Interim Guidance for Mitigation of COVID-19 Among Cruise Ship Crew During the Period of the No Sail Order

Summary of Recent Changes

June 1, 2020 Update

Added requirements for use of commercial travel to disembark crew members and clarified routine testing for SARS-CoV-2 infection.


April 28, 2020 Update

Clarified the stipulations for disembarking asymptomatic crew for transfer or repatriation.


April 21, 2020 Update

Clarified that notification to health departments for disembarking crews must include health departments with jurisdiction for the seaport and those with jurisdiction for the crew members’ residence.

Purpose

This document provides guidance for cruise ship operations in any international, interstate, or intrastate waterways subject to the jurisdiction of the United States to help prevent, detect, and medically manage confirmed and suspected COVID-19 infections, as well as exposures among crew members during periods of suspended cruise ship operations.

As a condition of obtaining controlled free pratique to continue to engage in any cruise ship operations, the CDC Director’s No Sail Orderexternal icon, published in the Federal Register on April 15, 2020, requires that cruise ship operators, among other things, develop plans to prevent, mitigate, and respond to the spread of COVID-19 on board cruise ships. This interim guidance is not intended as, and does not constitute, a comprehensive statement regarding a cruise ship operator’s duties and obligations under that order. Cruise ship operators should establish mechanisms to ensure compliance with the NSO, including any plans adopted pursuant to the order, and immediately notify CDC and United States Coast Guard (USCG) of any deviations, whether intentional, or as a result of error or omission.

This interim guidance reflects CDC’s reasoned judgement based on the best available current science regarding the subject areas discussed herein. Cruise ship operators should carefully consider and incorporate this interim guidance in developing their own prevention, mitigation, and response plans.

CDC will update this interim guidance to cruise ships as needed and as additional information becomes available. CDC will notify cruise lines when this website is updated.

Preventive Measures

Cruise ships involve the movement of large numbers of people in settings where they are likely to have close contact with one another. Close-contact environments facilitate transmission of respiratory viruses from person to person through exposure to respiratory droplets or contact with contaminated surfaces. Cruise ships may also be a means by which infected persons travel between geographic locations.

To reduce spread of SARS-CoV-2, the virus that causes COVID-19, on board during the period of suspended cruise ship operations, CDC recommends that cruise ship operators:

  • Relocate all crew to single-occupancy cabins with private bathrooms
  • Instruct crew members to remain in cabins as much as possible during non-working hours
  • Cancel all face-to-face employee meetings, group events (such as employee trainings), or social gatherings
  • Close all crew bars, gyms, or other group settings
  • Implement social distancing of crew members when working or moving through the ship (maintaining at least 6 feet [2 meters] from others)
  • Instruct crew members to wear a cloth face covering when outside of individual cabins
  • Modify meal service to facilitate social distancing (e.g., reconfigure dining room seating, stagger mealtimes, encourage in-cabin dining)
  • Eliminate self-serve dining options at all crew and officer messes
  • Discourage handshaking – encourage the use of non-contact methods of greeting
  • Promote respiratory and hand hygiene and cough etiquette
  • Place hand sanitizer (containing at least 60% alcohol) in multiple locations and in sufficient quantities to encourage hand hygiene
  • Ensure handwashing facilities are well-stocked with soap and paper towels
  • Place posters that encourage hand hygiene to help stop the spread in high-trafficked areas

Some exceptions to these measures can be made for those ships that have met the “Green” or “Yellow” criteria.

Surveillance for COVID-19

  • As an interim replacement to the Maritime Conveyance Cumulative Influenza/Influenza-Like Illness (ILI) Form for each international voyage, CDC requires weekly submission of the “Enhanced Data Collection (EDC) During COVID-19 Pandemic Form” during suspended cruise ship operations. This EDC Form will be used to conduct surveillance for COVID-19 among crew who remain on board cruise ships using cumulative reports of acute respiratory illness (ARI), influenza-like illness (ILI), and pneumonia, and other clinical indicators.
  • Access to the online EDC form will be provided to cruise lines by the Cruise Lines International Association (CLIA) or CDC. Cruise lines that do not receive CLIA’s email should contact CDC (email eocevent349@cdc.gov).
  • In addition to this weekly surveillance via the online EDC form, cruise ship operators should continue to report to USCG via Advance Notice of Vessel Arrival (ANOA), which constitutes the most timely source of illness information when the cruise ship is within waters subject to the jurisdiction of the United States.
  • Surveillance onboard should include routine testing for SARS-CoV-2 infection, including intermittent testing of a random sample of symptomatic and asymptomatic crew members.  Additional information on testing can be found on CDC’s website.

