Cdc guidelines for quarantine after international travel

On October 25, 2021 The Centers for Disease Control and Prevention (CDC) within the Department of Health and Human Services (HHS) amended its January 25, 2021 Order, titled, “Requirement for Proof of Negative COVID-19 Test or Recovery from COVID-19 for All Air Passengers Arriving in the United States.”

This amendment updates COVID-19 testing requirements for air passengers 2 years or older boarding a flight to the United States, depending on COVID-19 vaccination status.

This Amended Order was effective on November 8, 2021 at 12:01am EST (5:01am GMT), and was published in the Federal Register on November 5, 2021.

View the Attestation to the October 25, 2021 Order.

This Order will be replaced at 12:01 EST on December 6, 2021

View the Order [PDF – 65 pages].
On November 10, 2021, CDC reposted this Order to correct minor grammatical and typographical errors. The legal substance of the Order remains the same.

Purpose

Cruise ships are densely populated congregate settings where respiratory viruses, including SARS-CoV-2 (the virus that causes COVID-19), can spread easily among travelers (passengers and crew) on board. This document is intended to assist cruise ship operators in establishing health and safety protections to reduce the risk of introduction and spread COVID-19 during passenger operations and preserve onboard medical capacity. Cruise ship operators should carefully consider and incorporate these recommendations in developing their own health and safety protocols. Plans should include triggers for a graduated approach to outbreak management in response to increasing case counts or other public health concerns.

This guidance is based on the best available science regarding the subject areas covered. CDC will reevaluate the guidance for cruise ships periodically, based on scientific evidence and the state of the pandemic, and update the guidance as needed. CDC will notify cruise ship operators if the guidance is updated.

Onboard COVID-19 Response Plans

Cruise ships should develop and maintain COVID-19 response plans to prevent and mitigate introduction and onboard transmission of COVID-19. These plans should incorporate:

• Terminology and definitions that align with how CDC uses and defines the following terms: “confirmed COVID-19,” “COVID-19-like illness,” “close contact,” “fully vaccinated,” “up to date with COVID-19 vaccines,” “isolation,” and “quarantine” (including recommended time frames for isolation and quarantine)
• Surveillance protocols to detect COVID-19-like illness and confirmed COVID-19 among travelers
• COVID-19 testing protocols that align with CDC guidance (see below)
• Isolation and quarantine protocols, including how to increase capacity (e.g., isolation and quarantine cabins, personnel) in case of an outbreak
• Medical facility protocols that address staffing—including number and types of medical staff—and maintaining equipment and supplies in sufficient quantities to provide hospital level of care (e.g., ventilators, oxygen, well-fitting masks and other personal protective equipment, therapeutics) for infected patients without the immediate need to rely on shoreside hospitalization
• Procedures for disembarking travelers with COVID-19 who need a higher level of care than can be provided on board
• Training protocols for all crew on COVID-19 prevention, mitigation, and response activities

[1] Confirmed COVID-19 means laboratory confirmation for SARS-CoV-2, the virus that causes COVID-19, by viral test.

[2] COVID-19-like illness clinical criteria include the following:

• At least one or more of the following symptoms: fever, cough, difficulty breathing, shortness of breath, new olfactory disorder, or new taste disorder; OR
• At least two or more of the following symptoms: sore throat, nasal congestion, runny nose (rhinorrhea), chills, rigors, muscle or body aches (myalgias), headache, fatigue, vomiting, or diarrhea in the absence of a non-infectious diagnosis as determined by the ship’s physician (e.g., allergies); OR
• Severe respiratory illness with at least one of the following:
  • Clinical or radiographic evidence of pneumonia,
  • Acute respiratory distress syndrome (ARDS).

Shoreside Response Plans

Cruise ships should develop and maintain shoreside response plans to prevent and mitigate the introduction of COVID-19 to port communities. When developing their response plans, cruise ship operators should coordinate with the U.S. port authorities where the cruise ship operator intends to conduct passenger voyages and all health departments exercising jurisdiction over those ports.

• For the purpose of this guidance document only, “local health authorities” refers to all health departments responsible for implementing state, territorial, and local laws relating to public health (e.g., city, county, territorial, and/or state health departments) and exercising jurisdiction over the U.S. ports where the cruise ship operator intends to conduct passenger operations.
• For the purpose of this guidance document only, “U.S. port authorities” refers to the local officials responsible for exercising oversight and control over the U.S. ports where the cruise ship operator intends to conduct passenger operations.

Shoreside response plans should include the following components:

Port Operation Components

(Relating to maintaining the health and safety of travelers and port personnel)

• Embarkation procedures that the cruise ship operator intends to use during passenger voyages
• Procedures for day-of-embarkation screening for signs and symptoms of COVID-19 and COVID-19 testing of travelers, including testing locations and management of individuals who test positive and their close contacts
• Procedures for reporting COVID-19 cases identified during a voyage to local authorities (if requested), including thresholds for reporting, timelines, reporting mechanisms, and local points of contact
  • Reporting procedures, if any, should be incorporated into the plan and may be in addition to—but not replace—regulatory requirements to report to CDC and other federal agencies.
• Disembarkation procedures (e.g., separate disembarkation routes/times for travelers with suspected or confirmed COVID-19, passenger pick-up, luggage retrieval, and passenger transportation) that will be implemented in the event of an outbreak of COVID-19 onboard the ship
• Procedures for routine and outbreak-level cleaning in areas where travelers are reasonably expected to gather or otherwise use, including terminals, restrooms, and transportation vehicles under a cruise ship operator’s control (e.g., buses, shuttle vans)

Medical Care Components

(Relating to medical care, medical evacuation, and medical transport for travelers in need of care)

• Protocols that avoid medical evacuations at sea to the extent possible, for either COVID-19 or other medical conditions
  • Protocols should rely on commercial resources (e.g., ship tender, chartered standby vessel, chartered airlift) for unavoidable medical evacuation at sea and be designed to minimize the burden to the greatest extent possible on Federal, State, and Local government resources, including U.S. Coast Guard resources.
  • All medical evacuations at sea to a U.S. healthcare facility should be coordinated with the U.S. Coast Guard.
• Protocols for contacting emergency medical services while at port for exigent circumstances not covered by the medical care component of the plan (e.g., a medical emergency not related to COVID-19, such as a heart attack)
• Procedures for providing emergency medical transportation of critically ill persons with suspected or confirmed COVID-19 from the ship to a shoreside medical facility in such a manner as to minimize potential for exposure
• Considerations for the potential medical care needs of travelers including the capacity of local public health, port authority, hospital, and other emergency response personnel to respond to an onboard outbreak of COVID-19
  • These should include contingency planning to provide medical care to travelers in the event of limited hospital beds, medical personnel, or other factors potentially limiting the capacity of the local public health and medical infrastructure.

