cruise guidelines covid 19

Confused about changing COVID-19 rules for cruise ships? Here's everything you need to know

Do you still need a COVID-19 vaccine to board a cruise ship? A negative COVID-19 test? A mask?

Not too many months ago, the answer was "all of the above" for most cruise vessels. But today it's not so straightforward. Some cruise lines have been loosening their COVID-19 rules. Others have been mostly holding fast to policies.

The divergence has come as more countries around the world, including the United States, peel back their COVID-19 rules for cruise ships, leaving it up to individual lines to decide just how strict — or not — they want to be.

The result is that preparing for a cruise has become more confusing than ever.

For more cruise guides, news and tips, sign up for TPG's cruise newsletter .

Don't panic. We're here to help. In the segments below, we look at the COVID-19 policy landscape as it stands right now across the world's biggest cruise lines and try to make sense of it all.

It's a landscape that is likely to continue to change markedly in the coming months. In just the last few weeks, several lines have done away with pre-cruise COVID-19 testing requirements, and the buzz in the cruise world is that more lines soon will follow suit.

Already, mask-wearing rules on ships have mostly disappeared, though not everywhere.

Do I still need a COVID-19 vaccine to cruise?

For the most part, yes. With just a few exceptions, cruise lines still require most, if not all, passengers to present proof of a COVID-19 vaccine to board a ship.

Some lines make exceptions for young children and people who can't be vaccinated due to medical conditions or religious beliefs. The world's largest cruise line, Royal Caribbean , for instance, exempts children under the age of 12 from its vaccine requirement on most sailings. So does Carnival Cruise Line , the world's second-largest cruise brand.

This has been the broad policy at nearly all cruise lines since cruises allowing Americans restarted in 2021. In recent weeks, a few cruise lines have relaxed their vaccine rules slightly but not to a great extent.

Adults-only line Virgin Voyages, for instance, on Thursday said it would allow up to 10% of passengers on any given sailing to be unvaccinated for COVID-19. Under its previous policy, all passengers had to be vaccinated. Would-be cruisers who are unvaccinated must contact the line before booking a cruise to ensure one of the limited slots for unvaccinated travelers is available.

Related: Do I need a COVID-19 vaccine to cruise? A line-by-line guide

Are children required to have a COVID-19 vaccine to cruise?

In many cases, yes. But as noted above, some lines make exceptions to vaccination rules for young children.

Many major cruise lines require anyone who is eligible to receive a COVID-19 vaccine to be fully inoculated before being allowed to sail.

For cruisers from the U.S., that means anyone 5 years or older must have proof that they've had their shots. Anyone 4 years old or younger is exempt from the vaccination rule. Some lines such as Royal Caribbean, Carnival and MSC Cruises set the cut-off for mandatory vaccines higher at the age of 12.

Passengers under these age cutoffs who aren't vaccinated typically have to present negative COVID-19 test results and submit to mandatory testing at the port on embarkation day to board. In general, the testing requirements for the unvaccinated on ships are more rigorous than the testing requirements for the vaccinated.

Note that some lines require that all passengers boarding ships be vaccinated for COVID-19, no matter their age. This means that young children who are not eligible for a COVID-19 vaccine by definition cannot sail.

Lines with such a rule include Oceania Cruises , Regent Seven Seas Cruises, Scenic Luxury Cruises and Tours, Silversea Cruises and Windstar Cruises .

Related: Do children need to be vaccinated to cruise? Here's the policies at the biggest lines

Do I need to test negative for COVID-19 before boarding a cruise ship?

It depends. For much of the past year, every major cruise line required passengers to test negative for COVID-19 before boarding a ship. However, a handful of lines in recent weeks, including Virgin Voyages and Norwegian Cruise Line, have dropped pre-cruise testing requirements for at least some sailings, and more lines are expected to follow suit in the coming months.

Virgin Voyages is among the lines that have loosened testing rules the most. On Thursday, it said it would no longer require pre-cruise tests on any sailing in the two markets where it operates: Europe and North America (the new policy takes effect July 24 for sailings in Europe and July 27 for sailings in North America).

Small-ship specialist Azamara, which currently has all its ships in Europe, also dropped testing requirements for all sailings in recent days.

Other lines are taking a more scattershot approach to dropping testing requirements, mostly due to lingering testing rules in some of the countries where they operate.

Norwegian, for instance, recently said it would drop pre-cruise test requirements for most sailings in Europe but not other regions on Aug. 1. An exception will be sailings from Greece, where testing is required by the local government and will continue. Holland America recently waived pre-cruise testing requirements for just one vessel, Rotterdam, on select itineraries out of Amsterdam.

Just remember, no matter what your cruise line's policy is on pre-cruise testing, some countries around the world such as Japan still require a negative COVID-19 test for entry. If you're planning a cruise out of one of these countries and are not already within the country, you'll still need to test negative in advance of the trip even if your cruise line doesn't require a negative test result.

Related: Do I need to take a COVID-19 test before cruising?

Could I still be quarantined on a cruise ship if I test positive for COVID-19 while on board?

Yes. Cruise lines are still quarantining passengers who test positive for COVID-19 while on a ship. Passengers who display COVID-19 symptoms even without testing positive are also being quarantined on some ships. Passengers who are deemed to be "close contacts" of such passengers may also find themselves isolated for a time while they undergo COVID-19 testing.

Some cruise lines still warn passengers in their travel documentation that they could be quarantined on land for a time if they test positive for COVID-19 just before embarkation after flying to a ship. Additionally, passengers may be forced to quarantine on land for a time after disembarking a ship if they test positive while on board.

Related: I got quarantined after testing positive for COVID-19 on a ship; here's what it was like

Is the CDC still setting the rules for cruise ship COVID-19 policies?

No. In the early days of the COVID-19 pandemic, the U.S. Centers for Disease Control and Prevention issued rules that cruise lines had to follow in order to resume cruising in U.S. waters that touched on everything from mask-wearing policies on ships to pre-cruise testing. However, the rules have morphed into non-binding guidelines in several steps over the past year.

The CDC's initial Conditional Sail Order imposing COVID-19-related rules on cruise lines expired in February and was replaced by a set of recommended policies that cruise lines could opt-in or opt-out of following. On July 18, this subsequent optional program was replaced by an even less formal set of recommendations that the agency said cruise lines "should carefully consider."

The bottom line is cruise lines have been free to choose whether they follow CDC recommendations for COVID-19 protocols on ships for many months.

Is the CDC still listing the COVID-19 outbreak status of ships?

No. As of July 18, the CDC stopped posting information on the extent of COVID-19 cases on cruise ships on its website.

Previously the line listed a color status for every cruise ship sailing in U.S. waters — red, yellow or green — on its Program for Cruise Ships website. This color status indicated how widespread COVID-19 was on board. As COVID-19 screening policies have begun to vary more widely from line to line in recent months, making apples-to-apples comparisons between ships has become more difficult, the CDC suggested.

"The previous color-coding system under CDC's COVID-19 Program for Cruise Ships depended upon each cruise line having the same COVID-19 screening testing standards, which may now vary among cruise lines," the CDC said Monday in announcing the end to the color-coded status postings. "Therefore, the cruise ship color status webpage has been retired."

Cruise lines are still required to report COVID-19 cases on ships to the CDC. The data just aren't being reported to the public.

Do I need to wear a mask on a cruise ship?

In most cases, no. Mask-wearing requirements were common on cruise ships through much of 2021 and into early 2022 as COVID-19 spread across the globe in several major waves. But most major cruise lines dropped mask mandates earlier this year as COVID-19 cases worldwide dropped significantly.

Where you'll still find mask-wearing rules on ships is a bit hit-or-miss. It often has to do with local laws that require mask-wearing or with cruise line concerns about short-term spikes in COVID-19 cases in specific areas.

In recent months, itineraries where mask-wearing rules on ships have been more common include voyages in the Mediterranean that include stops in Italy (where ports specifically require passengers to wear KN95/FFP2 type masks) and some sailings to Alaska . Mask-wearing inside ships is also required by local regulation on all sailings out of Singapore.

Note that some ports around the world still require mask-wearing in terminals. You might find that you don't need to wear a mask while aboard a cruise ship but must wear one while boarding and disembarking the ship in ports.

Do I need a negative COVID-19 test to get home from a cruise?

The answer to this question depends in part on where your home is. For U.S.-based cruisers returning to the U.S. by plane from a cruise overseas, there is no longer a COVID-19 testing requirement , as of June 12. You also don't need to test negative for COVID-19 to return home to a U.S. address after disembarking a cruise at a U.S. port.

Do I need to worry whether ports on my itinerary have extra COVID-19 requirements?

For the most part, no. Many cruise lines warn in their travel documentation that "guests are ...responsible for complying with all local health and safety requirements which may include additional pre-embarkation testing at the terminal," as Norwegian puts it in its documentation.

However, lines will typically tell you in advance if there are specific COVID-19 requirements in ports that could affect your trip.

