Purpose

This document provides instructions for the initial phases of CDC’s Framework for Conditional Sailing Order for cruise ship operations in U.S. waters to ensure health and safety protections for the crew prior to resuming passenger operations in a way that mitigates the risk of spreading COVID-19.

As a condition of obtaining or retaining permission to engage in any cruise ship operations in U.S. waters, the Framework for Conditional Sailing Order (CSO) pdf icon[PDF – 40 pages], published in the Federal Registerexternal icon on November 4, 2020, requires that cruise ship operators take adequate safeguards for crew, as demonstrated through laboratory testing for SARS-CoV-2 infection and other measures, to prevent, mitigate, and respond to the risk of COVID-19 on board cruise ships.

These instructions are not intended as, and do not constitute, a comprehensive statement regarding a cruise ship operator’s duties and obligations under the Framework for Conditional Sailing Order. Cruise ship operators must establish mechanisms to ensure compliance with this Order, including any plans adopted pursuant to the Order, and immediately notify CDC and United States Coast Guard (USCG) within 24 hours of any deviations, whether intentional, or as a result of error or omission.

These instructions reflect CDC’s reasoned judgement based on the best available current science regarding the subject areas covered in the document. Cruise ship operators should carefully consider and incorporate these instructions in developing their own health and safety protocols.

CDC will update these instructions for cruise ships for the additional phases of resuming cruise ship passenger operations, as described in the Order and in future conditional sailing orders. CDC will notify cruise lines when these instructions are 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, aerosols, 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, CDC recommends that cruise ship operators:

• Explore options to vaccinate crew for COVID-19. This includes encouraging crew to get the COVID-19 vaccine when eligible and the vaccine is available.
• 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, and 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 face mask 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”, “Orange”, or “Yellow” criteria. See COVID-19 Color-coding System for Cruise Ships During the Initial Phases of Conditional Sailing Order.

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 daily submission of the “Enhanced Data Collection (EDC) During COVID-19 Pandemic Form” during the period of the Framework Order. This EDC Form will be used to conduct surveillance for COVID-19 on board cruise ships using cumulative reports of COVID-19-like illness ¹, which includes acute respiratory illness (ARI), influenza-like illness (ILI), pneumonia, and additional COVID-19-like illness (aCLI) clinical criteria.
• Access to the online EDC form has been provided to cruise lines by the Cruise Lines International Association (CLIA) or CDC. Cruise lines that do not have access should contact CLIA or CDC (email eocevent349@cdc.gov).
• In addition to this daily 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.

CDC may publish these surveillance data on its website or in other documents to inform the public.

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

• Persons with at least one or more of the following symptoms: fever, cough, difficulty breathing, shortness of breath, new olfactory disorder, or new taste disorder; OR
• Persons with 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
• Persons with severe respiratory illness with at least one of the following:
  • Clinical or radiographic evidence of pneumonia,
  • Acute respiratory distress syndrome (ARDS).

CSO Phase 1 Shoreside COVID-19 Laboratory Screening Testing of All Crew

• In preparation for the resumption of passenger operations, cruise ship operators must have adequate health and safety protections for crew members while they build the onboard laboratory capacity needed to test crew and future passengers. By December 29, 2020 (60 days after the effective date of the Framework Order)*, cruise ship operators were expected to collect clinical specimens for SARS-CoV-2 testing from all crew currently onboard their cruise ships and arrange for the transportation and testing of those specimens at a shoreside laboratory facility. This testing was to be conducted by a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory using nucleic acid amplification tests (NAATs). Examples of available NAATs for SARS-CoV-2 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), and helicase-dependent amplification (HDA), authorized for emergency use by the U.S. Food and Drug Administration (FDA) and that has been evaluated on the FDA reference panelexternal icon for SARS-CoV-2 with a limit of detection (LOD) value ≤18,000 NDU/ml ². Specimens must be collected via nasopharyngeal (NP) swab. At this point in time, CDC Maritime Unit does not permit specimens collected from saliva, the anterior nares, the nasal mid-turbinate, or the oropharynx.
• Prior to collecting specimens and conducting testing: Cruise ship operators must contact CDC at eocevent349@cdc.gov at least 7 calendar days prior to collecting specimens. Include “Laboratory Screening Testing of All Crew Onboard [SHIP NAME]” in the subject line as part of your request for CDC approval.
• CDC’s response to the cruise ship operator’s email may include additional information regarding best practices that may assist cruise ship clinicians or public health staff in collecting and transporting specimens.
• CDC may oversee the onboard collection of crew specimens through remote means allowing for visual observation.
• All specimens for a ship’s crew must be tested at the same laboratory and not divided between different shoreside laboratories.
• If the shoreside laboratory does not provide specimen collection kits, then CDC must approve the cruise ship operator’s selection of a supplier for the specimen collection kits.
• Cruise ship operators must report all laboratory results in aggregate to CDC through the Enhanced Data Collection (EDC) form.
  • To ensure the integrity of testing, persons with positive NAAT results must not be retested, and the original positive results must be reported. Subsequent negative results do not negate an initial positive result.
• Persistent Positives: CDC will consider all positive NAAT results as new cases, unless laboratory documentation of a previous SARS-CoV-2 by NAAT result within the previous 3 months is provided and the individual is asymptomatic. While some positive results may be from people who have recovered from COVID-19 and are no longer infectious (i.e., persistent positives), CDC cannot make this determination without submission of previous laboratory results.