CDC may publish these surveillance data on its website to inform the public.

Crew Monitoring

Crew should have twice daily temperature checks. If cruise ship operators can provide thermometers, self-temperature checks are preferable. All temperature checks should be reported to and recorded by the ship’s medical center. Additionally, crew members should be aware of the signs and symptoms of COVID-19 and the importance of not working and isolation in cabins while sick with fever or acute respiratory symptoms.

Disembarking Asymptomatic Crew for Transfer or Repatriation

During this period of suspended passenger operations, there are stipulations for crew transfers and repatriation.

  • Some crew will remain essential to maintaining basic ship operations (e.g., Minimum Safe Manning [MSM]). Cruise lines must submit requests to transfer crew (from one ship to another or embarking new crew members) in order to maintain basic ship operations to the U.S. Coast Guard for approval. This includes transferring necessary medical personnel or personnel necessary to maintain the seaworthiness or safety of the ship. If approved, these transfers may occur only via noncommercial transport.
  • CDC is allowing disembarkation of crew members for repatriation or non-essential transfers of crew members (for repatriation) if the cruise line attests pdf icon[PDF – 2 pages] that transport will occur only by industry-chartered private transport, industry-chartered private flights, or personal vehicles (no rental cars, taxis, or ride-share services) with measures in place to ensure those involved in transport are not exposed to the virus that causes COVID-19. Such measures must include the following:
    • Before disembarking crew, cruise ship operators must give 72-hour advance notice to the local and state health departments with jurisdiction over:
      • the port of disembarkation, and
      • the state and county of residence for any US-based crew disembarking for repatriation.
    • Cruise ship operators must notify the respective national public health authorities and adhere to any testing requirements of receiving countries for any repatriated crew based outside of the US.
    • Cruise ship medical staff must screen disembarking crew members for fever, cough, shortness of breath, or other symptoms compatible with COVID-19 by using temperature checks, visual observation for illness, and health questionnaires.
    • Cruise ship operators must ensure crew members with known exposures to COVID-19 are transported separately from those with no known exposure.
    • Cruise ship operators must provide face coverings, such as a cloth face covering, to disembarking crew members or confirm that they have their own face coverings. Face coverings should be worn by asymptomatic crew members during disembarkation, during transport to any flights, for the duration of the flight(s), and while taking ground transportation until they reach their final destination.
    • Cruise ship operators must instruct disembarking crew members to stay home for 14 days and continue to practice social distancing after reaching their destination.
    • Cruise ship operators must inform ship pilots, ground transportation, and air charter operators of the situation and confirm the operators have plans in place to notify and protect the health and safety of their staff (e.g., drivers, air crews).
    • Cruise ship operators must ensure that disembarking crew members:
      • will not stay overnight in a hotel before the flight or at any point until they reach their final destination
      • will not use public transportation (including taxis or ride-share services) to get to the airport/charter flight
      • will not enter the public airport terminal
      • will not take commercial aircraft after an initial charter flight
      • will not have a transportation layover exceeding 8 hours
      • will have no interaction with the public during their travel home (e.g., rental car companies, restaurants, etc.)
  • Use of commercial transportation by crew from ships unaffected by COVID-19 may occur only on a case-by-case basis with prior CDC approval; the cruise line must complete a statement attesting to the status of the ship.
  • To be considered currently unaffected by COVID-19, ships must have had no confirmed cases of COVID-19 [1] or COVID-like illness [2] in the past 28 days and if the ship received ship-to-ship [3] transfers within the past 28 days, crew must have come from a ship that had no confirmed COVID-19 or COVID-like illness within the 28 days before the transfer occurred. In addition, if land-based crew embarked, they must have been immediately quarantined for 14 days upon embarking the ship.
  • Use of commercial transportation by crew members who are determined to have fully recovered from COVID-19 based on CDC criteria for discontinuing isolation, and thus do not present a public health risk may occur as follows:
    • Cruise ship medical personnel are responsible for providing the crew member with a medical certificate stating that the crew member has recovered from COVID-19 and met CDC’s criteria for discontinuing isolation.
    • The medical certificate must meet the requirements of Department of Transportation regulationspdf iconexternal icon (14 Code of Federal Regulations § 382.23(c)(2)).