Generally, if a port on your itinerary requires passengers to show proof of a COVID-19 vaccine or a negative COVID-19 test, the line will make that a condition of your sailing. In cases where a negative COVID-19 test is required to enter a certain port or port country, lines will likely test you on board before arriving at that port, often for free.

Note that lines do make clear that it's your responsibility to figure out what COVID-19 vaccine or testing documentation you need to pass through countries by air or land on the way to your cruise.

As Norwegian puts it, the line "recommends for all guests to follow, and where possible, sign up for notifications from their local government on international travel regulations that may prevent, restrict, or require additional documentation when traveling to another country for embarkation or during their cruise."

What onboard COVID safety measures are cruise ships still taking?

As noted above, most cruise lines still require all or most passengers to be vaccinated for COVID-19. Most cruise lines also require all crew on ships to be vaccinated for COVID-19, and on most ships crew also continue to wear masks at all times.

In addition, as noted above, most lines still require passengers to test negative for COVID-19 before boarding ships and crew are regularly tested for COVID-19, too. Passengers and crew who test positive for COVID-19 while on board a vessel are isolated.

In the past two years, cruise lines have made significant investments in sophisticated air filtration systems for cabins and other onboard areas of ships and have increased cleaning and sanitizing efforts on ships. Medical centers on ships have also been upgraded and often are staffed at a higher level than in pre-COVID-19 times.

What can I do to minimize my exposure to COVID-19 on ships?

Although many cruise lines no longer require mask-wearing on ships, they still recommend that you wear one, based on guidance from various health authorities and experts.

Keeping socially distant from other passengers is another strategy for staying healthy on ships as is regular hand-washing and hand sanitizing.

Major cruise lines typically place free hand sanitizer at the entrance to most public rooms on ships. Restaurants on newer cruise ships often have hand-washing stations at their entrances. On some ships, cruise ship staff are assigned to stand at the entrances to onboard restaurants and require passengers to wash or sanitize their hands.

Where can I find my specific cruise line's COVID-19 policy?

Every major cruise line lists its COVID-19 policies including vaccination and testing requirements on its website, often in great detail. Cruise lines regularly update these web pages, and they are the best place to find the very latest information.

Here are the key COVID-19 information pages on the websites of the eight major lines that account for the majority of cruising in North America:

• Carnival Cruise Line's Have Fun. Be Safe. policies page .
• Celebrity Cruises' Healthy at Sea page .
• Disney Cruise Line's Know Before You Go page .
• Holland America's Travel Well FAQ page .
• MSC Cruises' What to Know Before You Go page .
• Norwegian Cruise Line's Sail Safe page .
• Princess Cruises' Cruise Health requirements page
• Royal Caribbean's Healthy Sail Center .

How will I find out if policies change after I book?

As noted above, cruise lines list their COVID-19 policies on their websites. To be safe, check these websites often in the months leading up to your cruise. Cruise lines also notify customers by email when there are significant changes to their COVID-19 policies, as well as alert travel agents who book cruises.

Can I cancel for free if I get covid-19 in advance of a sailing?

In many cases, yes. Major lines will usually offer you a refund, sometimes in the form of a future cruise credit , if you have to cancel a cruise because of a positive COVID-19 test in your traveling party in the days leading up to a sailing.

Royal Caribbean, for instance, promises a 100% refund if anyone in your travel party tests positive for COVID-19 within 10 days of your cruise. Carnival has a policy with similar wording.

Cruise lines will also offer a refund, typically in the form of a future cruise credit, if you are denied embarkation or reboarding, or quarantined or disembarked during a voyage, due to a positive COVID-19 test or being suspected of having COVID-19. If you are quarantined for just part of a cruise due to a positive COVID-19 test, you'll likely receive a pro-rated refund for the days of the cruise you missed.

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Cruising Is Returning This Year—Here’s What to Know

By Scott Laird

More than a year after COVID-19 virtually stopped most cruises , the industry has been in flux. with many large cruise ships anchored in international waters awaiting finalized clearance from the U.S. Centers for Disease Control to resume sailing from U.S. ports, or making alternate plans to sail from international destinations instead. But last week, the CDC released further clarification to the Conditional Sailing Order that's been in effect since October 2020 , allowing cruising to resume on a firmer timeline. Once the agency reviews cruise line plans for adherence, large ship cruises could resume from U.S. ports as early as July.

In a letter the CDC sent to U.S. cruise executives, the agency stipulated that if cruise lines can demonstrate at least 95 percent of customers and 98 percent of crew are vaccinated, they can skip plans for the time-consuming “simulated” test voyages that were in place as the next step to proving to the CDC that conditions were safe for sailing again, the Washington Post reported in April.

It’s important to note that cruise departures never entirely ceased during the pandemic—ships carrying fewer than 250 passengers have been allowed to operate, for example, and several lines resumed operations internationally beginning last summer, with few reported cases onboard. As the industry makes moves to resume on a wider scale, operations will be different from before. From new safety protocols to larger impacts on itineraries, here's what to expect as we prepare to welcome back cruising in 2021.

We’re reporting on how COVID-19 impacts travel on a daily basis. Find our latest coronavirus coverage here , or visit our complete guide to COVID-19 and travel .

New and varied itineraries

One benefit cruise lines have over other types of trips is their ability to physically move and be nimble if plans need to change. While cruise lines work with different countries and ports to address local needs and safety issues, it's meant a wave of new itineraries and destinations on the horizon.

Ships that might have been prevented from operating at U.S. homeports, for example, could be moved to embark U.S.-originating passengers at foreign ports. Prior to the CDC’s updated guidelines, some cruise lines—including Viking and Royal Caribbean—had taken advantage of their ships’ registries in Bermuda or The Bahamas and redeployed those vessels to sailings within those countries for much of the upcoming summer season, free of U.S. restrictions.

Norwegian and Celebrity are taking a similar approach with Mediterranean sailings this summer, sticking close to Greece, Turkey, and Croatia—all of which have easier entry requirements for international visitors. Other countries that have reopened to (vaccinated and/or COVID-tested) international visitors that also allow cruising include Iceland, Mexico, and French Polynesia.

Meanwhile, small ships that have still been able to operate have opened up a new era of interest in sailing U.S. waters. American Cruise Lines, Victory Cruise Lines, and American Queen Steamboat Company, for example, have rolled out more sailings on the Mississippi River, and added itineraries sailing the Great Lakes, Pacific Northwest, and East Coast for travelers who want to explore waterways closer to home.

Vaccinations and testing are essential

A key part of the CDC’s updated guidelines allows cruise lines to forego the onerous simulated voyages and lengthy notification periods that had been part of the original order—on the condition that they meet the requirements that virtually all passengers and crew on each sailing are fully vaccinated (many cruise lines have already created their own vaccination requirements ). The guidelines also allow vaccinated passengers to present results from faster, cheaper antigen tests prior to boarding instead of the more involved PCR test, although individual cruise lines may elect to impose more stringent requirements.

There may also be fewer children onboard sailings this summer, as vaccines are not yet approved for children under 16. Some cruise lines will allow unvaccinated children to sail with a negative PCR test, while others will not allow any unvaccinated passengers regardless of age. It's important to read and reach out to the cruise line directly when booking a sailing, to be sure you're meeting all of their protocols in order to sail.

In addition to following specific cruise line requirements, it’s also vital that guests review the vaccination and testing requirements for entering the country from which they're departing if they’re traveling to a cruise that sails outside the U.S.

The economic impact and sailings

Like many other travel sectors, the cruise industry is poised for a strong comeback based on pent-up demand and untapped travel budgets carried over from 2020—prior to the pandemic, it was set to be a record year for guests taking cruises. But in that time, there's no ignoring how much of an effect the halt in operations had on port communities and the economy at large—an ongoing issue that will continue to impact when and how we cruise.

The Cruise Lines International Association (CLIA) estimates that in 2019 the cruise industry contributed $9 billion in direct spend in Florida alone, generating just under 160,000 jobs—both at multiple cruise lines headquartered in the state, and in support industries. But many of those jobs were either furloughed or eliminated due to the halt in operations, meaning the industry could be facing a staffing shortage in certain locations where it sails.

Alaska has made it clear that the loss in cruise sailings effectively wiped out last year's tourism season , and both Florida and Alaska—respectively the largest and fifth largest benefactors of cruise industry dollars—filed suit against the CDC for a more expedient return. The legal case might now be moot, but the economic anxieties remain, particularly for Alaska, which is seeking a waiver to federal laws requiring foreign-flagged cruise ships (i.e., most of them) to call at a foreign port on every itinerary—a requirement that would prevent most large ship operations to Alaska until Canadian ports reopen to cruise ships in early 2022. 

With the CDC go-ahead, cruise passengers will soon be able to embark on large ship departures, however modified, to once again enjoy vacations at sea. But these factors will continue to impact where we can travel and when, especially as the summer travel season begins.

Have Fun. Be Safe.