• Medical personnel should document all positive SARS-COV-2 test results (pre-embarkation, throughout crew members’ contract duration, and post-disembarkation) in the ships’ medical records. These medical records must be made available for CDC inspection upon request.
• Crew who test positive for SARS-COV-2 should not be re-tested (e.g., as part of a contact tracing investigation) until 90-days post lab-confirmed diagnosis, unless they are symptomatic and no alternate infectious etiology (e.g., influenza, respiratory syncytial virus (RSV), Legionella, Streptococcal pharyngitis) has been identified through laboratory testing. These symptomatic crew must be isolated and re-evaluated, including retesting, regardless of prior positive test results.

*Note: For cruise ship operators with ships that have not been in U.S. waters during the period of the No Sail Order or voluntarily withdrew their ships, the 60-day period will begin upon: (1) CDC’s confirming to the cruise ship operator in writing that the operator has a complete and accurate NSO response plan, including having submitted to CDC a signed Acknowledgment of No Sail Order Response Plan Completeness and Accuracy; and (2) submission of the EDC form for the 28 days preceding the cruise ship’s expected arrival in U.S. waters.

[2] NDU=RNA NAAT detectable unit; CDC’s laboratory 2019-nCOV RT-PCR diagnostic panel was used to define the LOD cut-off value. A high LOD indicates that the assay has a lower sensitivity which may result in more false negative results, especially in asymptomatic infected people. A lower LOD represents an assay’s ability to detect a smaller amount of viral material in a given sample, signaling a more sensitive test.

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

• By December 29, 2020*, cruise ship operators, in coordination with CDC, were expected to implement onboard testing capabilities to be able to test all symptomatic travelers (crew and future passengers) and their close contacts for SARS-CoV-2.
• All cruise ships must procure NAAT point-of-care equipment to test symptomatic travelers (and their identified close contacts).
  • This test system must:
    • Be CLIA-waived;
    • Be evaluated on the FDA reference panelexternal icon for SARS-CoV-2 and possess a limit of detection (LOD) value ≤18,000 NDU/ml;
    • Provide a result without the need for operator interpretation; and
    • Allow for specimen-to-instrument transfer in a way that minimizes the risk of contamination.
  • Cruise ship operators must contact CDC prior to procuring this equipment.
  • Antigen testing is not recommended at this time because it is more likely to miss cases of SARS-CoV-2 infection (i.e., lower sensitivity) when compared to NAAT.
  • Specimens must be collected via nasopharyngeal (NP) swab. At this point in time, CDC Maritime Unit does not permit specimens collected from saliva, the anterior nares, the nasal mid-turbinate, or the oropharynx.
  • If separate nasopharyngeal specimens are collected for multiple tests (e.g., COVID-19 NAAT and influenza rapid antigen test) among symptomatic persons, these specimens should be collected from alternating nostrils of the case-patient with the first collected specimen designated for COVID-19 testing.
• Cruise ship medical clinic staff must be 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.
  • CDC may ensure competency by conducting oversight of these practices through remote, visual observation.
  • Cruise ship operators must maintain onboard SARS-CoV-2 testing equipment to manufacturer’s specifications.
• Once testing equipment has been obtained and cruise ship medical clinic staff are properly trained in its use, all symptomatic crew onboard the cruise ship must be tested for SARS-CoV-2 infection immediately upon notifying medical staff of symptom onset. Results must be reported to CDC in aggregate through the EDC form.
• Because of the potential for asymptomatic and pre-symptomatic transmission, it is important that close contacts of individuals with SARS-CoV-2 infection be quickly identified and tested.
  • NAAT for COVID-19 must not be performed earlier than 48 hours after the first exposure to the case.
  • A negative test during quarantine does not mean the contact will remain negative after test results have been obtained; therefore, close contacts must quarantine for 14 days.
• Clarification regarding requirement for “CLIA-waived point-of-care testing” as used in the Framework Order:
  • 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 authorized by FDA in an emergency use authorization (EUA) 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 must 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).
  • Under the Framework Order, cruise ship operators must use tests that are approved, cleared, or authorized for emergency use by FDA and evaluated on the FDA reference panelexternal icon for SARS-CoV-2 with a limit of detection (LOD) value ≤18,000 NDU/ml, as specified by CDC in technical instructions or orders.
    • For onboard testing, cruise ship operators must use a point-of-care test that is “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.