Housing Components

(Relating to housing plans for isolation or quarantine—as needed—of persons with suspected or confirmed COVID-19 and close contacts after disembarkation)

• Contingency plans for shoreside housing needs of travelers in need of continued isolation and quarantine after disembarkation.
  • CDC guidance for isolation or quarantine should be considered when planning for shoreside housing.
• Contingency plans in the event an outbreak requires the ship to be taken out of service (e.g., where the ship will be physically located—such as at the pier or at anchor—during the time the ship is out of service).
  • These should include details about when a cruise line would need to consider this option (e.g., a sudden and large outbreak, an outbreak that eclipses the cruise ship personnel’s ability to manage and/or safely operate the ship, the inability to control the outbreak over multiple voyages).
• Procedures for the transportation of all travelers needing shoreside housing to travel from the ship to the shoreside housing facilities and from the shoreside housing facility to the medical facilities or healthcare systems (if needed) with precautions in place to avoid exposure of vehicle operators, housing facility staff, and medical facility personnel
• Contingency plans should address the following needs of travelers under quarantine and isolation:
  • Availability and frequency of testing
  • Availability of mental health services, pharmacy delivery, and other essential services
  • A mechanism to notify public health authorities, as needed, in the event that a traveler attempts to end isolation or quarantine prior to meeting CDC’s guidance
  • A check-in process, including delivery of luggage, designed insofar as possible to minimize contact between infected travelers and unexposed persons
  • Procedures to ensure the daily monitoring of travelers in quarantine and/or isolation, including points of contact for travelers to notify if symptoms develop in between symptom checks
  • Procedures to minimize contact between travelers in quarantine and/or isolation and support staff, while still ensuring the delivery of essential services:
    • Food delivery
    • Laundry services
    • Cleaning and linen change
    • Garbage pick up
    • Cleaning and disinfection
  • Procedures to return travelers to their home communities after completing isolation or quarantine

COVID-19 Vaccines

CDC recommends all eligible travelers be up to date with their COVID-19 vaccines. In addition to the protection COVID-19 vaccines provide to individual travelers in preventing severe illness or death from COVID-19, having a high proportion of travelers on board who are up to date with COVID-19 vaccines reduces the likelihood that cruise ships’ medical centers are overwhelmed by cases of COVID-19.

Surveillance for COVID-19

• The Enhanced Data Collection (EDC) During COVID-19 Pandemic Form is an interim replacement for the:
  • Maritime Illness and Death Investigation form [PDF – 4 pages] for individual cases of COVID-19, typically reported to CDC quarantine stations.
  • Maritime Conveyance Cumulative Influenza/Influenza-Like Illness (ILI) form [PDF – 1 page] for each international voyage, formerly requested by CDC.
• In lieu of the above reporting forms, CDC requests daily submission of the EDC form. This EDC Form will be used to conduct surveillance for COVID-19 on board cruise ships using cumulative reports of confirmed COVID-19 [1] and COVID-19-like illness [2], which includes acute respiratory illness (ARI), influenza-like illness (ILI), and pneumonia.
• Access to the online EDC form has been provided to cruise lines by CDC. Cruise lines that do not have access should contact CDC (email ).
• If the cruise ship elects to not submit the EDC form daily, then the ship is required to report individual cases of COVID-19 via the Maritime Illness and Death Investigation form.
• Cruise ships must continue to report all deaths and other illnesses as defined by CDC to the CDC quarantine station at or nearest the U.S. port of arrival.

To reduce the spread of SARS-CoV-2, cruise ship operators should:

• Educate crew members about the following:
  • the signs and symptoms of COVID-19,
  • the need to notify cruise ship medical staff immediately if they develop symptoms, and
  • the need to notify cruise ship medical staff immediately if a passenger reports signs and symptoms of COVID-19.
• Implement procedures for maintaining records associated with active COVID-19 surveillance. These records include:
  • Surveillance log for acute respiratory illness (ARI), influenza-like illness (ILI), pneumonia, positive antigen test results, and positive nucleic acid amplification test (NAAT) results.
  • Medical documentation of prior positive SARS-CoV-2 viral test results for crew
    • Because retesting for SARS-CoV-2 is not recommended during the 90 days following a laboratory-confirmed diagnosis of COVID-19 (unless symptomatic), records should be available to review the ship’s tracking of the 90-day timeframe for crew who have tested positive prior to these crew resuming routine laboratory testing.
  • Records relating to the isolation of persons positive for SARS-CoV-2 and the quarantine of close contacts. These include dates of isolation and quarantine, originally assigned cabin numbers, cabin numbers for isolation and quarantine, medical records, and sign and symptom logs.
  • Records relating to the contact tracing of any identified close contacts
• All medical records should be maintained for at least 90-days and made available to CDC upon request for review.

COVID-19 Surveillance Testing Reminders

• Ships should maintain onboard capacity to conduct viral tests for SARS-CoV-2, including nucleic acid amplification tests (NAAT) and antigen tests.
  • Examples of NAATs include but are not restricted to reverse transcription polymerase chain reaction (RT-PCR), reverse transcription loop-mediated isothermal amplification (RT-LAMP), transcription-mediated amplification (TMA), nicking enzyme amplification reaction (NEAR), helicase-dependent amplification (HDA).
  • Tests used should be cleared or authorized for emergency use by the U.S. Food and Drug Administration (FDA), or the relevant national authority where the test is administered.
• CDC considers all positive viral test results as new cases, unless laboratory documentation of a previous SARS-CoV-2 by viral test result within the previous 90 days is provided and the individual is asymptomatic. Cruise ship operators should have a protocol for evaluating documentation of recovery from COVID-19 [3], including reviewing previous laboratory results.
• To ensure the integrity of testing, persons with positive NAAT results should not be retested, and the original positive results should be reported. Subsequent negative NAAT results do not negate a recent positive NAAT result.
• Cruise ship operators may use confirmatory NAAT testing for positive antigen screening tests in asymptomatic travelers following Guidance for Antigen Testing for SARS-CoV-2 for Healthcare Providers Testing Individuals in the Community.
  • Confirmatory testing for a positive antigen screening test should take place as soon as possible after the antigen test, and not longer than 48 hours after the initial antigen testing. If more than 48 hours separate the two specimen collections, or if there have been opportunities for new exposures, a NAAT should be considered a separate test – not a confirmation of the earlier test.
• Asymptomatic travelers who test positive for SARS-CoV-2 via NAAT should not be retested (e.g., as part of a contact investigation or routine screening testing) until 90 days post lab-confirmed diagnosis, unless they are symptomatic. Symptomatic passengers should be isolated and re-evaluated, including retesting for SARS-CoV-2. If an alternate infectious etiology (e.g., influenza, respiratory syncytial virus [RSV], Legionella, Streptococcal pharyngitis) is identified through laboratory testing, routine infection control precautions recommended for the diagnosis should be followed.