Cruising with Carnival is easy! Vaccines and testing are not required for most U.S. and European departures.*

Guests sailing to and from Australia must visit the Australia Have Fun. Be Safe. page for protocols specific to those cruises.

VACCINATION & TESTING

Although vaccines are not required, we encourage all guests, 5 years of age and older, to be up to date with their COVID-19 vaccines, when eligible, and carry proof of vaccination. Testing is not required for either vaccinated or unvaccinated guests. However, we encourage all guests, 5 years and older, to take a pre-cruise COVID-19 test within three days of their cruise.

*Carnival Luminosa - 9/14/2023: This Carnival Journeys Transpacific voyage will be calling on certain destinations (including Australia) which are still observing COVID-19 protocols. Below are more details regarding vaccination and testing requirements for this voyage:

• Guests, aged 12 years and older, must be fully vaccinated to sail. Additionally, we strongly recommend that guests get a booster, if eligible.
• All guests, aged two years and above, regardless of vaccination status, are required to take a self-administered Rapid-Antigen Test (RAT) within 24 hours of boarding or a PCR test within 48 hours prior to boarding. Evidence of a negative result is required to cruise.
• Vaccine exemptions are required for guests, aged 12 years and older, with medical conditions preventing vaccination. If you, or a member of your party, meet the criteria for a vaccine exemption, you may apply here .
• Full details regarding vaccination and testing requirements and FAQs are available on the Australia Have Fun. Be Safe. page .

DESTINATION REQUIREMENTS

We will continue to monitor the protocols and requirements of the destinations we visit and will update our guests directly and this page of any changes.

Have questions? Check out our Have Fun. Be Safe. FAQs for all sailings, except Carnival Luminosa’s 09/14/2023 voyage.

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Disney Cruise Line Important Travel Information

Our approach to health and safety.

Our focus remains on operating our ships in a responsible way that continues to create magic for all on board. We are resuming sailing in a gradual, phased approach that emphasizes multiple layers of health and safety measures, developed in consideration of guidance from the US Centers for Disease Control and Prevention and other medical experts. Visit  Know Before You Go  to learn more about COVID-19 protocols and sailing requirements.

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• CORONAVIRUS COVERAGE

How cruise lines are adapting to COVID-19 in the age of Omicron

The pandemic keeps disrupting the cruise industry. Here’s how to navigate if you plan to set sail.

The pandemic is upending the cruise industry once again.

In late December, just six months after cruise ships resumed sailing from United States ports, onboard cases of COVID-19 began to skyrocket—rising from 162 in the first two weeks of the month to 5,000 in the latter half of the month. As U.S. Centers for Disease Control and Prevention director Rochelle Walensky recently told lawmakers , it was about a 30-fold increase.

In the weeks that followed, the CDC warned travelers to avoid cruises even if they’re fully vaccinated . There has been a flurry of cancellations, including several Royal Caribbean and Norwegian Cruise Line sailings , because of crew members calling in sick and destinations closing their ports to cruises. The ships that do set sail have had to tighten their COVID-19 protocols—which include vaccine mandates, testing, and masking—and make last-minute itinerary changes.

Further complicating matters, the CDC’s Conditional Sailing Order—a framework of mandatory safety procedures for foreign-flagged ships in U.S. waters—expired on January 15. Following that guidance will now be optional for cruise ships, meaning they will be able to chart their own safety course.

For people who planned their trips months or even years before Omicron’s arrival, these rapidly changing circumstances have proven almost impossible to navigate around.

“People traveling at all right now have to be very flexible,” says Chris Gray Faust, managing editor of online industry publication Cruise Critic . “Dig into what your cruise line is requiring. What was the policy a month ago may not be the policy today.”

So how can travelers make sense of it all? Here’s what experts say.

How are COVID-19 protocols changing?

Eager to shed their early pandemic reputation as floating disease carriers, cruise lines worked with the CDC to institute fairly rigorous onboard COVID-19 protocols—the agency’s condition for allowing ships to sail from U.S. ports again. The CDC laid out guidance for testing crew and passengers and how to deal with outbreaks. Most cruise lines also instituted vaccine mandates.

( These photos show the surreal world of cruising during the pandemic’s height .)

Not much will change for the ships that participate in the CDC’s new voluntary program. They will still report COVID-19 data to the agency daily and follow specific testing regimes for passengers and crew. Cruise lines won’t get to choose which protocols to follow either, says Captain Aimee Treffiletti, head of the CDC’s maritime unit. If they choose to participate, they must agree to everything.

Norwegian Cruise Line has already indicated that it will join the CDC program. Brian Salerno, senior vice president of global maritime policy for the Cruise Lines International Association , expects many cruise lines will ultimately take part. He argues that cruise lines have often gone beyond CDC requirements—installing air purification technology or even onboard PCR testing laboratories —and aren’t likely to start slacking now.

“It’s a business imperative to do this right,” Salerno says. “Nobody’s going to relax during Omicron.”

It’s also a matter of public image. The CDC plans to continue issuing each ship a color-coded status that anyone can access to check transmission at any given time. Ships that are shaded green have no reported cases of COVID-19, while those that are shaded red are under CDC investigation. Cruise lines that aren’t part of the voluntary program will be shaded gray. Those ships may have their own health and safety protocols, but they haven’t been reviewed by the CDC.

“Nobody wants to be gray,” Salerno says. “Obviously everybody wants to be green.”

But with Omicron cases soaring, why is the CDC loosening its grip on the cruise industry? Treffiletti says the agency is confident that it has identified the best practices for mitigating transmission aboard a cruise ship—which she emphasizes was done in partnership with cruise lines. Now, she says, the CDC has decided to flex its regulatory authority “on a case-by-case basis rather than shutting down all the cruise ships at once.”

The CDC will still be able to board any ship in U.S. waters and conduct inspections, she points out. Ships that aren’t participating in the voluntary program will also have to report every case of COVID-19—just not every day—and will still be subject to the agency’s order requiring masks on public transportation .

How do the vaccine mandates work?

Most cruise lines currently require all passengers, including eligible children, to be fully vaccinated (meaning two doses of Pfizer or Moderna, one dose of Johnson & Johnson, or a WHO-approved equivalent). Salerno says the vaccination rates aboard cruise ships right now are close to 95 percent for passengers and crew members.

Some companies do accommodate children who haven’t gotten a jab: Royal Caribbean and Carnival, for example, require all guests older than 12 to be vaccinated , while younger passengers can board with a negative test. Disney Cruise Lines requires everyone over the age of five to be vaccinated. (The Walt Disney Company is the majority owner of National Geographic Partners.)

Cruise lines also align their vaccination policies with those of their destinations. So even though the United Kingdom considers children fully vaccinated after just one dose of an mRNA vaccine, a ship that sets sail to the Caribbean may only allow children who have had two doses.

Meanwhile, as Omicron spreads, some cruise lines have begun to require booster shots. Beginning February 1, Viking will require anyone who is eligible for a booster dose to get it at least 14 days before setting sail from the U.S. In addition, the CDC recently emphasized that being “up to date” on vaccines includes a booster dose.

Omicron is even more transmissible than the Delta variant—and better at evading vaccine immunity. But while the vaccines are no longer as effective at preventing you from getting infected, they are still the best protection, says Kathryn Willebrand, an epidemiologist who recently co-authored a study of COVID-19 transmission aboard cruise ships with infectious disease physician Lauren Pischel.

Willebrand points out that vaccines are still effective at preventing severe illness—which is especially important when you’re in the middle of the ocean on a boat whose medical staff might be overwhelmed or sick themselves. “You don’t want to need medical care when you’re far from home,” she says.

( Can booster shots protect you from Omicron? )

How often will you be tested?

Cruise lines have been requiring passengers and crew to test before boarding a ship, although specific requirements differ. Some only accept PCR tests, while others will accept the results of a rapid antigen test—in some cases only if the test is overseen by a health professional . And while some companies require you to get tested before you leave home, others administer tests at the terminal prior to boarding .

Crew members are generally subjected to routine testing throughout the voyage because they’re particularly vulnerable to infection. They spend more time on the ship, in closer quarters, and tend to have more interaction with others. But passengers might be required to test before any shore excursion if the port of call requires it, or if they develop symptoms during the trip.

If you don’t have any symptoms, you generally don’t have to be tested before disembarking the ship. Instead, Treffiletti and the CDC recommend getting tested five days after your trip. However, Gray Faust cautions that if you’re flying internationally, your final destination may require a negative test—or the cruise line may administer tests to everyone if there’s a particularly bad COVID-19 outbreak on board.

( 5 things to know about COVID-19 tests in the age of Omicron .)

What happens if there’s an outbreak?

Still, COVID-19 has proven adept at slipping past these protocols, particularly in the time of Omicron. Since COVID-19 is airborne and cruise ships are enclosed environments, the boats are higher risk environments for transmission, says Willebrand. Thousands of people pass through dining rooms, casinos, and other areas where virus particles may be hanging in the air.

