Interim Recommendations

Recommendations in this guidance document are based on standard infection control and industrial hygiene practices. They should be implemented immediately in order to protect passengers and crew members from infection and prevent the spread of this virus via cruise ship travel. All cruise ship personnel and passengers should follow the practices and instructions described below to prevent spreading infectious disease and becoming ill.

Stay Home If You Are Sick

If you are sick with flu-like illness, CDC recommends that you stay home for at least 24 hours after your fever is gone except to get medical care or for other necessities. (Your fever should be gone without the use of a fever-reducing medicine.) Keep away from others as much as possible. This is to keep from making others sick.

Hand Washing

Wash your hands often with soap and warm water for at least 20 seconds, especially after you cough or sneeze. Alcohol-based hand cleaners are also effective. Avoid touching your eyes, nose and mouth because germs spread that way.

Cough Etiquette

Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it. If you don't have a tissue, cough or sneeze into your upper sleeve, not your hands.

Gloves

Crew members should wear impermeable, disposable gloves if they need to have direct contact with ill passengers or potentially contaminated surfaces, rooms, or lavatories used by ill passengers. They should avoid touching their face with gloved or unwashed hands. Improper use of gloves may actually increase transmission.

Facemasks and Respirators

On May 27, 2009, CDC issued updated Interim Recommendations for Facemask and Respirator Use to Reduce Novel Influenza A (H1N1) Virus Transmission.

People with symptoms of influenza-like illness (ILI) should not leave home or travel. Crew members or passengers who develop symptoms of ILI should protect others by wearing a facemask, if available and tolerable, to reduce the number of droplets coughed or sneezed into the air. If a facemask can not be tolerated, they should use a tissue to cover their nose and mouth when coughing or sneezing.

In community settings, the use of facemasks and respirators generally are not recommended. However, for certain circumstances a facemask or respirator may be considered, specifically for persons at increased risk of severe illness from influenza.

The use of N95 respirators or facemasks is not recommended for cruise ship crew members for general work activities. The following recommendations should be followed when possible for work activities that involve contact with people who have ILI, such as escorting a person with ILI, interviewing a person with ILI, and providing assistance to an individual with ILI:

• maintain a distance of 6 feet or more from the ill person;
• keep interactions with ill persons as brief as possible;
• ask the ill person to follow good cough etiquette and hand hygiene and to wear a facemask, if able, and one is available;
• workers at increased risk of severe illness from influenza infection (see footnote 3 of table 1) should avoid people with ILI (possibly by temporary reassignment); and,
• where workers cannot avoid close contact with persons with ILI, some workers could consider wearing a facemask or N95 respirator on a voluntary basis. Requirements for the voluntary use of respirators in the workplace can be found on the OSHA website (http://www.osha.gov/SLTC/etools/respiratory/voluntaryuses.html).

While facemasks provide barrier protection against droplet and contact transmission of the virus, they do not protect against inhalation of very small airborne particles.  Droplets are still considered to be the primary route of influenza virus transmission, but airborne transmission can not be ruled out at this time. Disposable facemasks and respirators should not be reused; once removed they should be discarded.

Management of Passengers or Crew Members with Symptoms of Influenza

If a passenger is displaying signs and symptoms of an ILI prior to the cruise, they should not board the ship. Crew members should display signs and symptoms of ILI before boarding or during a voyage, and passengers who develop ILI en route, should be medically evaluated and asked to stay in their cabin quarters for the duration of the illness, except to seek medical care or for other necessities. Ill people should cover their nose and mouth when coughing or sneezing, use tissues to contain respiratory secretions and dispose of used tissues in the nearest waste receptacle after use. If tolerated and if facemasks are available, they should protect others by wearing a facemask to reduce the number of droplets coughed or sneezed into the air. If a facemask can not be tolerated, they should use a tissue to cover their nose and mouth when coughing and sneezing when they are near other people (see Table 2). Hands should be washed after contact with respiratory secretions or contaminated objects or materials.