[3] Documentation of recovery from COVID-19 includes the following:

• Paper or electronic copies of their previous positive viral test result (dated no less than 10 days and no more than 90 days before date of embarkation)
  • A positive test result dated less than 10 days before embarkation may be acceptable if accompanied by a signed letter from a licensed health care provider indicating symptom onset more than 10 days before the voyage.

Procedures for Embarking Passengers

Health Screening

• Cruise ship operators should screen passengers for signs or symptoms of COVID-19, known close contact exposure to a person with COVID-19 within the 10 days before embarkation, or a positive COVID-19 viral test within the 10 days before embarkation.
  • For passengers with signs or symptoms of COVID-19:
    • Consider denying boarding.
    • Considerations for allowing boarding can include:
      • A negative result of a COVID-19 viral test (antigen-negative should be confirmed with NAAT) conducted on the day of boarding
      • An alternate infectious etiology (e.g., influenza, respiratory syncytial virus (RSV), Legionella, Streptococcal pharyngitis) is identified through laboratory testing, routine infection control precautions recommended for the diagnosis should be followed.
  • For passengers who have a known close contact exposure within the 5 days before embarkation:
    • Consider denying boarding unless up to date with their COVID-19 vaccines or have documentation of recovery [3].
    • Considerations for allowing boarding can include:
      • Up to date with their COVID-19 vaccines, asymptomatic, and a negative result of a COVID-19 viral test conducted on the day of boarding
      • Documentation of recovery from COVID-19 and asymptomatic
    • If allowed to board, see information below regarding recommendations for management onboard.
  • Passengers who tested positive for COVID-19 within 10 days before embarkation should be denied boarding.

Pre-embarkation COVID-19 Testing

• To reduce likelihood of onboard transmission, cruise ship operators should consider requiring travelers to get tested for current infection with a viral test as close to the time of departure as possible (no more than 3 days before travel) and present their negative test result prior to boarding. Testing within 1 day of embarkation is highly recommended. Cruise ship operators may also consider conducting embarkation testing for all or a subset of passengers.
  • Recommended information requirements for pre-embarkation testing documentation:
    • Type of test (indicating it is a NAAT or antigen test)
    • Entity issuing the result (e.g., laboratory, healthcare entity, telehealth service)
    • Specimen collection date
    • Information that identifies the person (full name plus at least one other identifier such as date of birth or passport number)
    • Test result
• Cruise ship operators should consider testing all passengers on back-to-back sailings [4] prior to the ship sailing on the next voyage.
• Cruise ship operators that choose to conduct embarkation testing should follow their shoreside response plans to ensure all travelers identified through embarkation testing as positive for SARS-CoV-2 are appropriately managed.
• Ships that allow travelers to use a self-test (sometimes referred to as home test), may consider the following criteria:
  • The test is a SARS-CoV-2 viral test (NAAT or antigen test) with an Emergency Use Authorization (EUA) from the Food and Drug Administration (FDA) or the relevant national authority where the test is administered.
  • The testing procedure includes a telehealth service affiliated with the manufacturer of the test that provides real-time supervision remotely through an audio and video connection. Some FDA-authorized self-tests that include a telehealth service may require a prescription.
  • The telehealth provider confirms the person’s identity, observes the specimen collection and testing procedures, confirms the test result, and issues a report that meets the information requirements listed below.
  • Cruise ship operators can review and confirm the person’s identity and the test result details.

[4] Back-to-back sailing refers to passengers who stay on board for two or more voyages.

Procedures for Symptomatic Travelers (Crew and Passengers) and Close Contacts

Onboard COVID-19 Testing and Quarantine of Close Contacts

Symptomatic Travelers: Identifying and isolating travelers with possible symptoms of COVID-19 as soon as possible is essential to minimize transmission of the virus. All travelers onboard the cruise ship with signs and symptoms of COVID-19, regardless of vaccination status, should be isolated and tested for SARS-CoV-2 infection immediately upon notifying medical staff of symptom onset. Results should be reported to CDC in aggregate through the EDC form.

Close Contacts: Because of the potential for asymptomatic and pre-symptomatic transmission in this high-risk residential congregate setting, it is important that close contacts of individuals with SARS-CoV-2 infection be quickly identified and tested. CDC has provided guidance for quarantine in community and high-risk congregate settings. In addition to this guidance, cruise ship operators can consider the following options.

• Travelers who Are Up to Date with their COVID-19 Vaccines:
  • Option 1: Test these close contacts with a viral test daily until 5 days after their last exposure in lieu of a 5-day quarantine.
    • For a full 10-day period after their last exposure, these individuals should have in-cabin dining and properly wear a well-fitting mask at all times when outside of their cabin (indoors and outdoors). They should also wear a well-fitting mask inside their cabin if any other person (e.g., a crew member) enters the cabin.
  • Option 2: Quarantine these close contacts until at least 5 full days after their last exposure (the day of last close contact is counted as day 0).
    • They should receive a viral test (NAAT or antigen, NAAT preferred) immediately and on day 5 (or later) before ending quarantine. They may end quarantine after 5 days if they remain asymptomatic and both viral tests are negative.
    • For a full 10-day period after their last exposure, these individuals should have in-cabin dining and properly wear a well-fitting mask at all times when outside of their cabin (indoors and outdoors). They should also wear a well-fitting mask inside their cabin if any other person (e.g., a crew member) enters the cabin.
• Travelers who Are Not Up to Date with their COVID-19 Vaccines:
  • Option 1: Quarantine these contacts until 5 days after their last exposure followed by 5 days of daily viral testing.
    • If they end quarantine after 5 days, then during days 6-10 after their last exposure, these individuals should have in-cabin dining and properly wear a well-fitting mask at all times when outside of their cabin (indoors and outdoors). They should also wear a well-fitting mask inside their cabin if any other person (e.g., a crew member) enters the cabin.
  • Option 2: Quarantine these close contacts until at least 10 days after their last exposure (the day of last close contact is counted as day 0). They should receive a viral test (NAAT or antigen, NAAT preferred) immediately and on day 10 before ending quarantine. If they remain asymptomatic after 10 days and both viral tests are negative, they may end quarantine.

Onboard COVID-19 Testing for Symptomatic Travelers (Crew and Passengers) and Testing and Quarantine of Close Contacts†

Onboard COVID-19 Testing for Symptomatic Travelers (Crew and Passengers) and Testing and Quarantine of Close Contacts

† If a cruise ship cannot maintain minimum safe manning because crew members are in isolation or quarantine, the cruise ship may consider a “working quarantine” (i.e., crew perform job duties then return to cabin quarantine) for essential crew who are not up to date with their COVID-19 vaccines to ensure the safety of ship as it immediately returns to port. When choosing essential crew for a working quarantine, the cruise ship should prioritize crew who are fully vaccinated over those who are not. See guidance below regarding masking and dining.