Under the CDC guidance , cruise lines are supposed to educate both crew and passengers to identify and report COVID-19 symptoms. If someone onboard develops symptoms, they are tested and isolated until the results come back or until they’re no longer infectious. Those who are still infectious at the end of a journey are typically required to quarantine on shore—and Treffiletti says the CDC can work with cruise lines to facilitate that.

Since passengers are vaccinated, however, close contacts don’t necessarily have to quarantine unless they begin to develop symptoms. Gray Faust says cruise lines have been successful at contact tracing to notify those close contacts for the same reason that cruise ships are so vulnerable to transmission—they are closed communities.

“If you go to a restaurant and the person next to you is sick, you won’t know that,” Gray Faust says. “But on a ship, they do go back and find people. That is something that the cruise ships have developed that really is beyond what other types of travel have done.”

All of this relies on the honor system. Much as we’ve seen on land, there’s always the risk that your fellow seafarers may refuse to comply with mask mandates or hide their symptoms from crew to avoid quarantine. Cruise lines have the power to ask those passengers to disembark and travel home at their own expense.

Still, those rules aren’t always enforced—which is why experts say that the decision to set sail ultimately comes down to your own risk tolerance.

( Here’s what you need to know about traveling during Omicron . )

What can you do to ensure a smoother trip?

Although the CDC recommends that people avoid cruises, Treffiletti says that there are some things you can do to help mitigate your risk if you do decide to travel.

For one, before setting sail, check the color-coded chart on the CDC website to see if your ship is participating in the agency’s voluntary COVID-19 program. If so, you’ll be able to see whether there are any outbreaks on board. If things look grim, most cruise lines have implemented fairly flexible rebooking and cancellation policies.

If you’re just booking now, research the protocols of each cruise line to see if they align with your own comfort level. Gray Faust recommends purchasing trip delay and COVID-19 insurance—an extra cost that will be worth it if you get infected and can’t board your ship.

Gray Faust says your packing list should also account for uncertainties. She recommends packing extra clothing and medication in case you are quarantined at any point. If you can snag them, toss in some extra KN95 masks and rapid antigen tests, too.

But most of all, Gray Faust says cruisers need to go into a trip accepting that there will be health protocols in place—which might change as conditions worsen or improve—and that they’re there to keep you safe.

“You need to be OK with that,” she says. “You can still have a great trip. But you’re protecting yourself and other people by wearing masks and by getting your vaccines.”

National Geographic Expeditions and Adventures by Disney offer cruise departures to many destinations around the world. The Walt Disney Company is the majority owner of National Geographic Partners.

Amy McKeever is a senior writer and editor at National Geographic. You can find her on Twitter .

Related Topics

• CORONAVIRUS
• PUBLIC HEALTH
• CRUISE SHIPS

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• Section 8 - Road & Traffic Safety
• Section 8 - Motion Sickness

Cruise Ship Travel

Cdc yellow book 2024.

Author(s): Kara Tardivel, Stefanie White, Aimee Treffiletti, Amy Freeland

Cruise Ship Medical Capabilities

Illness & injury, infectious disease health risks, noninfectious health risks, travel preparation.

Cruise ship travel presents a unique combination of health concerns. Travelers from diverse regions brought together in the often crowded, semi-enclosed shipboard environment can facilitate the spread of person-to-person, foodborne, and waterborne diseases. Outbreaks on ships can be sustained over multiple voyages by crewmembers who remain onboard, or by persistent environmental contamination. Port visits can expose travelers to local diseases and, conversely, be a conduit for disease introduction into shoreside communities.

Some people (e.g., those with chronic health conditions or who are immunocompromised, older people, pregnant people) merit additional considerations when preparing for a cruise. Because travelers at sea might need to rely on a ship’s medical capabilities for an extended period, potential cruise passengers with preexisting medical needs should prepare accordingly by calling the cruise line’s customer service center to learn what type and level of health care services are (and are not) available on specific ships.

Medical facilities on cruise ships can vary widely depending on ship size, itinerary, cruise duration, and passenger demographics. Generally, shipboard medical centers can provide medical care comparable to that of ambulatory care centers; some are capable of providing hospitalization services or renal dialysis. Although no agency officially regulates medical practice aboard cruise ships, the American College of Emergency Physicians (ACEP) published consensus-based guidelines for cruise ship medical facilities in 1995, and updated the guidelines in 2013. ACEP guidelines , which most major cruise lines follow, state that cruise ship medical facilities should be able to provide quality medical care for passengers and crew; initiate appropriate stabilization, diagnostic, and therapeutic maneuvers for critically ill or medically unstable patients; and assist in the medical evacuation of patients in a timely fashion, when appropriate.

Cruise ship medical centers deal with a wide variety of illnesses and injuries; ≈10% of conditions reported to cruise ship medical centers are an emergency or require urgent care. Approximately 95% of illnesses are treated or managed onboard, with the remainder requiring evacuation and shoreside consultation for dental, medical, or surgical issues. Roughly half of all passengers seeking medical care are >65 years old.

Medical center visits are primarily the result of acute illness or injury. The most frequently reported diagnoses include respiratory illnesses (30%–40%); injuries from slips, trips, or falls (12%–18%); seasickness (10%); and gastrointestinal (GI) illness (10%); 80% of onboard deaths are due to cardiovascular events.

Infectious Disease Outbreaks

The most frequently reported cruise ship outbreaks involve GI infections (e.g., norovirus), respiratory infections (e.g., coronavirus disease 2019 [COVID-19], influenza), and other vaccine-preventable diseases (VPDs), such as varicella. Although cruise ships do not have public health authority, to reduce the risk of introducing communicable diseases, some ships conduct medical screening during embarkation to identify ill passengers, prevent them from boarding, or require isolation if permission to board is given.

Before travel, to help limit the introduction and spread of communicable diseases on cruise ships, prospective cruise ship travelers and their clinicians should consult the Centers for Disease Control and Prevention (CDC) Travelers’ Health website for updates on outbreaks and destination-specific travel health notices. People who become ill with a communicable disease before a voyage should consult their health care provider and delay their travel until they are no longer contagious. When booking a cruise, travelers should check the trip cancellation policies and consider purchasing trip cancellation insurance (see Sec. 6, Ch. 1, Travel Insurance, Travel Health Insurance & Medical Evacuation Insurance ).

Travelers who become ill during a voyage should seek care in the ship’s medical center; the onboard staff will provide clinical management, facilitate infection-control measures, and take responsibility for reporting potential public health events. For information on how to report travelers who become ill with suspected communicable diseases after they return home from a cruise, see Sec. 8, Ch. 8, Airplanes & Cruise Ships: Illness & Death Reporting & Public Health Interventions .

Gastrointestinal Illnesses

During 2006–2019, rates of GI illness among passengers on voyages lasting 3–21 days fell from 32.5 to 16.9 cases per 100,000 travel days. Despite the decrease, outbreaks continue to occur. CDC assists the cruise ship industry to prevent and control the introduction, transmission, and spread of GI illnesses on cruise ships. See information on cruise ship GI illnesses and updates on GI illness outbreaks involving ships with US ports of call, specifically.

On cruise ships, >90% of GI illness outbreaks with a confirmed cause are due to norovirus. Characteristics of norovirus that facilitate outbreaks include a low infective dose, easy person-to-person transmissibility, prolonged viral shedding, absence of long-term immunity, and the ability of the virus to survive routine cleaning procedures (see Sec. 5, Part 2, Ch. 16, Norovirus ). For international cruise ships porting in the United States during 2006–2019, an average of 12 norovirus outbreaks occurred each year.

Other Sources of Gastrointestinal Illness

GI outbreaks on cruise ships also have been caused by contaminated food or water; most outbreaks were associated with  Campylobacter ,  Clostridium perfringens , or enterotoxigenic  Escherichia coli .

Protective Measures

Travelers can reduce the risk of acquiring a GI illness on cruise ships by frequently washing hands with soap and water, especially before eating and after using the restroom. Travelers should call the ship’s medical center promptly, even for mild symptoms of a GI illness, and strictly follow cruise ship guidance regarding isolation and other infection-control measures.

Respiratory Illnesses

Respiratory illnesses are the most common medical complaint on cruise ships. During the pretravel visit, evaluate whether vaccines or boosters (e.g., COVID-19, influenza) are needed and emphasize the importance of practicing good respiratory hygiene and cough etiquette while onboard. As with GI illnesses, cruise ship passengers should report respiratory illness to the medical center promptly and follow isolation recommendations as instructed.

Coronavirus Disease 2019

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19, spreads more easily between people in close quarters, and multiple studies have concluded that transmission rates of SARS-CoV-2 among travelers on ships are much greater than in other settings. Cruise ship COVID-19 outbreaks can tax onboard medical and public health resources. Ship-to-shore medical evacuations to facilities capable of providing higher levels of medical care can present logistical challenges and pose additional risks to ill patients.