*Note: For cruise ship operators with ships that have not been in U.S. waters during the period of the No Sail Order or voluntarily withdrew their ships, the 60-day period will begin upon: (1) CDC’s confirming to the cruise ship operator in writing that the operator has a complete and accurate NSO response plan, including having submitted to CDC a signed Acknowledgment of No Sail Order Response Plan Completeness and Accuracy; and (2) submission of the EDC form for the 28 days preceding the cruise ship’s expected arrival in U.S. waters.

Screening Testing of All Newly Embarking Crew

• On the day of the crew members’ embarkation, cruise ship operators must collect specimens for SARS-CoV-2 testing from all newly embarking land-based crew. Cruise ship operators must immediately transport the specimens to a CLIA-certified laboratory or to their onboard laboratory for testing.
• The shoreside laboratory must use a NAAT that has been authorized for emergency use by FDA and that has been evaluated on the FDA reference panelexternal icon for SARS-CoV-2 with a limit of detection (LOD) value ≤18,000 NDU/ml. CDC must approve the cruise ship operator’s selection of a CLIA-certified laboratory. All additional requirements as listed for Shoreside COVID-19 Laboratory Screening Testing of All Crew, above, must also be followed.
• Onboard testing must be completed on a NAAT point-of-care instrument that is CLIA-waived and has been evaluated on the FDA reference panel for SARS-CoV-2 with a limit of detection (LOD) value ≤18,000 NDU/ml. All additional requirements as listed for Onboard COVID-19 Testing for Symptomatic Travelers (Crew and Future Passengers) and Close Contacts, above, must also be followed.
• Specimens must be collected via nasopharyngeal (NP) swab. At this point in time, CDC Maritime Unit does not permit specimens collected from saliva, the anterior nares, the nasal mid-turbinate, or the oropharynx.
  • If additional screening tests (e.g., antigen) are being used at the discretion of the cruise ship operator, these specimen collections must not precede the NAAT specimen collection (i.e., the first NP swab must always be used for the NAAT).
• Cruise ship operators must report results in aggregate to CDC through the EDC form.
• All embarking land-based crew must be immediately quarantined onboard for 14 days.
  • Those who test positive must be isolated until criteria are met for discontinuation of isolation according to the most current CDC guidance.
• CDC may oversee, through remote, visual observation, the collection of specimens.
• Persistent Positives: CDC will consider all positive NAAT results as new cases, unless laboratory documentation of a previous SARS-CoV-2 by NAAT result within the previous 3 months is provided and the individual is asymptomatic. While some positive results may be from people who have recovered from COVID-19 and are no longer infectious (i.e., persistent positives), CDC cannot make this determination without submission of previous laboratory results.
  • Medical personnel should document all positive SARS-COV-2 test results (pre-embarkation, throughout crew members’ contract duration, and post-disembarkation) in the ships’ medical records. These medical records must be made available for CDC inspection upon request.
  • Crew who test positive for SARS-COV-2 should not be re-tested (e.g., as part of a contact tracing investigation) until 90-days post lab-confirmed diagnosis, unless they are symptomatic and no alternate infectious etiology (e.g., influenza, respiratory syncytial virus (RSV), Legionella, Streptococcal pharyngitis) has been identified through laboratory testing. These symptomatic crew must be isolated and re-evaluated, including retesting, regardless of prior positive test results.
• End of Quarantine Testing for Newly Embarking Crew: Asymptomatic crew members must be tested via onboard NAAT point-of-care equipment or by NAAT at a CDC-approved shoreside laboratory on day 14 of quarantine (i.e., prior to leaving quarantine).
  • If the crew member’s results are pending, they must remain in quarantine until the test result is available.
  • If the crew member’s results are positive, they must begin an isolation period.

