37.8° C]) without the use of fever-reducing medications.
Passengers and crew who may have been exposed to a person suspected of having influenza should monitor their health for 7 days after the exposure. Passengers and crew who are still onboard should report any of the following signs or symptoms to the shipboard infirmary immediately: fever, cough, sore throat, runny or stuffy nose, body aches, headache, chills, and sometimes diarrhea or vomiting.
Antiviral Treatment and Prophylaxis Use and Outbreak Control
Interim recommendations for the use of antiviral medications in the treatment and prevention of influenza for the 2009-10 season.
The following recommendations should be followed, when possible, by crew members whose work activities involve contact with passengers and other crew members who have ILI.
- Practice good hand hygiene. Wash hands often with soap and water. If soap and water are not available and hands are not visibly soiled, an alcohol-based hand rub can be used as an interim measure.
- Maintain a distance of 6 feet or more from the ill person while interviewing, escorting, or providing other assistance.
- Keep interactions with ill persons as brief as possible.
- Limit the number of persons who interact with ill persons. To the extent possible, the ill person should receive care and meals from a single person.
- Ask the ill person to follow good cough and sneeze etiquette and hand hygiene, and to wear a facemask, if it can be tolerated.
- If a facemask cannot be tolerated, provide tissues and ask the ill person to cover his or her mouth and nose when coughing or sneezing. Used tissues should be disposed of immediately in a disposable container (plastic bag) or a washable trash can.
Personal Protective Equipment
Ships should carry a sufficient quantity of personal protective equipment (PPE) such as facemasks, N95 respirators, and disposable gloves. Crew members and other staff who may have contact with persons with ILI should be instructed in the proper use, storage, and disposal of PPE. Improper handling of PPE can actually increase transmission risk.
Crew members should wear impermeable, disposable gloves if they need to have direct contact with ill persons or potentially contaminated surfaces, rooms, or lavatories used by ill passengers and crew members. Crew members should wash their hands with soap and water after gloves are removed. Gloves should be discarded in the trash and should not be rewashed or saved for reuse.
Crew members should avoid touching their faces with gloved or unwashed hands.
Facemasks and Respirators
Use of N95 respirators or facemasks is not generally recommended for cruise ship crew members for general work activities. CDC’s Interim Recommendations for Facemask and Respirator Use to Reduce Novel Influenza A (H1N1) Virus Transmission.
Cruise ship workers who cannot avoid close contact with persons with ILI may consider voluntarily wearing a facemask or N95 respirator. Employers who allow workers to wear an N95 respirator voluntarily should review the Occupational Safety and Health Administration (OSHA) requirements for Employer Voluntary Use of Respirators in the workplace.
Crew members who are providing health care to passengers or to other crew members, e.g., onboard nurses and physicians, should follow the CDC’s infection control guidelines for health-care personnel. These guidelines recommend the use of an N95 respirator when health-care personnel are in close contact (within 6 feet of the patient or entering a small enclosed airspace shared with the patient) with a person with suspected or confirmed 2009 H1N1 influenza.
Medications and Supplies
Ships should carry a sufficient quantity of supplies to meet day-to-day needs. Contingency plans are recommended for rapid resupply in outbreak situations. For antiviral treatment of 2009 H1N1 virus infection, either oseltamivir or zanamivir is recommended
Ships are encouraged to carry sterile viral transport media and sterile swabs to collect nasopharyngeal and nasal specimens. These optimal recommendations can be modified to reflect individual ship capabilities and characteristics.
Cleaning and Disinfection
Routine cleaning and disinfection strategies used during influenza seasons can be used for environmental management of 2009 H1N1 influenza. Commonly touched surfaces, such as handrails, countertops, and doorknobs, should be cleaned frequently with routine cleaning methods. Additional information on cleaning and disinfecting environmental surfaces can be accessed by using the links listed at the end of this document.
Based on the prevalence and level of severity of 2009 H1N1 flu-related illness thus far, CDC does not recommend that ships traveling to or within the United States report individual cases of suspected or confirmed 2009 H1N1 influenza.
The following situations should be immediately reported to the CDC Quarantine Station in the jurisdiction of the U.S. seaport where the ship is expected to arrive:
- Changes in the clinical profile and severity of illnesses reported or severe complications among at least two epidemiologically linked cases.
- Outbreaks among both passengers and crew members at the same time.
- A death caused by or suspected to be associated with influenza or ILI onboard the vessel.
Vessel captains may request assistance from CDC to evaluate or control infection, as needed. If the ship will not be arriving imminently at a U.S. seaport, CDC quarantine officials will assist cruise ship officials with the management and isolation of the suspect case and with recommendations for other passengers and crew members.
For cases requiring hospitalization, CDC quarantine officials will work with the cruise line and local and state health departments to assist with medical transportation of the patient upon arrival. In outbreak situations, CDC staff may also assist with disease control and containment measures, passenger and crew notification and surveillance activities, communicating with local public health authorities, and ship cleaning procedures.
For ships on international voyages, if an illness has occurred onboard the Maritime Declaration of Health should be completed and sent to the competent authority, according to the 2005 International Health Regulations (IHR) and the national legislation of the country of disembarkation. Before entering a seaport, cruise ships may also be required to report the previous itinerary.
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