Cruise passengers and crewmembers who are not up to date with their COVID-19 vaccines are at increased risk for severe illness, hospitalization, medical evacuation, and death. Since cruising will always pose some risk of SARS-CoV-2 transmission, ensure that people planning cruise ship travel are up to date with their vaccinations, and assess their likelihood for developing severe COVID-19. For people at increased risk of severe COVID-19 regardless of their vaccination status (e.g., pregnant people, people who are immunocompromised), discuss the potential health hazards associated with cruise ship travel. CDC has developed recommendations and guidance designed to help cruise ship operators provide a safer and healthier environment for crewmembers, passengers, port personnel, and communities.

Historically, influenza has been among the most often reported VPDs occurring on cruise ships. Because passengers and crew originate from all regions of the globe, shipboard outbreaks of influenza A and B can occur year-round, with exposure to strains circulating in different parts of the world (see Sec. 5, Part 2, Ch. 12, Influenza ). Thus, anyone planning a cruise should receive the current seasonal influenza vaccine ≥2 weeks before travel if vaccine is available and no contraindications exist. For people at high risk for influenza complications, health care providers should discuss chemoprophylaxis and how and when to initiate antiviral treatment.

See additional guidance on the prevention and control of influenza on cruise ships .

Legionnaires’ Disease

Less common on cruise ships, Legionnaires’ disease is nevertheless a treatable infection that can result in severe pneumonia leading to death (see Sec. 5, Part 1, Ch. 9, Legionnaires’ Disease & Pontiac Fever ). Approximately 10%–15% of all Legionnaires’ disease cases reported to CDC occur in people who have traveled during the 10 days before symptom onset. Clusters of Legionnaires’ disease associated with hotel or cruise ship travel can be difficult to detect, because travelers often disperse from the source of infection before symptoms begin. Data reported to CDC during 2014–2015 included 25 confirmed cases of Legionnaires’ disease associated with cruise ship exposures.

In general, Legionnaires’ disease is contracted by inhaling warm, aerosolized water containing the bacteria,  Legionella . Transmission also can sometimes occur through aspiration of  Legionella -containing water. Typically, people do not spread  Legionella  to others; a single episode of possible person-to-person transmission of Legionnaires’ disease has been reported. Contaminated hot tubs are commonly implicated as a source of shipboard  Legionella  outbreaks, although potable water supply systems also have been culpable. Improvements in ship design and standardization of water disinfection have reduced the risk for  Legionella  growth and colonization.

Diagnosis & Reporting

People with suspected Legionnaires’ disease require prompt antibiotic treatment. When evaluating cruise travelers for Legionnaires’ disease, obtain a thorough travel history of all destinations during the 10 days before symptom onset to assist in identifying potential sources of exposure, and collect urine for  Legionella  antigen testing. Most cruise ships have the capacity to perform this test, which detects  L. pneumophila  serogroup 1, the most common serogroup.

Perform culture of lower respiratory secretions on selective media to detect non– L. pneumophila  serogroup 1 species and serogroups. Culture also is used for comparing clinical isolates to environmental isolates during an outbreak investigation. Notify CDC of any travel-associated Legionnaires’ disease cases by sending an email to [email protected]. Quickly report all cases of Legionnaires’ disease to public health officials, who can determine whether a case links to previously reported cases and work to stop potential clusters and new outbreaks.

Other Vaccine-Preventable Diseases

Although most cruise ship passengers come from countries with routine vaccination programs (e.g., Canada, the United States), many of the crew are from low- or middle-income countries where immunization rates can be low. Outbreaks of hepatitis A, measles, meningococcal disease, mumps, pertussis, rubella, and varicella have all been reported on cruise ships. The majority (82%) of these outbreaks occur among crewmembers; prior to the COVID-19 pandemic, varicella was the most frequently reported VPD. Other VPDs (e.g., pertussis) occur more often among passengers.

Each cruise line sets its own policies regarding vaccinations for its crew; some have limited or no requirements. Thus, all passengers should be up to date with routine vaccinations before travel, as well as any required or recommended vaccinations specific for their destinations. People of childbearing age should have documented immunity to measles, rubella, and varicella (either by vaccination or titer) before cruise ship travel.

Vectorborne Diseases

Some cruise ship ports of call include destinations where vectorborne diseases (e.g., dengue, Japanese encephalitis, malaria, yellow fever, Zika) are known to be endemic. In addition, new diseases can surface in unexpected locations; chikungunya was reported for the first time in the Caribbean in late 2013, with subsequent spread throughout the region and numerous other North, Central, and South American countries and territories. Zika was first reported in Brazil in 2015, and subsequently spread across the Caribbean and Latin America, sparking concern because of its association with microcephaly and other congenital abnormalities in the fetus. For disease-specific information, see the relevant chapters of Section 5.

For guidance on how to avoid bites from mosquitoes and other disease-transmitting arthropod vectors, both onboard and while on shore at ports of call, see Sec. 4, Ch. 6, Mosquitoes, Ticks & Other Arthropods . For specific details on yellow fever vaccination and malaria prevention, see Sec. 2, Ch. 5, Yellow Fever Vaccine & Malaria Prevention Information, by Country .

Stresses of cruise ship travel include varying weather and environmental conditions, and unaccustomed changes to diet and levels of physical activity. Despite modern stabilizer systems, seasickness is a common complaint, affecting up to 25% of travelers (see Sec. 8, Ch. 7, Motion Sickness ). Note that travel is an independent risk factor for behaviors such as alcohol and illicit drug use and misuse (see Sec. 3, Ch. 5, Substance Use & Substance Use Disorders ), and unsafe sex (see Sec. 9, Ch. 12, Sex & Travel ).

Cruise ship travelers have complex itineraries due to multiple short port visits. Although most port visits do not include overnight stays off ship, some trips offer travelers the opportunity to venture off the ship for ≥1 night. These excursions can complicate decisions about exposures and the need for specific antimicrobial prophylaxis, immunizations, and other prevention measures.  Boxes 8-04  and  8-05  summarize recommended cruise travel preparations and healthy behaviors during travel for health care providers and cruise ship travelers.

Box 8-04 Healthy cruise travel preparation: a checklist for health care providers

Risk assessment & risk communication.

☐ Discuss itinerary, including season, duration of travel, and activities at ports of call. ☐ Review the traveler’s medical and immunization history, allergies, and any additional health needs. ☐ Discuss relevant travel-specific health hazards and risk reduction. ☐ Provide travelers with documentation of their medical history, immunizations, and medications.

VACCINATION & RISK MANAGEMENT

☐ Provide routinely recommended (age-specific), required (yellow fever), and recommended vaccines. ☐ Discuss safe food and water precautions. ☐ Discuss insect bite prevention. ☐ Provide older travelers with a baseline electrocardiogram, especially those with coronary artery disease.

MEDICATIONS BASED ON RISK & NEED

☐ Consider prescribing malaria chemoprophylaxis if itinerary includes stops in malaria-endemic areas. ☐ Consider prescribing motion sickness medications for self-treatment.

Box 8-05 Healthy cruise travel preparation: a checklist for travelers

☐ Carry prescription drugs in original containers with a copy of the prescription and a physician’s letter. ☐ Check the Centers for Disease Control and Prevention (CDC) Outbreak Updates for International Cruise Ships website for gastrointestinal outbreaks. ☐ Consider purchasing additional insurance coverage for overseas health care and medical evacuation. ☐ Consult medical and dental providers before cruise travel. ☐ Consult CDC Travelers’ Health website for travel health notices . ☐ Defer travel while acutely ill. ☐ Evaluate the type and length of the planned cruise in the context of personal health requirements. ☐ Notify the cruise line of additional health needs (e.g., dialysis, supplemental oxygen, wheelchair). ☐ Pack Environmental Protection Agency (EPA)–registered insect repellent; consider treating clothes and gear with permethrin. ☐ Pack sunscreen.

DURING TRAVEL

☐ Avoid contact with people who are ill. ☐ Follow safe food and water precautions when eating off ship at ports of call. ☐ Maintain good fluid intake and avoid excessive alcohol consumption. ☐ Practice safe sex. ☐ Report all illnesses to ship’s medical center and follow their recommendations. ☐ Use insect bite precautions during port visits, especially in vectorborne disease–endemic areas or areas experiencing outbreaks of vectorborne diseases (e.g., Zika, yellow fever) ☐ Use sun protection. ☐ Wash hands frequently with soap and water; if soap and water are not available, use ≥60% alcohol–based hand sanitizer.

POST TRAVEL

☐ See CDC’s latest post-cruise health guidance regarding coronavirus disease 2019.

Travelers with Additional Considerations

Travelers with chronic illnesses and travelers with disabilities who have additional needs (e.g., dialysis, supplemental oxygen, wheelchairs) should inform their cruise line before traveling. Highly allergic travelers and travelers with underlying medical conditions should carry a file that contains essential, pertinent health information (e.g., allergies, blood type, chest radiograph [if abnormal], chronic conditions, electrocardiogram, medication list, primary and/or specialty care provider contact information). Travelers also should bring any medications recommended by their health care provider (e.g., an epinephrine auto-injector) to help facilitate care during a medical emergency. For detailed information on preparing travelers who have additional considerations for international travel, including severe allergies, chronic illness, disabilities, or immune compromise, see Section 3.