• Cruise ship personnel should be aware of the possible symptoms of novel influenza A (H1N1) virus including fever, cough, sore throat, body aches, headache, runny or stuffy nose, chills, fatigue, and in some cases, diarrhea and vomiting. Visit CDC’s novel H1N1 flu website.
• Minimize the number of personnel directly exposed to the ill person.
• Separate the ill person from others as much as possible (at least 6 feet).
• Move the sick person to an isolated area such as their cabin quarters. They should remain in their cabins for the duration of their illness except to seek medical care or for other necessities.
• Consider isolating the sick person with a family member or companion if necessary for control, comfort, or compliance. The companion should take appropriate precautions to protect themselves.
• When the ill person must be in a common area or is within about 6 feet of another person, have the ill person wear a facemask, if it can be tolerated, to reduce the number of droplets coughed or sneezed into the air. Facemasks should not be reused.
• If a facemask can not be tolerated, provide tissues and ask the ill person to cover his or her mouth and nose when coughing or sneezing.
• Wash hands for 20 seconds with soap and warm water before tending to the sick person and after handling garbage, touching commonly touched surfaces, contacting respiratory secretions or tending to the sick person.
• Wash hands before removing a facemask or respirator and after removing gloves and a facemask or respirator.
• Use waterless, alcohol-based hand gels when soap is not available and hands are not visibly soiled.
• Personnel tending to the ill person or contacting potentially infectious materials should use impermeable, disposable gloves. Gloves are not intended to replace proper hand hygiene. Gloves should be carefully removed and discarded and hands should be cleaned immediately after activities involving contact with body fluids. Gloves should not be washed or reused.
• Personnel who cannot avoid having close contact with an ill person may choose to wear a facemask or N95 respirator on a voluntary basis.
• Dispose of soiled material, gloves, items contaminated with body fluids, and disposable respirators in a sturdy plastic bag that should be tied shut and not reopened, and disposed of according to state solid waste regulations.
• Ensure that the cruise ship is adequately cleaned and disinfected by personnel wearing appropriate PPE.

If a suspect H1N1 influenza case is identified aboard a ship (see Interim Guidance on Case Definitions to be Used For Investigations of Swine-Origin Influenza A (H1N1) Cases) the captain is required by law to report the illness to the CDC Quarantine Station in the jurisdiction of the U.S. port where the ship is expected to arrive (see Quarantine Stations).

If the ship will not be arriving imminently at a U.S. port, Quarantine health authorities will assist ship officials with the management and isolation of the suspect case and the recommendations for other passengers and crew members.

When the ship arrives in a U.S. port, Quarantine officials will work with the cruise ship industry and local and state health departments to assist with medical transportation of the patient upon arrival, disease control and containment measures, passenger and crew notification and surveillance activities, communicating with local public health authorities, and cruise ship disinfection procedures.

Management of Crew Following Exposure

Crew members who may have been exposed to a passenger or coworker suspected of having novel H1N1 influenza should monitor their health for 7 days after the exposure and notify their supervisor. If they become ill with ILI, they should immediately take the following steps:

• Notify their supervisor
• Report to the shipboard dispensary 
• Crew members should stay home for at least 24 hours after their fever is gone except to get medical care or for other necessities. (Their fever should be gone without the use of a fever-reducing medicine.)
• If the crew member is taken to a health care facility off the ship, inform the facility before visiting about the possible exposure to novel H1N1 influenza.
• Limit contact with others as much as possible. When not alone or when in a public place, protect others by wearing a facemask to reduce the number of droplets coughed or sneezed into the air.

For ill persons or those exposed to someone with novel H1N1 influenza, clinicians may decide to prescribe influenza antiviral medications.  Information on recommendations for the use of antiviral medications (see Interim Guidance on Antiviral Recommendations for Patients with Novel Influenza A (H1N1) Virus Infection and Their Close Contacts can be found at http://www.cdc.gov/h1n1flu/recommendations.htm.