  1. Confirmed COVID-19 means laboratory confirmation for SARS-CoV-2, the virus that causes COVID-19, by polymerase chain reaction (PCR) testing
  2. COVID-like illness means acute respiratory illness (ARI), influenza-like illness (ILI), or diagnosis of pneumonia.
  3. Ship-to-ship transfers are defined as any movement of crew between ships.

Symptomatic Crew Members

Identifying and isolating crew with possible symptoms of COVID-19 as soon as possible is essential to minimize transmission of the virus. Crew should self-isolate immediately and inform the onboard medical center if they develop a fever (100.4°F / 38°C or higher), begin to feel feverish, develop acute respiratory symptoms (cough or difficulty breathing), or other symptoms of COVID-19.

Cruise ship medical personnel and cruise line telemedicine providers should reference CDC’s COVID-19 website Information for Healthcare Professionals for the latest information on infection control, clinical management, collecting clinical specimens, evaluating patients who may be sick with or who have been exposed to COVID-19, or identifying close contacts. For additional cruise ship information, please refer to Interim Guidance for Ships on Managing Suspected Coronavirus Disease 2019.

Isolation of Symptomatic Crew and Confirmed Cases and Quarantine of Close Contacts

Crew with ARI, ILI, or pneumonia should be isolated using the same guidelines as a confirmed COVID-19 case. Quarantine of asymptomatic crew that are identified as close contacts of symptomatic crew or confirmed cases is also needed to minimize transmission of SARS-CoV-2 on board.

  • Isolate or quarantine crew in single-occupancy cabins, with private bathrooms, with the door closed.
  • Selection of cabins for isolation or quarantine should consider the following:
    • Proximity to the medical facility and gangways for ease of patient transport
    • Location in dead-end corridors or low-traffic areas to minimize potential exposures
    • Spacing between other occupied cabins to reduce transmission risk
    • Absence of interconnecting doors to reduce accidental exposures
    • Positioning within view of security cameras for enforcement of isolation or quarantine
    • Presence of balconies for psychological morale
  • Isolated or quarantined crew members should have no direct contact with other crew except for designated medical staff.
  • Designated medical staff or other personnel should wear proper personal protective equipment (PPE) per CDC guidance when in proximity to isolated or quarantined crew members.
  • Meals should be packaged in disposable dining ware with single-use cutlery and delivered to individual cabins with no face-to-face interaction during this service.
  • Cabins housing isolated or quarantined crew should not be cleaned by other crew members. Supplies such as paper towels, cleaners, and disinfectants, and extra linens can be provided to isolated or quarantined persons so they can clean their cabin by themselves as necessary.
  • Food waste and other trash should be collected and bagged by the isolated or quarantined crew member and placed outside the cabin during designated times for transport to the waste management center for incineration or offloading.
  • Soiled linens and towels should be bagged in water-soluble bags by the isolated or quarantined crew member and placed outside the cabin during designated times for transport to the laundry room.
  • Consider use of surveillance cameras or security personnel to ensure compliance with isolation or quarantine protocols wherever possible.

Medical Management of Suspected or Confirmed COVID-19

Cruise ship medical centers are recommended to follow the operational guidelinesexternal icon published by the American College of Emergency Physicians (ACEP). Ships should carry a sufficient quantity of PPE, medical and laboratory supplies listed on CDC’s Interim Guidance for Ships on Managing Suspected Coronavirus Disease 2019. Maintaining adequate supplies of antipyretics (e.g., acetaminophen and ibuprofen), antiviral and antimicrobial medications, supplemental oxygen, and FDA-approved rapid diagnostic tests for COVID-19 is also recommended. Information to estimate needed medical staffing and equipment can be found in the Federal Healthcare Resilience Task Force Alternate Care Site Toolkit pdf icon[PDF – 136 pages]external icon, Supplement 2. As treatment and testing become more available in the United States, cruise ships should align with the latest CDC recommendations.

Disembarking Crew Members to Obtain Medical Care

Cruise lines are responsible for the medical care of ill or infected persons on board, including those who need hospitalization. For crew who need emergency medical attention that cannot be provided on board the ship, cruise lines should coordinate with the shoreside healthcare facility and U.S. Coast Guard.