CSO Phase 2A Routine COVID-19 Screening Testing of All Crew

As per CDC’s Framework for Conditional Sailing Order, after the completion of the initial 60-day crew testing requirement, laboratory testing for every crew member must be conducted on a weekly basis or at such other intervals as required by CDC.

CDC revised the color-coding criteria by reducing the 28-day duration of color status to 14-days based on the increased availability of onboard testing, routine screening testing protocols, and daily reporting via the EDC form.

Screening Testing^ Frequency by Ship Color Status

^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.

• For routine screening testing of all crew (as outlined above in the Screening Testing Frequency by Ship Color Status table), cruise ship operators can choose to use either:
  • A CDC-approved shore-side laboratory.
    • CDC must approve the cruise ship operator’s selection of a CLIA-certified laboratory and the cruise ship operator’s procurement of specimen collection kits.
      • The tests must have been evaluated on the FDA reference panel for SARS-CoV-2external icon with a limit of detection (LOD) value <18,000 NDU/ml[1].
      • If the cruise ship operator has a CLIA-certified laboratory previously approved by CDC, it can continue to use the laboratory without obtaining additional CDC approval.
      • If the cruise ship operator does not have CLIA-certified laboratory previously approved by CDC or wishes to use a different laboratory, it must contact CDC at eocevent349@cdc.gov at least 7 calendar days prior to collecting specimens and conducting testing. The request for CDC approval should include “Routine Laboratory Screening Testing of All Crew Onboard SHIP NAME” in the subject line. This approval is necessary to help ensure the validity of sampling, testing, and test results.
      • Specimens collected for testing may be pooled and/or batched in accordance with CDC guidance and Instructions for Use (IFU) for the specific assay.
      • All additional requirements as listed for Shoreside COVID-19 Laboratory Screening Testing of All Crew, above, must also be followed.
  • OR
     
  • The CDC-approved onboard NAAT point-of-care equipment.
    • This instrument must be CLIA-waived, have been evaluated on the FDA reference panel for SARS-CoV-2external icon, and demonstrated a lower limit of detection correlating to higher sensitivity.
    • To optimize the viral load obtained from the nasopharyngeal specimen for the NAAT, specimen collection for the NAAT must not be preceded by specimen collection for an alternative test (i.e., antigen).
    • Specimens collected for testing cannot be pooled for testing.
    • Antigen testing is not recommended at this time because it is more likely to miss cases of SARS-CoV-2 infection (i.e., lower sensitivity) when compared to NAAT.
    • All additional requirements as listed for Onboard COVID-19 Testing for Symptomatic Travelers (Crew and Future Passengers) and Close Contacts, above, must also be followed.
• Persistent Positives: CDC will consider all positive NAAT results as new cases, unless laboratory documentation of a previous SARS-CoV-2 by NAAT result within the previous 3 months is provided and the individual is asymptomatic. While some positive results may be from people who have recovered from COVID-19 and are no longer infectious (i.e., persistent positives), CDC cannot make this determination without submission of previous laboratory results.
  • Medical personnel should document all positive SARS-COV-2 test results (pre-embarkation, throughout crew members’ contract duration, and post-disembarkation) in the ships’ medical records. These medical records must be made available for CDC inspection upon request.
  • Crew who test positive for SARS-COV-2 should not be re-tested until 90-days post lab-confirmed diagnosis, unless they are symptomatic and no alternate infectious etiology (e.g., influenza, respiratory syncytial virus (RSV), Legionella, Streptococcal pharyngitis) has been identified through laboratory testing. These symptomatic crew must be isolated and re-evaluated, including retesting, regardless of prior positive test results.
• Repeat Testing of Positive Results: To ensure the integrity of testing, persons with positive NAAT results must not be retested, and the original positive results must be reported. Subsequent negative results do not negate an initial positive result.
• Staggered Testing: Cruise ship operators at their discretion may stagger whole ship crew testing during the corresponding color-coding interval (e.g., weekly, every two weeks, every 28 days). For example, the cruise ship operator may choose to test the same percentage of crew on each day of the week if required to test weekly. To ensure consistency, screening testing must be completed within 4 consecutive days of each color-coding interval and the testing schedule for each crew member should remain the same across all color-coding intervals.