^ Individual should properly wear a well-fitting mask at all times when outside of cabin (indoors and outdoors) until 10 days after the last close contact with someone with COVID-19 (the date of last close contact is considered day 0). They should also wear a well-fitting mask inside their cabin if any other person (e.g., a crew member) enters the cabin.

• All cruise ships should procure NAAT point-of-care equipment to test symptomatic travelers (and identified close contacts, regardless of vaccination status).
  • These test systems should:
    • Be authorized by FDA for use in a CLIA-waived setting;
    • Be evaluated using the FDA reference panel for SARS-CoV-2 and possess a limit of detection (LoD) value ≤18,000 NDU/ml. For tests that do not have the FDA reference panel available, tests will be accepted using sensitivity data ≥ 95% from clinical samples as indicated in the manufacturer’s IFU; and
    • Allow for specimen-to-instrument transfer in a way that minimizes the risk of contamination.
• Cruise ships may also consider procuring antigen testing systems to provide additional capacity.
  • Antigen test systems should:
    • Be authorized by FDA for use in a CLIA-waived setting or authorized for use by the national authority in another country where the ship has operated; and
    • Allow for specimen-to-test system transfer in a way that minimizes the risk of contamination.
  • For antigen testing, cruise ship operators should follow CDC’s Guidance for Antigen Testing for SARS-CoV-2 for Healthcare Providers Testing Individuals in the Community.
• Symptomatic persons with COVID-19-like illness who initially test negative for SARS-CoV-2 via NAAT and for whom no alternative etiology is identified (e.g., influenza, Legionella, Streptococcal pharyngitis, infectious mononucleosis, or respiratory syncytial virus [RSV]):
  • Should be isolated for COVID-19 per isolation guidelines below, and
  • May be retested via NAAT collected at least 24 hours after the initial COVID-19 test
    • Isolation may be discontinued if the repeat NAAT result is negative.
    • If an alternate infectious etiology is identified (through either laboratory testing or clinical diagnosis), routine infection control precautions (e.g., isolation) recommended for the diagnosis should be followed.
    • For example, if symptomatic person has only vomiting and diarrhea and tests negative for COVID-19 twice, then acute gastroenteritis (AGE) protocols should be followed.
  • Cruise ships should report only final diagnostic test results on EDC form.
• Cruise ship medical personnel and cruise line telemedicine providers should reference CDC’s COVID-19 webpage 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 information, please refer to Interim Guidance for Ships on Managing Suspected or Confirmed Cases of Coronavirus Disease 2019.

Considerations for Isolation or Quarantine

Cruise ship operators should consider the following elements when isolating cases or quarantining close contacts:

• Isolating or quarantining travelers in single-occupancy cabins, with private bathrooms, with the door closed.
• Designating isolation and quarantine cabins in areas separate from other cabins.
  • If a traveler is identified as a case or a close contact is disembarking the ship within 36 hours, it may be more practical for the cruise ship operator to keep the traveler in their original cabin if the traveler will be the only person in that cabin.
• Ensuring isolated travelers (except if the traveler is a child or other dependent person who needs a caregiver) do not have direct contact with other travelers except for designated medical staff.
  • Asymptomatic travelers with confirmed COVID-19 may share a cabin.
• Ensuring designated medical staff or other personnel wear proper personal protective equipment (PPE) per CDC guidance when in proximity to isolated or quarantined travelers.
• Delivering meals to individual cabins with no face-to-face interaction during this service.
• Ensuring cabins housing isolated or quarantined travelers are not cleaned by crew members. Supplies such as paper towels, cleaners, disinfectants, and extra linens should 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 traveler 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 a manner that limits exposure to crew members (e.g., water-soluble bags, biohazard double-bags) by the isolated or quarantined traveler and placed outside the cabin during designated times for transport to the laundry room.
• Use of surveillance cameras or security personnel to ensure compliance with isolation or quarantine protocols wherever possible.
• Potential criteria when selecting cabins for isolation or quarantine:
  • 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

Discontinuation of Isolation for Travelers (Crew and Passengers)

To calculate the traveler’s isolation period, day 0 is their first day of symptoms or the day of their positive viral test if asymptomatic.

CDC has provided guidance for isolation in community and high-risk congregate settings. If isolation is ended before 10 days are completed, travelers should properly wear a well-fitting mask when outside of cabin (indoors and outdoors) through day 10. During this time, these individuals should have in-cabin dining and also wear a well-fitting mask inside their cabin if any other person (such as a crew member) enters the cabin.

Cruise ship operators can consider the following for the discontinuation of isolation:

• For symptomatic travelers with suspected or confirmed COVID-19
  • End isolation after 5 days from symptom onset, if
    • They are fever-free for 24 hours without the use of fever-reducing medication, and
    • Their other symptoms have improved (loss of taste and smell may persist for weeks or months after recovery and need not delay the end of isolation​), and
    • They have two negative antigen [6] tests collected at least 24 hours and no more than 48 hours between tests—test no earlier than day 5 (with day 0 being the first day of symptoms).
• For asymptomatic travelers with confirmed COVID-19
  • End isolation after 5 days from date of first positive test, if
    • They have two negative antigen tests collected at least 24 hours, and
    • No more than 48 hours between tests—test no earlier than day 5 (with day 0 being the day of their positive viral test).

[6] As noted in the labeling for authorized over-the-counter antigen tests: Negative results should be treated as presumptive. Negative results do not rule out SARS-CoV-2 infection and should not be used as the sole basis for treatment or patient management decisions, including infection control decisions.

Onboard Medical Centers

Medical centers on cruise ships can vary widely depending on ship size, itinerary, length of cruise, and passenger demographics.

• Cruise ship medical centers are recommended to follow the operational guidelines published by the American College of Emergency Physicians (ACEP).
• To reduce the spread of SARS-CoV-2, cruise ship medical centers:
  • Carry a sufficient quantity of PPE, medical, and laboratory supplies listed on CDC’s Interim Guidance for Ships on Managing Suspected or Confirmed Cases of Coronavirus Disease 2019.
  • Maintain adequate supplies of antipyretics (e.g., acetaminophen and ibuprofen), antivirals and other therapeutics for COVID-19, if commercially available, other antimicrobial medications, oral and intravenous steroids, and supplemental oxygen.
  • Adhere to standard and transmission-based precautions when healthcare personnel are caring for patients with suspected or confirmed SARS-CoV-2 infection. Recommended PPE is described in the Infection Control Guidance.
  • Stay up to date on COVID-19 training and Clinical Care Considerations.