  • Crew member should wear a cloth face covering, during the disembarkation process and throughout transportation to the shoreside healthcare facility, if a face covering can be tolerated.
  • If crew member is known to be infected with or has symptoms compatible with COVID-19:
    • All escorting personnel should wear appropriate proper PPE per CDC guidance.
    • Ensure a separate pathway or sanitary corridor where the disembarking crew member will exit with their personal belongings such as luggage.
    • The pathway used for disembarkation, any potentially contaminated surfaces (e.g., handrails) along the pathway, and any equipment used (e.g., wheelchairs) should be cleaned and disinfected immediately after disembarkation (see Cleaning and Disinfection section below).

Discontinuation of Isolation

Isolation may be discontinued for symptomatic crew with suspected or confirmed COVID-19, or asymptomatic crew with laboratory-confirmed COVID-19, once criteria outlined in CDC’s guidance for Discontinuation of Isolation for Persons with COVID-19 Not in Healthcare Settings are met.

Discontinuation of Quarantine

Quarantine may be discontinued for asymptomatic crew who have had close contact with suspected or confirmed COVID-19 cases under the following conditions:

  • 14 days has passed since last exposure to a suspected or confirmed case (considering the last exposure date to case as Day 0); and
  • the exposed crew member has remained afebrile; and
  • the exposed crew member has not developed acute respiratory symptoms

Cleaning and Disinfection

Current evidence suggests that COVID-19 may remain viable for hours to days on surfaces made from a variety of materials. Cleaning of visibly dirty surfaces followed by disinfection is a best practice measure for prevention of COVID-19 transmission.

In addition to routine cleaning and disinfection strategies, ships should focus on cleaning and disinfecting common areas where crew members may come into contact with infectious persons.  Consider frequent, routine cleaning and disinfection of commonly touched surfaces such as handrails, countertops, and doorknobs with an EPA-registered disinfectantexternal icon effective against coronaviruses.

Additional information on cleaning and disinfecting on cruise ships can be found on CDC’s Interim Guidance for Ships on Managing Suspected Coronavirus Disease 2019.

Other environmental considerations include:

  • Wait 24 hours or as long as practical before beginning cleaning and disinfection of cabins vacated by crew members with confirmed or suspect COVID-19.
  • In order to minimize the possibility of dispersing virus through the air, do not shake dirty laundry.
  • Launder soiled linens and towels collected from cabins occupied by isolated or quarantined crew in washing machines set at the warmest appropriate water setting for the items, and dry items completely.
  • Identify pathways to minimize risk of respiratory transmission when crew are required to move in and out of isolation and quarantine corridors and during the transport of waste and soiled linens generated by isolated or quarantined crew members.
  • Designated trolleys/carts used for the transportation of waste and soiled linens from isolated or quarantined cabins must be cleaned and disinfected with an effective disinfectant after each use.

Medical personnel who have direct contact with isolated or quarantined persons and crew members who handle waste or soiled linens must wear proper PPE per CDC’s Interim Guidance for Ships on Managing Suspected Coronavirus Disease 2019.

COVID-19 Color-coding System for Cruise Ships During the Period of the No Sail Order

This guidance and the commercial transportation attestation are only applicable to cruise ship operators with a complete and accurate No Sail Order response plan for crew management and for their ships that have met CDC’s criteria for a “Green” ship. Cruise company officials must sign an acknowledgment of the completeness and accuracy of their response plan. Status of ships is contingent upon weekly submission of the Enhanced Data Collection (EDC) during COVID-19 Pandemic.

Green Ship Criteria

  • No confirmed cases of COVID-19 or COVID-like illness for 28 days, as determined by a qualified medical professional.
  • If the ship received ship-to-ship transfers within the past 28 days, crew must have come from a ship that had no confirmed COVID-19 or COVID-like illness within the 28 days before the transfer occurred.
  • If land-based crew embarked, they were immediately quarantined for 14 days upon embarking the ship.

Note: To maintain Green status, ships must submit a weekly EDC form to CDC. Failure to submit, changes ship status to Red. Green ship status means that CDC believes the ship is currently unaffected by COVID-19 based on information provided by the cruise ship operator.