Pregnant Travelers

Most cruise lines have policies that do not permit people to board after their 24th week of pregnancy. Contact cruise lines directly for specific guidance before booking. For additional information on preparing pregnant people for international travel, see Sec. 7, Ch. 1, Pregnant Travelers .

Insurance Coverage

All prospective cruise travelers should verify coverage with their health insurance carriers and, if not included, consider purchasing additional insurance to cover medical evacuation and health services received onboard cruise ships and in foreign countries (see Sec. 6, Ch. 1, Travel Insurance, Travel Health Insurance & Medical Evacuation Insurance ).

The following authors contributed to the previous version of this chapter: Kara Tardivel, Stefanie B. White, Krista Kornylo Duong

Bibliography

Hill CD. Cruise ship travel. In: Keystone JS, Kozarsky PE, Connor BA, Nothdurft HD, Mendelson M, editors. Travel medicine, 4th edition. Philadelphia: Saunders Elsevier; 2019. pp. 377–82. 

Jenkins KA, Vaughan GHJ, Rodriguez LO, Freeland AL. Acute gastroenteritis on cruise ships—United States, 2006–2019. MMWR Morb Mortal Wkly Rep. 2021;70(6):1–19. 

Kordsmeyer A-C, Mojtahedzadeh N, Heidrich J, Militzer K, von Münster T, Belz L, et al. Systematic review on outbreaks of SARS-CoV-2 on cruise, navy and cargo ships. Int J Environ Res Public Health. 2021;18(10):5195. 

Millman AJ, Kornylo Duong K, Lafond K, Green NM, Lippold SA, Jhung MA. Influenza outbreaks among passengers and crew on two cruise ships: a recent account of preparedness and response to an ever-present challenge. J Travel Med. 2015;22(5):306–11. 

Mouchtouri VA, Lewis HC, Hadjichristodoulou C. A systematic review for vaccine-preventable diseases on ships: evidence for cross-border transmission and for pre-employment immunization need. Int J Environ Res Public Health. 2019;16(15):2713. 

Payne DC, Smith-Jeffcoat SE, Nowak G, Chuwkwuma U, Geibe JR, Hawkins RJ, et al. SARS-CoV-2 infections and serologic responses from a Sample of U.S. Navy service members—USS Theodore Roosevelt, April 2020. MMWR Morb Mortal Wkly Rep 2020;69(23):714–21. 

Peake DE, Gray CL, Ludwig MR, Hill CD. Descriptive epidemiology of injury and illness among cruise ship passengers. Ann Emerg Med. 1999;33(1):67–72. 

Rice ME, Bannerman M, Marin M, Lopez AS, Lewis MM, Stamatakis CE, et al. Maritime varicella illness and death reporting, U.S., 2010–2015. Travel Med Infect Dis. 2018;23:27–33. 

Rocklöv J, Sjödin H, Wilder-Smith A. COVID-19 outbreak on the Diamond Princess cruise ship: estimating the epidemic potential and effectiveness of public health countermeasures. J Travel Med. 2020;27(3):taaa030. 

Stamatakis CE, Rice ME, Washburn FM, Krohn KJ, Bannerman M, et al. Maritime illness and death reporting and public health response, United States, 2010–2014. J Travel Med Inf Dis. 2017;19:16–21.

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Guidance for Cruise Ships on Management of Acute Respiratory Illness (ARI) due to Viral Infection

CDC Respiratory Virus Guidance has been updated. The content of this page will be updated soon.

Describing and Defining Passengers and Crew with Acute Viral Respiratory Illness (ARI)

Reducing the spread of viral respiratory infections, vaccination of crew and passengers, managing passengers or crew with ari upon disembarkation, medical evaluation and management, diagnostic tests for acute viral respiratory illness (ari), respiratory and hand hygiene, outbreak control, infection prevention and control.

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Attribution Statement

Outbreaks of influenza, COVID-19, r espiratory syncytial virus (RSV) , and other viral respiratory infections can occur at any time of the year among cruise ship passengers and crew members. Many cruise ship travelers are older adults or have underlying medical conditions that put them at increased risk of complications from these respiratory virus infections. Early detection, prevention, and control of such acute viral respiratory infections are important, not only to protect the health of passengers and crew members on cruise ships, but also to avoid spread of these viruses into communities.

This document provides guidance for cruise ships originating from or stopping in the United States to help prevent, diagnose, and medically manage acute respiratory illness (ARI) caused by SARS-CoV-2 (the virus that causes COVID-19), influenza virus, or RSV. This guidance to cruise ship clinics will be updated as needed. CDC recognizes that cruise ships travel worldwide, necessitating awareness of, and responsiveness to, local jurisdictional requirements. Cruise ship management and medical staff need to be flexible in identifying and caring for people with ARI. The healthcare provider’s assessment of a patient’s clinical presentation and underlying risk factors is always an essential part of decisions about the need for further medical evaluation, testing, and treatment.

This document also provides guidance for preventing spread of ARI during and after a voyage, including personal protective measures for passengers and crew members and control of outbreaks.

Signs and symptoms of ARIs can include acute onset of some or all of the following:

• fever or feeling feverish
• nasal congestion
• sore throat
• shortness of breath
• difficulty breathing
• muscle or body aches
• fatigue (tiredness)
• loss of taste or smell

For cruise ship surveillance purposes, CDC defines ARI as an illness of presumed viral etiology with at least two of the following symptoms : fever/feverishness, cough, runny nose, nasal congestion, or sore throat and excluding:

• Confirmed acute respiratory infection diagnoses other than COVID-19 [1] , influenza [2] , or RSV [3] (e.g., Streptococcal pharyngitis, Epstein-Barr virus infection), *
• Diagnoses of bacterial pneumonia: either clinical or test-positive (e.g., by urine Legionella antigen, urine Streptococcus pneumoniae antigen), and
• Non-infectious conditions as determined by the ship’s physician (e.g., allergies)

Fever (a temperature of 100°F [37.8°C] or higher) will not always be present in people with influenza, COVID-19, or RSV. Cruise ship medical personnel should consider someone as having a fever if the sick person feels warm to the touch, gives a history of feeling feverish, or has an actual measured temperature of 100°F (37.8°C) or higher.

*Other respiratory viruses—for which point-of-care diagnostic tests are not available—may also cause ARI (e.g., rhinovirus, adenovirus, enterovirus, human parainfluenza viruses, human metapneumoviruses).

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

[2] Confirmed influenza means laboratory confirmation for influenza A or B by viral test.

[3] Confirmed RSV means laboratory confirmation for RSV by viral test.

Commercial maritime travel is characterized by the movement of large numbers of people in enclosed and semi-enclosed settings. Like other close-contact environments, these settings can facilitate the transmission of respiratory viruses from person to person through droplets and small particles or potentially through contact with contaminated surfaces.

CDC recommends that efforts to reduce the spread of respiratory viruses on cruise ships focus on encouraging crew members and passengers:

• 6 months and older to get vaccinated annually for influenza
• 6 months and older to stay up to date with their COVID-19 vaccines
• who are 60 years and above  to discuss and consider RSV vaccination  with their healthcare provider
• To follow recommendations for babies and young children  and if applicable, to receive monoclonal antibody products to prevent severe RSV
• To avoid contact with ill people prior to scheduled cruising
• To postpone travel if sick with an acute respiratory illness (passengers)
• To take steps to protect themselves and others while traveling
• To consider wearing a mask  in crowded or poorly ventilated indoor areas.

Cruise ship management should include:

• Encouraging good respiratory hygiene and cough etiquette
• Early identification and isolation of crew members and passengers with ARI
• Use of antiviral medications for treatment of people with suspected or confirmed influenza or COVID-19 with severe or complicated illness, or at increased risk of severe illness or complications
• Use of antiviral chemoprophylaxis for post-exposure prophylaxis (PEP) or during influenza outbreaks, if indicated, for people at increased risk of complications

All passengers and crew are also recommended to be up to date with all routine vaccines .

Influenza : CDC recommends that all people 6 months of age and older be vaccinated each year with the influenza vaccine. Crew members should be vaccinated yearly. Vaccination of passengers, especially those at high risk for influenza complications, is recommended at least 2 weeks before cruise ship travel, if influenza vaccine is available and the person has not already been vaccinated with the current year’s vaccine. For more information on influenza vaccine recommendations, see Seasonal Influenza Vaccination Resources for Health Professionals .

COVID-19: CDC recommends that all people 6 months of age and older 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 will be overwhelmed by cases of COVID-19. For more information on COVID-19 vaccine recommendations, see COVID-19 Vaccination Clinical and Professional Resources .