Laboratory

To ensure safe and effective laboratory procedures, cruise ship operators should:

• Ensure that an onboard testing instrument (see specifications above) is properly installed and that the assay is being used.
• Designate a laboratory point of contact (POC) responsible for managing quality assurance and quality control and decision-making.
• Follow Interim Guidelines for Collecting and Handling of Clinical Specimens for COVID-19 Testing.
• Ensure test results are traceable from specimen collection through reporting to the individual, including all supporting materials, records, and equipment.
• Follow assay storage and handling guidance found in the assay’s FDA Emergency Use Authorization (EUA) Instructions for Use (IFU) document or equivalent for those authorized in other national jurisdictions.
• Develop and maintain a testing manual to be followed on each applicable ship for the testing instrument and assay. The testing manual should be made available to CDC inspectors upon request for review.
  • The testing manual should include the following content:
    • CDC’s Nasopharyngeal Specimen Collection Infographic [PDF – 2 pages]
    • Specimen collection, storage, and handling procedures, including documentation and labeling of specimens
    • Instructions for Use (IFU) for the onboard testing instrument
    • Reporting procedures for results, including how results are reported and who receives test results
    • Equipment manual provided by the manufacturer
    • Procedure for daily documentation of testing location and reagent storage area temperatures
• Maintain the following records as part of the testing manual or in a separate document accessible to CDC inspectors:
  • Personnel training records for specimen collection, labeling, storage, testing, and reporting
  • Documentation that all onboard medical personnel involved with specimen collection and laboratory testing have completed “Ready? Set? Test! Checklist [PDF – 4 pages]” (regulatory sections do not apply)
  • Documentation that all onboard medical personnel involved with specimen collection and laboratory testing have completed competency testing [PDF – 11 pages]
  • Documentation that all onboard medical personnel have read and reviewed:
    • Good Laboratory Practices for Waived Testing Sites: Survey Findings from Testing Sites Holding a Certificate of Waiver Under the Clinical Laboratory Improvement Amendments of 1988 and Recommendations for Promoting Quality Testing
    • “To Test or Not to Test? Considerations for Waived Testing” [PDF – 60 pages]
    • “Ready? Set? Test! Patient Testing Is Important. Get the right results.” [PDF – 56 pages]
  • Preventive equipment maintenance records as specified by the manufacturer and quality assurance as described in the “Ready? Set? Test! Checklist [PDF – 4 pages]”
  • Daily documentation of the testing and reagent storage area temperatures
  • Supplies/reagent inventory records (e.g., list of kits, reagents, supplies with lot numbers, expiration dates, storage conditions and other relevant information found in the IFU)
  • Documentation of corrective action if any quality assurance failures occur
  • Documentation of testing, including equipment logs, maintenance records, quality control documents, and test results
• Display instructions, infographics, and similar material in close vicinity to where the CDC-approved onboard testing instrument is used and in clear view of the medical personnel using the instrument. The following posters should be displayed near the onboard testing instrument:
  • Specimen collection instructions [PDF – 2 pages]
  • “Ready Set? Test!” Poster [PDF – 1 page]

Disembarking Travelers (Crew and Passengers)

If a traveler is known to be infected with or has symptoms compatible with COVID-19:

• All escorting personnel should wear appropriate proper PPE per CDC guidance.
• The cruise ship operator should ensure a separate pathway or sanitary corridor where the disembarking traveler 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).

Disembarkation to Obtain Medical Care

Cruise ship operators should have clear protocols that avoid medical evacuations at sea to the extent possible for COVID-19 and other medical conditions. Protocols should rely on commercial resources (e.g., ship tender, chartered standby vessel, chartered airlift) for unavoidable medical evacuations at sea and be designed to minimize the burden on federal (including U.S. Coast Guard), state, and local government resources. Travelers with COVID-19 should properly wear a well-fitting mask covering their mouth and nose during the disembarkation process and throughout transportation to the shoreside healthcare facility, if a mask can be tolerated and does not interfere with medical treatment (e.g., supplemental oxygen administered via an oxygen mask).

Other Travelers with COVID-19 and Close Contacts

• Travelers who test positive for COVID-19 and who disembark before completing their 10-day isolation period may end isolation after 5 days, following guidance for the general public. Travelers who test positive for COVID-19 should not travel commercially after they disembark from a ship until a full 10 days after their symptoms started or the date their positive test was taken if they had no symptoms.
  • If discontinuation of the 10-day isolation period occurs on board, CDC recommends cruise ship medical personnel provide the travelers with a signed letter, on official letterhead that contains the name, address, and phone number of a licensed healthcare provider, stating that the traveler has been cleared to end isolation and therefore can travel.
• Travelers with signs and symptoms of COVID-19 should not travel commercially until COVID-19 has been ruled out.
• Travelers who are identified as close contacts should follow CDC’s recommendations before they travel.

COVID-19 Screening Testing of Crew

Screening Testing of Newly Embarking Crew

• Cruise ship operators should test newly embarking crew on the day of embarkation and again 3-5 days after embarkation.
  • Crew members should wear well-fitting masks outside of their cabin during this time period.
  • If the crew member’s results are positive, they should be isolated until criteria are met for discontinuation of isolation according to the Discontinuation of Isolation for Travelers (Crew and Passengers) section above.
• Medical personnel should document all positive SARS-CoV-2 test results (pre-embarkation, throughout crew member’s contract duration, and post-disembarkation) in the ship’s medical records. These medical records should be made available for CDC inspection upon request.
• Cruise ship operators should report results in aggregate to CDC daily through the EDC form.
• Cruise ships should follow the requirements in section Screening Testing Specifications below.

Routine COVID-19 Screening Testing and Monitoring of All Crew

Screening testing is defined as testing of asymptomatic crew who have not been identified as a close contact to a confirmed case or a case of COVID-19-like illness.

• Laboratory testing of all crew members, or a subset of crew members from each department, on a routine basis (every 1-2 weeks) is recommended to reduce asymptomatic transmission, monitor trends in infection on board the ship, and prevent large-scale outbreaks.
• The cruise ship operator should consider increased frequency of routine screening testing of medical center personnel and any crew in passenger-facing positions (i.e., front-facing crew).
• Cruise ship operators should consider enhancing viral (antigen or NAAT) screening testing of crew to every 48–96 hours for ships when the 7-day traveler (crew or passenger) attack rate reaches 2%. See section below on calculating the 7-day Crew or Passenger Attack Rates.