[3] CDC’s laboratory 2019-nCOV RT-PCR diagnostic panel was used to define the LOD cut-off value. A high LOD indicates that the assay has a lower sensitivity which may result in more false negative results, especially in asymptomatic infected people. A lower LOD represents an assay’s ability to detect a smaller amount of viral material in a given sample, signaling a more sensitive test.

Procedures for Embarking Overnight Contractors and Overnight Visitors

In lieu of requiring overnight contractors and visitors to quarantine onboard for 14 days, ships may follow the procedures below if the contractor or visitor will be onboard for 7 or less nights:

• Embarkation-day testing using a CDC-approved onboard point-of-care instrument (or CDC-approved shoreside laboratory) is required. All additional requirements outlined for crew in Screening Testing of All Newly Embarking Crew must be followed.
  • If test is negative, the following public health measures are needed:
    • Strict social distancing
    • All meals in cabin
    • No interaction with crew, except to perform duties
    • Daily symptom checking
    • Limit number of crew that have contact with contractor or visitor (i.e., limit interaction to only one engineer opposed to multiple)
    • Mask must be worn at all times when out of cabin
    • Not permitted to roam the ship when off duty and must return to their cabin when not working
  • If test is positive before embarkation, contractor or visitor should not board until criteria for discontinuing isolation are met.
  • If test result not available same day, contractor or visitor must quarantine onboard until the result is available.
    • If negative, individual can be released from quarantine following public health measures above.
    • If positive, individual must remain in isolation on board until criteria for discontinuing isolation are met.
  • Crew members working with the contractor or visitor onboard and who would be considered close contacts to the contractor or visitor must:
    • Avoid interaction with other crew during the period they are working with contractor or visitor, and
    • Quarantine for 14 days after work with contractor or visitor is completed.

All contractors and visitors who are expected to remain onboard for more than 7 nights are required to quarantine for 14 days upon embarkation and are subject to all crew protocols including a negative test at a shoreside or onboard laboratory on day of embarkation.

All overnight contractors and visitors, regardless of how many nights they remain on the ship, must be reported on the EDC form as crew members. They must be included in the total number of crew onboard, and their day of embarkation test results must be reported to CDC on the EDC form.

Procedures for Embarking Day Contractors and Day Visitors

• Day contractors and day visitors must:
  • Be denied boarding if exhibiting signs or symptoms of COVID-19 or have a known exposure to a person with COVID-19 within the past 14 days.
  • Wear a mask for the duration of their visit onboard the ship.
  • Maintain appropriate social distancing of 6 feet when possible.
  • Observe proper hand hygiene.
• Ensure that all areas in which day contractors and day visitors worked while onboard are disinfected after they exit the areas.

Boarding Non-Essential Crew

As a condition of a ship’s obtaining controlled free pratique to board non-essential crew, CDC must verify that the cruise ship operator has documented the approval of all U.S. port and local health authorities where the ship intends to dock or make port during one or more simulated voyages or restricted passenger voyages. Cruise ship operators must follow all requirements of the Technical Instructions for a Cruise Ship Operator’s Agreement with Port and Local Health Authorities under CDC’s Framework for Conditional Sailing Order and continue to follow these Technical Instructions for screening testing of embarking crew and the quarantine and isolation of crew.