Yellow Ship Criteria

  • Previously designated Green, but now has 1 or more COVID-like illness cases pending COVID-19 polymerase chain reaction (PCR) test.
    • If PCR positive, status changes to Red (must sign attestation again after meeting criteria again)
    • If PCR negative, status goes back to Green
    • If crew with COVID-like illness are not tested by PCR or if results are not available within 1 week of the case being reported, status changes to Red.
  • If the ship received ship-to-ship transfers within the past 28 days, crew must have come from a ship that had no confirmed COVID-19 or COVID-like illness within the 28 days before the transfer occurred. If not, status changes to Red.
  • If land-based crew embarked, they were immediately quarantined for 14 days upon embarking the ship. If not, status changes to Red.

Red Ship Criteria

  • One or more cases of confirmed COVID-19 or COVID-like Illness within the past 28 days, or
  • Ship received ship-to-ship transfers from a ship that had confirmed COVID-19 or COVID-like illness within the 28 days before the transfer occurred, or
  • If land-based crew embarked, they were not immediately quarantined for 14 days upon embarking the ship, or
  • During the past 28 days, the ship missed one or more weekly submission of the EDC form.

Note: Embarkation of passengers is strictly prohibited for all ships during the period of the No Sail Order and may result in suspension and revocation of this limited permission to operate in U.S. waters.

COVID-19 Color-coding System for Cruise Ships During the Period of the No Sail Order
Preventive Measures Based on Ship Status
GREEN YELLOW RED
Crew Transfers and Repatriation Via Non-Commercial Transportation Permitted Permitted Permitted
Crew Transfers and Repatriation Via Commercial Transportation Permitted Not Permitted Not Permitted
Asymptomatic Crew Restrictions Relocate all crew to single-occupancy cabins with private bathrooms Recommended Required Required
Instruct crew members to remain in cabins as much as possible during non-working hours Not Required Not Required Required
Cancel all face-to-face employee meetings, group events (such as employee trainings), or social gatherings Not Required Required Required
Close all crew bars, gyms, or other group settings Not Required Required Required
Implement social distancing of crew members when working or moving through the ship (maintaining at least 6 feet [2 meters] from others) Recommended Required Required
Instruct crew members to wear a cloth face covering when outside of individual cabins Recommended Required Required
Modify meal service to facilitate social distancing (e.g., reconfigure dining room seating, stagger mealtimes, encourage in-cabin dining) Not Required Required Required
Eliminate self-serve dining options at all crew and officer messes Required Required Required
Discourage handshaking – encourage the use of non-contact methods of greeting Required Required Required
Promote respiratory and hand hygiene and cough etiquette Required Required Required
Place hand sanitizer (containing at least 60% alcohol) in multiple locations and in sufficient quantities to encourage hand hygiene Required Required Required
Place posters that encourage hand hygiene to help stop the spread in high-trafficked areas Required Required Required

Procedure for “Green” Cruise Ships Requesting to use Commercial Transportation

  1. Cruise ship operator determines that the ship meets CDC’s criteria for “Green” status.
  2. Cruise ship operator submits a signed unaltered Attestation for Commercial Transportation of Disembarking Crew for Cruise Ship Operators under a No Sail Order Response Plan to CDC at eocevent349@cdc.gov.
  3. To confirm Green status, CDC will assess the status of the ship by reviewing surveillance data submitted weekly using the EDC form.
  4. If CDC clears the ship as meeting Green status, CDC will send cruise ship operator a clearance email informing them that arrangements for commercial flights can now be made.
    1. To inform transportation partners (e.g., Federal Aviation Administration, Transportation Security Administration, and airlines) of the ship’s ability to arrange commercial travel, CDC will post on its website the names of all ships with Green status and a signed attestation for commercial travel.
    2. The attestation will be valid from the time of CDC clearance until the ship’s status changes (to “Yellow” or “Red”) or the end of the NSO period.
  5. Once a ship has achieved “Green” status and has a cleared attestation, CDC will continue to review the ship’s status on a weekly basis to determine if it changes to Yellow or Red. Failure to submit weekly EDC form, changes ship status to Red.
  6. If ship’s status changes from Green to Yellow or Red based on criteria:
    1. CDC will notify the cruise ship operator by email.
    2. CDC will update the ship’s status on its website.
    3. Commercial travel from the ship must not occur.
  7. Cruise lines whose ships have achieved Green status, including a signed and approved attestation, may provide a letter informing the airline that the crew member will disembark a Green ship. The letter can be provided to the:
    1. commercial airline upon booking, and/or
    2. crew member upon disembarkation.