Crew Screening Testing Specifications

• When choosing a testing method, cruise ship operators should consider the differences in sensitivity between NAAT and antigen tests. At this time, CDC preferentially recommends NAAT for cruise ships because it is less likely to miss cases of SARS-CoV-2 infection (i.e., higher sensitivity) when compared to antigen testing.
• Tests should be performed as authorized under their Emergency Use Authorization (EUA) and described in the manufacturer’s instructions for use (IFU) or equivalent for those authorized in other national jurisdictions. Any specimen type and source specified in the IFU may be used and should be collected by, or under the supervision of, a health care professional.
  • Refer to the FDA website for a list of the SARS-CoV-2 point-of-care and rapid tests that have received Emergency Use Authorization (EUA).
    • Tests that have been authorized for use in a point-of-care setting will have a W, for Waived, in the Authorized Settings column of the FDA table.
    • The laboratory or testing site should use a test authorized for point-of-care use by the FDA and should follow the manufacturer’s instructions for each test.
• Cruise ship operators should immediately transport the specimens to the testing equipment location. Locations may include a CLIA-certified laboratory, onboard laboratory, pier-side equipment, or an offsite area.
• Viral test (including NAAT and antigen tests) systems should:
  • Be authorized by FDA for use in a CLIA-waived setting or authorized for use by the national authority in another country where the ship has operated;
  • Allow for specimen-to-test system transfer in a way that minimizes the risk of contamination.
• If SARS-CoV-2 antigen tests that are FDA cleared or authorized under the EUA are used for the screening of asymptomatic individuals without known exposure, these tests should be performed according to the frequency and intervals specified in the test’s IFU to ensure adequate detection of infected individuals. For antigen testing, cruise ship operators should follow CDC’s Guidance for Antigen Testing for SARS-CoV-2 for Healthcare Providers Testing Individuals in the Community.
• For NAAT, the test should have been FDA cleared or authorized for emergency use by FDA and be a laboratory-based test or a test performed in a CLIA-certified laboratory.
  • Tests should be evaluated on the FDA reference panel for SARS-CoV-2 with a limit of detection (LoD) value ≤18,000 NDU/ml prior to use, or,
  • If test has not been evaluated on the FDA reference panel, sensitivity data should be ≥ 95% using clinical samples included in the manufacture’s IFU should be taken into consideration.
• Self-collection of the sample should only be permitted with the following stipulations:
  • Self-collection should be permitted in the IFU.
  • The specimen should be collected under the observation of trained staff.
  • Trained staff should only observe the collection of a single individual at a time.
• Staff conducting screening testing should be trained and competent in specimen collection, be able to properly use testing equipment, follow all manufacturer’s instructions, and have access to and use recommended personal protective equipment (PPE) for specimen collection, handling, and testing.
  • Cruise ship operators should maintain onboard SARS-CoV-2 testing equipment to manufacturer’s specifications.
• The SARS-CoV-2 virus has developed mutations with the potential to negatively impact the performance of tests for its detection.
  • FDA webpage provides information regarding the potential impact of viral mutations on COVID-19 tests.
• Clarification regarding requirement for “CLIA-waived point-of-care testing” as used in this guidance document:
  • All facilities in the United States that perform laboratory testing on human specimens for health assessment or the diagnosis, prevention, or treatment of disease are regulated by the Centers for Medicare and Medicaid Services (CMS) under the Clinical Laboratory Improvement Amendments of 1988 (CLIA).
  • Waived COVID-19 diagnostic test systems include those cleared or with an EUA by FDA for point-of-care use (e.g., outpatient medical facilities or mobile clinics) and those tests categorized by FDA as waived after FDA approval or clearance (though no COVID-19 tests have been cleared or approved yet). Laboratories that perform only waived tests should obtain and maintain, at minimum, a Certificate of Waiver.
  • CLIA allows for a primary site (e.g., a shoreside corporate office) to have a CLIA Certificate of Waiver and perform testing at temporary sites (e.g., cruise ship medical centers).
  • Cruise ship operators should only use viral tests that are cleared or authorized for emergency use by FDA.
    • For onboard testing, cruise ship operators should only use point-of-care tests that are “CLIA-waived” (i.e., tests that have been determined by FDA to be simple and have a low level of erroneous results through the EUA process or CLIA test categorization process).
      • To the extent that CLIA might apply to a foreign-flagged cruise ship operating or intending to operate in U.S. waters, CMS is temporarily exercising enforcement discretion under CLIA for SARS-CoV-2 testing. Specifically, neither CMS nor the State survey agencies on its behalf will require such foreign-flagged cruise ships to obtain a Certificate of Waiver to perform such testing.

Preventive Measures

Strict adherence to passenger and crew testing protocols and vaccination levels will aid in mitigating transmission and illness onboard; however, continued prevention efforts are necessary to reduce the possibility of transmission to others if a case occurs on board the ship.

General Preventive Measures

• Inform passengers of any mandatory cruise line specific public health measures prior to boarding.
• Incorporate COVID-19 vaccination strategies to maximally protect passengers and crew in the maritime environment, seaports, and in land-based communities.
• Ensure crew remain up to date with their vaccines, which includes additional doses for individuals who are immunocompromised or booster doses at the appropriate times.
• Recommend passengers aged 2 years or older wear a well-fitting mask, in indoor settings, especially when crowded.
• Consider instructing crew members to properly wear a well-fitting mask when outside of individual cabins.
• Consider strategies to improve ventilation of indoor areas and maximize use of outdoor spaces.
• Implement physical distancing to avoid crowding of crew members when working or moving through the ship.
• Reduce face-to-face interactions between crew and passengers to the extent practicable.
• Consider strategies to reduce crowding in all venues and where travelers wait in line.
• Modify meal service to facilitate physical distancing (e.g., reconfigure dining room seating, stagger mealtimes, encourage in-cabin or outdoor dining).
• Encourage passengers to avoid touching eyes, nose, and mouth with unwashed hands.
• Discourage handshaking – encourage the use of non-contact methods of greeting.
• Inform travelers that use of cigarettes, e-cigarettes, pipes, or smokeless tobacco can lead to increased contact between potentially contaminated hands and their mouths.
• Promote respiratory and hand hygiene and cough etiquette.
• Make hand sanitizer (containing at least 60% alcohol) available to passengers, crew, and port personnel throughout the ship and terminal.
• Clean/disinfect frequently touched surfaces regularly.

Embarkation/Disembarkation Procedures

• Recommend passengers, crew, and port personnel wear a well-fitting mask, in indoor areas of the terminal.
• Ensure embarkation and disembarkation procedures follow the processes outlined in the shoreside emergency response plan.
• Ensure there is a private screening area for people identified as needing additional medical screening during the embarkation and check-in process.
• Stagger or schedule embarkation/disembarkation times.
• Provide touchless check-in/check-out processes.
• Ensure written notifications about COVID-19 prevention and control are presented before passengers reach the check-in point to give them enough time to review before check-in.
• Use touchless garbage cans or pails and cashless payment options when possible. Otherwise, exchange cash or card by placing payment in a receipt tray, if available, or on the counter.