The cruise ship operator must contact CDC at eocevent349@cdc.gov at least 7 calendar days in advance of the first embarkation of non-essential crew. The request for CDC approval should include “Request for Non-essential Crew Embarkation for SHIP NAME” in the subject line. Once CDC approves the request the ship will no longer be required to submit any crew (essential or non-essential) embarkation requests to CDC. Non-essential crew cannot be transferred to another ship that has not received approval from CDC to board non-essential crew.

Crew Monitoring

Cruise ship operators should educate crew members about the signs and symptoms of COVID-19; the need to notify cruise ship medical staff immediately if symptoms develop; and the importance of not working and isolating in their cabins while sick with fever or other symptoms or COVID-19 until they meet criteria for discontinuation of isolation according to CDC guidance, as determined by cruise ship medical staff.

Crew must be monitored daily for signs and symptoms of COVID-19. If cruise ship operators can provide thermometers, self-temperature checks are preferable.

Disembarking Asymptomatic Crew for Transfer or Repatriation

During the initial phases of the Framework Order, there are stipulations for crew transfers and repatriation.

• Use of commercial transportation by crew from ships unaffected by COVID-19, as defined below, may occur. The cruise line must complete the Attestation for Commercial Transportation of Disembarking Crew for Cruise Ship Operators During the Initial Phases of CDC’s Framework for Conditional Sailing Order before crew can travel commercially.
• To be considered currently unaffected by COVID-19, ships must have had no confirmed cases of COVID-19 [1] or COVID-19-like illness in the past 14 days and if the ship received ship-to-ship [2] transfers within the past 14 days, crew must have come from a ship that had no confirmed COVID-19 or COVID-19-like illness within the 14 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.
• For crew members who disembark for repatriation, but whose travel arrangements are cancelled:
  • If crew member re-embarks the same day of disembarking (i.e., without an overnight shoreside stay), then:
    • Ship re-embarkation testing is not required
    • Quarantine is not required
  • If crew member re-embarks less than 48 hours from disembarking and with an overnight shoreside stay, then:
    • Ship re-embarkation testing is not required
    • Quarantine is required until next disembarkation or for 14 days, whichever is lesser
  • If crew member re-embarks more than 48 hours from disembarking, then:
    • Ship re-embarkation testing is required
    • Quarantine is required until next disembarkation or for 14 days, whichever is lesser
• Use of commercial transportation by crew members who have recovered from COVID-19 and met criteria for release from isolation according to CDC guidance within the previous 3 months 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 regulations pdf icon[PDF – 958 pages]external icon (14 Code of Federal Regulations § 382.23(c)(2)).
• Crew members who recovered from COVID-19 more than 3 months ago are subject to the same conditions for disembarkation as other crew members on board the ship.

1. Confirmed COVID-19 means laboratory confirmation for SARS-CoV-2, the virus that causes COVID-19, by NAAT.
2. COVID-19-like illness means acute respiratory illness (ARI), influenza-like illness (ILI), diagnosis of pneumonia, or other signs and symptoms of COVID-19.

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 must 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 information, please refer to Interim Guidance for Ships on Managing Suspected or Confirmed Cases of Coronavirus Disease 2019.

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

Crew with COVID-19-like illness (CLI) must be isolated using the same procedures as a crew member with confirmed COVID-19. If the symptomatic crew member has a negative SARS-CoV-2 test result, they must continue to follow CDC’s COVID-19 isolation guidance. 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 must have no direct contact with other crew except for designated medical staff.
• Designated medical staff or other personnel must 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 must be 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 or Confirmed Cases of Coronavirus Disease 2019. Maintaining adequate supplies of antipyretics (e.g., acetaminophen and ibuprofen), antiviral and antimicrobial medications, oral and intravenous steroids, and supplemental oxygen is also recommended. Information to estimate needed medical staffing and equipment can be found in the Federal Healthcare Resilience Task Force Alternate Care Site Toolkitpdf iconexternal icon, Supplement 2. As treatment and testing become more available in the United States, cruise ships must 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. Cruise ship operators should have clear protocols that avoid medical evacuations at sea to the extent possible for either COVID-19 and non-COVID-19-related medical reasons. Protocols must 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. All medical evacuations at sea must be coordinated with the U.S. Coast Guard.

• Crew member must wear a face mask, i.e., a cloth mask or surgical 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).
• 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.
  • Cruise ship operator must 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 have 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 or other clinical indicators of COVID-19.