RSV : CDC recommends adult travelers ages 60 years and older discuss RSV vaccination with their healthcare provider prior to cruise travel. These new vaccines—which are the first ones licensed in the U.S. to protect against RSV—have been available since the fall of 2023. Babies and young children should follow recommendations and if applicable, receive monoclonal antibody products to prevent severe RSV. For more information, see For Healthcare Professionals: RSV (Respiratory Syncytial Virus) .

Pre-embarkation COVID-19 Testing

To reduce the likelihood of onboard transmission of SARS-CoV-2, pre-embarkation testing is recommended for all passengers, including those on back-to-back sailings [4] . Completion of testing closer to the time of embarkation (within 1 to 2 days) maximizes the benefit of preventing introduction of infectious persons onboard. Ships that choose to use COVID-19 antigen tests should follow FDA guidance .

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

Viral ARI Screening Procedures for Embarking Passengers

Cruise ship operators should consider screening embarking passengers for viral ARI symptoms, a history of a positive COVID-19 viral test within the 10 days before embarkation, and a history of exposure to a person with COVID-19 within the 10 days before embarkation.

Cruise ship operators should consider performing viral testing (e.g., COVID-19, influenza, RSV) for passengers with ARI before they embark. Ships that choose to use COVID-19 antigen tests should follow FDA guidance .

Cruise ship operators should consider denying boarding for passengers who test positive for infectious viral etiologies during pre-embarkation screening, as well as those who tested positive for COVID-19 within 10 days before embarkation. If boarding is permitted, see guidance for isolation and other measures provided below .

If the cruise ship operator chooses to test for other infectious etiologies and testing identifies an alternate etiology (e.g., Legionella , Epstein-Barr virus, Streptococcal pharyngitis) through laboratory testing, routine infection control precautions specific to the diagnosis should be followed.

For asymptomatic passengers who have a known COVID-19 close-contact exposure within the 10 days before embarkation, considerations for allowing boarding can include:

• being up to date with COVID-19 vaccines,
• having a negative result on a COVID-19 viral test conducted on the day of boarding, or
• having documentation of recent recovery [5]  from COVID-19

People who are up to date with COVID-19 vaccines are less likely to have severe outcomes if they develop COVID-19 after boarding. Testing is generally not recommended for asymptomatic people who recovered from COVID-19 in the past 30 days. If exposed passengers are allowed to board, see information below regarding recommendations for management onboard .

[5] Documentation of recent recovery from COVID-19 can include the following:

• Paper or electronic copies (including documentation of at-home antigen results) of their previous positive viral test result dated no less than 10 days and no more than 30 days before date of embarkation
• A positive test result dated less than 10 days before embarkation accompanied by a signed letter from a licensed healthcare provider indicating symptom onset more than 10 days before the voyage

Managing Cruise Travelers with ARI and Contacts while on Board

Travelers with ARI who board, as well as those who become sick with ARI onboard, should be identified and tested as soon as possible to minimize transmission of respiratory viruses. The table below provides disease-specific recommendations for persons on board with COVID-19, influenza, or RSV and those exposed (i.e., contacts).

§ The day of last exposure to a case is counted as day 0. Additional testing prior to day 6 can identify new cases earlier. Cruise ship operators may consider this strategy in situations where exposures may have occurred in crowded settings, if unsure of the date of exposure, or if there is difficulty identifying index cases, as often occurs in the cruise ship environment.

^ Individual should properly wear a respirator or well-fitting mask  at all times when outside of cabin indoors until 10 days after the last close contact with someone with COVID-19 (the date of last exposure to a case is considered day 0). During this time, these individuals should have in-cabin dining (with food trays placed and collected outside of cabins) and also wear a respirator or well-fitting mask inside their cabin if any other person (such as a crew cleaning staff) enters the cabin.

† Contacts with high risk of influenza complications should be identified in order to offer post-exposure prophylaxis (PEP)

Crew members with ARI, even if mild, should take the following additional steps—regardless of their COVID-19, influenza, or RSV vaccination status:

• Notify their supervisors.
• Report to the medical center for evaluation and testing, if indicated, according to shipboard protocols.
• Continue to practice respiratory hygiene, cough etiquette, and hand hygiene after returning to work, because respiratory viruses may be shed after the isolation period ends.

Disembarking cruise ship passengers or crew members who have ARI should continue to take recommended precautions after disembarkation. If a passenger or crew member with viral ARI is taken to a healthcare facility off the ship, the facility should be informed before arrival. Medical transport providers should also be notified in advance.

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) as well as disease-specific clinical guidelines (see links provided at the bottom of this section).
• PPE should include surgical masks and NIOSH Approved® N95® filtering facepiece respirators or higher, eye protection such as goggles or disposable face shields that cover the front and sides of the face, and disposable medical gloves and gowns.
• Antiviral agents and other therapeutics for COVID-19 , influenza , and RSV (if commercially available), and other antimicrobial medications
• Antipyretics (e.g., acetaminophen and ibuprofen), oral and intravenous steroids, supplemental oxygen
• Onboard capacity to conduct viral tests for SARS-CoV-2 and influenza, and RSV, as well as other infections that may be in the differential diagnosis (e.g., group A Streptococcus , Streptococcus pneumoniae, Legionella )
• Medical center staff should adhere to standard and transmission-based precautions when healthcare personnel are caring for patients with suspected or confirmed COVID-19, influenza, RSV, or other communicable diseases.

For more information, read updated resources for clinicians and guidance on the medical evaluation and management of people with COVID-19 , influenza , or RSV  are available on CDC’s websites.

Respiratory specimens for ARI testing should be collected immediately upon illness onset, with the understanding that repeat testing may be indicated based on the viral etiology or state of the COVID-19 pandemic. In general, molecular tests are recommended over antigen tests because of their greater sensitivity; multiplex assays are available that can detect SARS-CoV-2, influenza A and B, and RSV.

Healthcare providers should understand the advantages and limitations of rapid diagnostic tests, and proper interpretation of negative results of any antigen diagnostic tests. Rapid antigen diagnostic tests have a lower sensitivity compared with RT-PCR, and false negative results can occur frequently. In symptomatic persons, negative rapid antigen diagnostic test results do not exclude a diagnosis of COVID-19, influenza, or RSV; clinical diagnosis of these illnesses should be considered; however, positive test results are useful to establish a viral etiology and to provide evidence of infection in passengers and crew members aboard ships.

People with ARI should be advised of the importance of covering coughs and sneezes and keeping hands clean because respiratory viruses may be shed after the isolation period ends.

Cruise operators should ensure passengers and crew have access to well-stocked hygiene stations with soap and water and/or hand sanitizer, tissues, paper towels, and trash receptacles.

Respirators or well-fitting masks should be readily available and symptomatic passengers and crew should be encouraged to use them if they have to be outside their cabins.

Passengers and crew members should be reminded to wash their hands often with soap and water, especially after coughing or sneezing. If soap and water are not available, they can use an alcohol-based hand sanitizer that contains at least 60% alcohol.

Used tissues should be disposed of immediately in a disposable container (e.g., plastic bag) or a washable trash can.

For more information on respiratory hygiene, see Coughing and Sneezing .

A combination of measures can be implemented to control ARI outbreaks, including isolation of infected people, increased infection prevention and control efforts, antiviral chemoprophylaxis of influenza-exposed people, crew member and passenger notifications, and active surveillance for new cases.

Recommendations when a voyage’s crew or passenger ARI attack rate reaches 2% ‡

• Provide all crew members with respirators or well-fitting masks and provide crew with information on how to properly wear, take off , and clean (if reusable)
• Minimize the number of crew members sharing a cabin or bathroom to the extent possible.
• Instruct crew members to remain in cabins as much as possible during non-working hours.
• Cancel nonessential face-to-face employee meetings as well as group events (such as employee trainings) and social gatherings.
• Close all crew bars, gyms, and other group settings.
• Close indoor crew smoking areas.
• Maximize the introduction of outdoor air and adjust HVAC systems to increase total airflow to occupied spaces. For additional information on ventilation, see Ventilation in Buildings
• Maximize air circulation in crew outdoor smoking areas.
• Expedite contact tracing (including the use of wearable technology, recall surveys, and the onboarding of additional public health staff).
• Consider serial viral (antigen or NAAT) screening testing of crew every 3–5 days. The onboarding of additional laboratorians may be needed to facilitate the testing process.
• If an influenza outbreak, antiviral chemoprophylaxis  can be considered for prevention of influenza in exposed people depending on their risk for complications, or could be given to all contacts on a cruise ship when the threshold is met or exceeded.