Muster Drills

• Conduct virtually or in a staggered manner to avoid crowding between individuals who are not traveling companions or part of the same family.

Dining

• Change restaurant and bar layouts to avoid crowding between parties (such as removing tables/stools/chairs, marking tables/stools/chairs that are not for use).
• Limit seating capacity to allow for physical distancing to avoid crowding.
• Discourage crowded waiting areas by using phone app or text technology to alert patrons when their table is ready. Avoid using “buzzers” or other shared objects.
• Food and beverage stations
  • Use physical guides such as stanchions to direct flow and prevent crowding around beverage station machines and counters.
  • Provide hand sanitizer (containing at least 60% alcohol) at the entrances to food and beverage stations.
• Install physical barriers, such as sneeze guards and partitions in areas where it is difficult for individuals to maintain proper physical distance to avoid crowding, such as serving stations and food pick up areas.
• Provide and encourage outdoor dining and bar/beverage service options.
• Provide and encourage in-room passenger dining service.
• Ensure adequate supplies to minimize sharing of high-touch materials (e.g., serving spoons) to the extent practicable; otherwise, limit use of supplies and equipment by one group of food workers at a time and clean and disinfect between use.
• Consider options for consumers to order ahead of time to limit the amount of time spent in the restaurant.
• Provide alternative meal services options, such as prepackaged grab-and-go meals, for consumption on open decks or in individual cabins to minimize risks associated with congregate indoor dining.
• Use touchless payment options as much as possible, if available.

Elevators

• Limit capacity.
• Consider adding supplemental air ventilation or local air treatment devices in frequently used elevator cars.

Entertainment Venues and Activities

• Improve ventilation in venues
• Limit capacity in areas with performances, dancing, acting, and singing, and similar activities.
• Limit capacity in areas with activities such as rock-climbing walls, zip-lines, mini golf, sports courts, jogging, skating, arcade rooms, and similar activities to avoid crowding.
• Provide adequate space between exercise equipment.
• Limit class sizes to avoid crowding.

Casinos

• Improve ventilation in casinos.
• Increase the space between seats and gaming equipment to avoid crowding between individuals.
• Limit capacity at gaming tables.
• Set up physical barriers to avoid crowding.

Public Toilet Rooms

• Ensure handwashing facilities are well-stocked with soap and a method to dry hands, such as paper towels or air dryers, in accordance with the 2018 VSP Operations Manual [PDF – 291 pages].
• Provide information on how to wash hands properly.

Recreational Water Facilities (RWFs)

• Reduce the bather load for each facility to avoid crowding. When physical distancing between bathers is not possible, such as in small whirlpool spas, RWFs should be used by the same family or traveling companions. This can be accomplished by close monitoring by crew. Exceptions to physical distancing may be needed to:
  • Rescue a distressed swimmer, perform cardiopulmonary resuscitation (CPR), or provide first aid; or
  • Evacuate the water or pool deck due to an emergency.
• Place seating area items located in or around RWFs, such as tables, chairs, loungers, sun beds, and poufs apart from each other to encourage to physical distancing. These items can be grouped together for families and traveling companions.
• Encourage physical distancing recommendations to avoid crowding in lines to use slides and other interactive RWF areas.

Signs and Messages

• Post signs, in highly visible locations (such as at entrances and in toilet rooms), to promote steps that prevent the spread of the virus (such as practicing physical distancing to avoid crowding, washing hands with soap and water frequently, using appropriate cough etiquette, and properly wearing a well-fitting mask or respirator).

Shore Excursions & Transportation Services

• Ensure all shore excursion tour companies facilitate physical distancing to avoid crowding between individuals who are not traveling companions or part of the same family; encourage mask wearing while indoors; and adhere to cleaning and disinfection, and other COVID-19 public health measures throughout the tour.
• Develop and maintain a protocol for managing persons with COVID-19 and close contacts who are recommended to quarantine and who need to disembark at a foreign port of call. At a minimum, the protocol should include the following:
  • Plans for disembarking and housing persons with suspected or confirmed COVID-19 needing shore-based hospital care and their travel companion(s) for the duration of their isolation or quarantine period.
  • Commercial repatriation of U.S.-based persons with COVID-19 and close contacts should follow CDC guidance. For commercial repatriation of foreign-based persons with COVID-19 or close contacts, cruise ship operators should consult with all relevant public health authorities.

Other

• Consider the use of wearable proximity alerting technology, such as proximity bands, to aid in contact tracing.

7-day Crew or Passenger Attack Rates

Crew: 7-day crew attack rates are calculated using the cumulative number of crew cases in the last 7 days divided by the average number of crew onboard the ship in the last 7 days.

Passenger: 7-day passenger attack rates are calculated using the cumulative number of passenger cases in the last 7 days divided by the average number of passengers onboard the ship in the last 7 days.

The following persons should not be included in these calculations because they do not pose a risk of transmission onboard the ship:

1. passengers who test positive on day of embarkation who do not board the ship, or
2. newly embarking crew members who test positive during quarantine.

Disclaimer: The accuracy of attack rates is dependent upon the frequency of routine screening testing of asymptomatic travelers on board.

Enhanced Preventive Measures (recommended when 7-day crew or passenger attack rate reaches 1%)

• Recommend passengers aged 2 years or older wear a well-fitting mask, when indoors and any crowded outdoor settings.
• Minimize the number of crew sharing a cabin or bathroom to the extent practicable.
• 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, and other group settings.
• Expedite contact tracing (including the use of wearable technology, recall surveys, and the onboarding of additional public health staff).
• Close crew indoor smoking areas.
• Provide all crew members with well-fitting, high-quality masks or respirators, such as KN95s.

Outbreak Public Health Interventions (recommended when 7-day crew or passenger attack rate reaches 2%)

• Require mask use by passengers when indoors and any crowded outdoor settings, regardless of vaccination status.
• Provide all passengers with well-fitting masks or respirators, such as KN95s, and
  • Provide passengers and crew with information on how to properly wear, take off, and clean (if reusable) masks.
  • Remind passengers and crew not to touch their masks when wearing them.
  • Position posters educating passengers on how to properly wear well-fitting masks in high traffic areas throughout the ship.
• Increase frequency of viral (antigen or NAAT) screening testing of crew to every 48–96 hours. The onboarding of additional laboratorians may be needed to facilitate the testing process.
• Implement a “working quarantine” (i.e., crew perform job duties then return to cabin quarantine) policy for crew who are not identified as close contacts.
• Reduce the dining cohort size for crew (to as few as 20 crew members per dining room) while ensuring physical distancing and shorter dining times.
• Maximize the introduction of outdoor air and adjust HVAC systems to increase total airflow to occupied spaces.
• Ensure physical distancing and maximize air circulation in crew outdoor smoking areas.
• Eliminate self-serve dining options at all crew and officer messes.
• Cancel crew shore leave.
• Test all passengers prior to the end of the voyage, regardless of their vaccination status.
• Send written notification to passengers on the current, previous, and subsequent voyages informing them of the COVID-19 conditions and measures being taken to reduce transmission on board.