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 disinfectantexternal icon effective against coronaviruses is required.

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 Initial Phases of the Framework for Conditional Sailing Order

These instructions 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 daily submission of the Enhanced Data Collection (EDC) during COVID-19 Pandemic.

Green Ship Criteria

• No confirmed cases of COVID-19 or COVID-19-like illness for 14 days, as determined by a qualified medical professional.
• If the ship received ship-to-ship transfers within the past 14 days, crew must have come from a ship that had no confirmed COVID-19 or COVID-19-like illness within the 14 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 daily EDC form to CDC. Failure to submit by 0900 ET each day changes ship status to Red. Green ship status means that CDC considers the ship to be currently unaffected by COVID-19 based on information provided by the cruise ship operator.

Orange Ship Criteria

Orange ship status in the absence of pre-existing Red ship status or a case report on the same day that would change the ship’s status to Red.

• One or more cases of confirmed COVID-19 among newly embarking crew that:
  • Were diagnosed within their embarkation 14-day quarantine period,
  • As determined by a qualified medical professional, had a non-contact embarkation process and no close contacts were identified during the embarkation process (i.e., absence of exposures during embarkation), and
  • The ship had no other confirmed cases of COVID-19 onboard during the past 14-days.

• OR
   
• One or more cases of COVID-19-like illness with negative or repeatedly inconclusive/invalid (i.e., never able to register a positive or negative result) NAAT results for COVID-19 within the past 14-days (with no other laboratory-confirmed respiratory pathogens (e.g., influenza, RSV, Legionella, Streptococcal pharyngitis))
  • Diagnosed either within or outside of their embarkation 14-day quarantine period, and
  • The ship had no other confirmed cases of COVID-19 onboard during the past 14-days.
• If the ship received ship-to-ship transfers within the past 14 days, crew must have come from a ship that had no confirmed COVID-19 or COVID-19-like illness within the 14 days before the transfer occurred.
• If land-based crew embarked, they were immediately quarantined for 14 days upon embarking the ship.

Yellow Ship Criteria

• Ship was previously designated Green or Orange, but now has 1 or more COVID-19-like illness cases pending SARS-CoV-2 NAAT due to lack of onboard testing capability (e.g., ran out of testing cartridges or ship is still within 60-day Phase 1 CSO requirements).
  • If all cases are NAAT-negative, ship status goes to Orange
  • If any cases are NAAT-positive, ship status changes to Red (must re-sign attestation after meeting Green criteria again)
  • If crew with COVID-19-like illness are not tested by NAAT or if results are not available within 1 week of the first case being reported, ship status changes to Red.
• If the ship received ship-to-ship transfers within the past 14 days, crew must have come from a ship that had no confirmed COVID-19 or COVID-19-like illness within the 14 days before the transfer occurred. If not, ship status changes to Red.
• If land-based crew embarked, they were immediately quarantined for 14 days upon embarking the ship. If not, ship status changes to Red.

Red Ship Criteria

• One or more cases of confirmed COVID-19 that do not meet criteria for Orange status, or
• Ship received ship-to-ship transfers from a ship that had confirmed COVID-19 or COVID-19-like illness within the 14 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 14 days, the ship missed one or more daily submissions of the EDC form.

COVID-19 Color-coding System for Cruise Ships During the Initial Phases of the Framework for Conditional Sailing Order

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 During the Initial Phases of CDC’s Framework for Conditional Sailing Order to CDC at eocevent349@cdc.gov.
3. To confirm Green status, CDC will assess the status of the ship by reviewing surveillance data submitted daily 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 CSO period.
   3. Crew can continue to use commercial travel if the ship’s status change from Green to Orange.
5. Once a ship has achieved “Green” status and has a cleared attestation, CDC will continue to review the ship’s status on a daily basis to determine if it changes to Orange, Yellow, or Red. Failure to submit daily EDC form, changes ship status to Red.
6. If ship’s status changes from Green or Orange 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 or changed from Green to Orange, including a signed and approved attestation, may provide a letter informing the airline that the crew member will disembark a ship that is cleared for commercial travel. The letter can be provided to the:
   1. commercial airline upon booking, and/or
   2. crew member upon disembarkation.