Considerations for Suspending Operations

Additional public health precautions, such as returning to port immediately or delaying the next voyage, should be taken to help ensure the health and safety of onboard travelers or newly arriving travelers.

A ship should consider suspending operations based on the following factors:

• Sustained transmission of COVID-19, defined as a 7-day:
  • Crew attack rate greater than or equal to 10% occurring at least once weekly over 3 consecutive weeks;
  • Passenger attack rate greater than or equal to 10% occurring at least once weekly over 3 consecutive weeks;
  • Crew attack rate greater than or equal to 20% occurring on any single day;
  • Passenger attack rate greater than or equal to 20% occurring on any single day; or
  • Traveler (crew AND passenger) attack rate greater than or equal to 30% occurring on any single day [7].
• Severe COVID-19 among passengers or crew resulting in:
  • Shortages of supplemental oxygen or other medical supplies related to COVID-19 treatment, or
  • 2 or more deaths in passengers and/or crew in a 7-day period.
• Potential for COVID-19 cases to overwhelm on board medical center and/or public health resources, defined as the inability to maintain:
  • Adequate staff to
    • Evaluate symptomatic travelers and their close contacts,
    • Conduct diagnostic and screening testing of travelers,
    • Conduct routine medical checks of travelers in isolation or quarantine, or
    • Conduct contact tracing of close contacts.
  • Adequate supplies of
    • Personal protective equipment (PPE) listed on CDC’s Interim Guidance for Ships on Managing Suspected or Confirmed Cases of Coronavirus Disease 2019,
    • Testing equipment for routine and diagnostic screening,
    • Antipyretics (fever-reducing medications such as acetaminophen and ibuprofen),
    • Antivirals and other therapeutics for COVID-19, if commercially available,
    • Oral and intravenous steroids, or
    • Supplemental oxygen.
• Inadequate onboard capacity to fulfill minimum safe manning or minimal operational services, including but not limited to housekeeping and food and beverage services.
• A variant of concern or a new or emerging variant with potential for increased severity or transmissibility identified among cases on board.

[7] These thresholds are subject to change based on the characteristics of the dominant COVID-19 variant in the U.S.

Infection Prevention and Control Plan

Infection prevention and control (IPC) is critical to reducing the spread of SARS-CoV-2. Each cruise ship should maintain a written Infection Prevention and Control Plan (IPCP) that details standard procedures and policies to specifically address infection control and cleaning/disinfection procedures to reduce the spread of COVID-19.

To reduce the spread of SARS-CoV-2, cruise ship operators should include the following as part of a written IPCP:

• Duties and responsibilities of each department and their staff for all passenger and crew public areas.
• Steps in IPC management and control and the triggers required for action at each step. At a minimum, triggers should address a graduated approach to IPC management in response to increasing case counts.
• Disinfectant products or systems used, including the surfaces or items the disinfectants will be applied to, concentrations, and required contact times. Use disinfectant products or systems that are listed on the Environmental Protection Agency (EPA) List N: Disinfectants for Coronavirus (COVID-19).
• Procedures for informing passengers and crew members that a threshold of COVID-19 has been met or exceeded. This section should address the procedures for notification of passengers and crew currently onboard the ship and those embarking the vessel on the subsequent voyage.
• Graduated procedures for returning the vessel to normal operating conditions after a threshold of COVID-19 has been met or exceeded, including de-escalation of cleaning and disinfection protocols.
• Procedures to protect passengers and crew from exposure to disinfectants, if not already included in the ship’s safety management system. At a minimum, this should include the following:
  • Safety data sheets (SDSs)
  • PPE per CDC guidance for crew
  • Health and safety procedures to minimize respiratory and dermal exposures to both passengers and crew

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. Frequent, routine cleaning and disinfection of commonly touched surfaces such as handrails, countertops, and doorknobs with an EPA-registered disinfectant effective against coronaviruses is strongly recommended. 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 and CDC’s Vessel Sanitation Program 2018 Operations Manual [PDF – 291 pages].

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

Other environmental considerations include:

• Waiting 24 hours or as long as practical before beginning cleaning and disinfection of cabins vacated by travelers with confirmed or suspect COVID-19.
• Not shaking dirty laundry in order to minimize the possibility of dispersing virus through the air.
• Laundering 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/or using detergents effective against coronaviruses, and drying items completely.
• Identifying 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 travelers.
• Designating trolleys/carts used for the transportation of waste and soiled linens from isolated or quarantined cabins and cleaning/disinfecting them with an effective disinfectant after each use.

Frequently Asked Questions

The following frequently asked questions (FAQs) for cruise ship operators and medical center personnel to provide more detail about CDC recommendations for cruise ships.

CDC recommends all eligible travelers be up to date with their COVID-19 vaccines. A threshold cruise ship operators can consider is operating with least 90% passengers and 95% crew who are up to date with their COVID-19 vaccines. While the protection COVID-19 vaccines provide to individual travelers in preventing severe illness or death from COVID-19, having a high proportion of travelers on board who are up to date with COVID-19 vaccines reduces the likelihood that cruise ships’ medical centers are overwhelmed by cases of COVID-19.

Yes, for the purpose of the cruise ship guidance, if an eligible traveler has not received a booster dose but is within 1 month of their recommended booster vaccination date, then they can be considered up to date with their COVID-19 vaccines.

Example for mRNA vaccines (Pfizer BioNTech/Moderna):

1. Traveler A (a healthy 45-year-old female) received their second Pfizer BioNTech/Moderna dose on January 1, 2022, the traveler can be considered up to date with their COVID-19 vaccines until July 1, 2022. If Traveler A does not get a booster by July 1, 2022, then they will not be considered up to date with their COVID-19 vaccines.

Example for J&J/Janssen vaccine:

1. Traveler B (a healthy 25-year-old male) received their J&J/Janssen dose on January 1, 2022, then the traveler can be considered up to date with their COVID-19 vaccines until April 1, 2022. If Traveler A does not get a booster by April 1, 2022, then they will not be considered up to date with their COVID-19 vaccines.

How many days after travel should I quarantine?

How long do international travelers have to quarantine?

What precautions should I take after traveling internationally during the Covid