Recommendations when a voyage’s crew or passenger ARI attack rate reaches 3% ‡

• Provide all passengers with respirators or well-fitting masks and provide crew with information on how to properly wear, take off , and clean (if reusable)
• Position posters educating passengers on how to properly wear respirators or well-fitting masks  in high traffic areas throughout the ship.
• Eliminate self-serve dining options at all crew and officer messes.
• Reduce the dining cohort size for crew, and shorten dining times to avoid crowding.
• Send written notification to passengers on the current, previous, and subsequent voyages informing them of the ARI conditions and measures being taken to reduce transmission on board.
• Cancel crew shore leave.
• Implement a “working quarantine” policy for all crew (i.e., crew perform job duties then return to cabin).
• Require use of respirators or well-fitting masks and provide crew with information on how to properly wear, take off , and clean (if reusable)
• Test all passengers for COVID-19 prior to the end of the voyage, regardless of their vaccination status. Advise those who test positive or have known exposure to follow guidance following disembarkation .

‡ Sources of data should include medical center records and other established surveillance systems for passengers and crew (e.g., employee illness reports).

Considerations for Suspending Passenger Operations

In some circumstances, additional public health precautions, such as returning to port immediately or delaying the next voyage, may be considered 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:

• 15% or more of the passengers have met ARI criteria; or
• 15% or more of the crew have met ARI criteria; or
• 15% or more of total travelers have met ARI criteria. [6]
• Shortages of supplemental oxygen or other medical supplies related to management of patients with ARI, or
• 3 or more deaths due to ARI in passengers and/or crew during a voyage.
• Evaluate symptomatic travelers and their close contacts,
• Conduct diagnostic and screening testing of travelers,
• Conduct routine medical checks of travelers in isolation, or
• Conduct contact tracing of close contacts, if applicable
• Testing equipment,
• Antipyretics (fever-reducing medications such as acetaminophen and ibuprofen),
• Antivirals and other therapeutics for COVID-19, influenza, and RSV (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 novel respiratory virus or SARS-CoV-2 variant of concern or a new or emerging SARS-CoV-2 variant with potential for increased severity or transmissibility identified among cases on board

[6] These thresholds are subject to change based on the characteristics of the dominant COVID-19 variant or a novel respiratory virus in the United States or elsewhere.

CDC requests that cruise ships submit a cumulative ARI report (even if no ARI cases have occurred) preferably within 24 hours before arrival in the U.S. [7] , and sooner if a voyage’s crew or passenger ARI attack rate reaches 3% [8] . These reports are requested by completing the Cruise Ship Cumulative Acute Respiratory Illness (ARI) Reporting Form. Access to the online reporting form has been provided to cruise lines by CDC. Cruise lines that do not have access may contact CDC (email [email protected] ).

In addition, CDC emphasizes that any deaths—including those caused by or suspected to be associated with influenza, COVID-19, RSV, or ARI—that occur aboard a cruise ship destined for a US port must be reported to CDC immediately. Report ARI deaths by submitting an individual  Maritime Conveyance Illness or Death Investigation Form [PDF – 4 pages] for each death.

Vessel captains may request assistance from CDC to evaluate or control ARI outbreaks as needed. If the ship will not be arriving imminently at a U.S. seaport, CDC maritime staff will provide guidance to cruise ship officials regarding management and isolation of infected people and recommendations for other passengers and crew members. CDC staff may also help with disease control and containment measures, passenger and crew notification, surveillance activities, communicating with local public health authorities, obtaining and testing laboratory specimens, and provide additional guidance as needed.

[7] For international voyages with >1 U.S. port (e.g., Canada to multiple Alaskan ports), please submit report to CDC within 24 hours before arrival in the final U.S. port.

[8] For international voyages with >15 days prior to arrival in the U.S., the time period for calculating this attack rate begins at day 15 prior to arrival at a U.S. port.

Infection prevention and control (IPC) are critical to reducing the spread of ARI. 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 ARI.

To reduce the spread of ARI, 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
• A graduated approach for escalating infection prevention and control measures in response to ARI cluster or outbreaks during a voyage with action steps and criteria for implementation
• Procedures for informing passengers and crew members that a threshold of ARI has been met or exceeded, and of any recommended or required measures to prevent spread of infection
• Crew members entering cabins or other areas where people with confirmed or suspected COVID-19 are should be limited, and crew should wear an NIOSH Approved® N95® filtering facepiece respirator or higher in accordance with the Occupational Safety and Health Administration’s (OSHA) Respiratory Protection standard   (29 CFR 1910.134 )
• Disinfectant products or systems used, including the surfaces or items the disinfectants will be applied to, concentrations, and required contact times
• Safety data sheets (SDSs)
• PPE recommendations for crew, which may include surgical masks or NIOSH Approved® N95® filtering facepiece respirators or higher, eye protection such as goggles or disposable face shields that cover the front and sides of the face, and disposable medical gloves and gowns in addition to those recommended by the disinfectant manufacturer in the SDS; for information on health hazards related to disinfectants used against viruses, see Hazard Communication for Disinfectants Used Against Viruses .
• Health and safety procedures to minimize respiratory and dermal exposures to both passengers and crew, when recommended
• Graduated procedures for returning the vessel to normal operating conditions after a threshold of ARI has been met, including de-escalation of cleaning and disinfection protocols

Frequent, routine cleaning and disinfection of commonly touched surfaces with an Environmental Protection Agency (EPA)-registered disinfectant is recommended. For COVID-19, EPA-registered disinfectant  effective against coronaviruses is strongly recommended.

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Cruise comeback: How South Florida's cruising industry bounced back

Not only has cruising bounced back, but cruise lines and ports are seeing more passengers than ever before.

When the COVID-19 pandemic stopped the world in its tracks back in 2020, the cruising industry was among those hit the hardest.

The images were broadcast across the world -- cruise ships filled with passengers and crew members quarantined -- all before the virus even had its official name.

However, Miami-Dade County Mayor Daniella Levine Cava says work continued on land, to prepare for the eventual comeback we are witnessing in 2024.

"I think we use that period to really do planning, engagement -- make sure that we could build back better," Levine Cava explained. "And the industry is growing worldwide. People love to cruise the appetite for cruising is insatiable. So we are very fortunate that we are the beneficiaries of this growth."

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Icon of the Seas, the world's largest cruise ship, arrives at PortMiami

Not only has cruising bounced back, but cruise lines and ports are seeing more passengers than ever before.

"Cruising is back. The industry is stronger than ever," Port Director and Port Miami CEO Hydi Webb said. "Passengers have pent up demand to be back out at sea."

Webb says the local community was especially confident that cruising would bounce back.

"The industry, the port, Miami Dade County have always believed in the comeback," Webb added. "We never stopped building during COVID. As soon as COVID was over, we opened up three new cruise terminals."

South Florida is home to two of the busiest ports in the world -- Port Miami is number one on the list and dubbed as the cruise capital of the world.

Not far behind is Port Everglades in Fort Lauderdale, at No. 3.

"We recovered 29 different ships during the shutdown and then worked with the cruise lines to put that confidence back in place for the for the public," Port Everglades Acting Director Glenn Wiltshire explained.

Combined more than 10 million passengers set sail from the two ports. Port Miami even set a new mark for passenger travel in 2023.

“We now have the record for the world at almost 7.3 million passengers. That is really extraordinary, especially post COVID,” Levine Cava said.

While some of those 10 million passengers are from right here in South Florida, many of them are from across the globe.

Wiltshire says Port Everglades conducted an impact analysis in 2023 and found that the average family spends about $900 either before or after their cruise here in town -- providing a valuable boost to the local economy.

Plus, the ports and cruise lines also provide jobs for thousands of South Floridians.

"Port Everglades from a cruise impact, just for example -- 2500 jobs in the community over $600 million of economic activity and just the multiplier effect of all those people coming into town," Wiltshire continued.

The future is even brighter, with expansion and construction already underway to welcome new ships, new terminals and new passengers to South Florida.

"We have another the world's largest cruise terminal under construction right now on the east end of the port in conjunction with MSC Cruises, Webb said on Port Miami. "It will be the world's largest cruise terminal able to accommodate three vessels ultimately at one time from three different cruise lines."

To watch the full documentary, tune in to NBC6's Youtube channel by clicking here .

CDC updates, simplifies COVID-19 isolation guidelines as deaths and hospitalizations continue to fall

J ACKSON, Miss. (WLBT) - The next time you come down with COVID-19, you won’t have to worry about quarantining for a set number of days.

This comes as part of the Centers for Disease Control and Prevention’s  latest guidance .

The CDC’s updated and simplified guidelines even the playing field between COVID-19 and other respiratory illnesses like the flu.

Baptist Memorial Healthcare’s Medical Director of Infectious Disease, Dr. Stephen Threlkeld, says the change reflects a recognition that COVID isn’t the disease it was four years ago and that people aren’t doing a good job of testing themselves for it anyway.

There’s no question the CDC’s COVID-19 guidance has undergone a number of changes over the years.

Threlkeld says a lot of that can be credited to the fact that all of us are learning about the deadly disease in real-time.

“What’s the impact of kids missing school versus protecting the kids against COVID? These aren’t easy questions. They’re not questions that guidelines can really necessarily keep up with very well. But we have to try,” he said. “I think if you don’t change guidelines in response to dramatic increases in your data, you’re probably not doing the best thing.”

The latest guidance frees people to go out in the community once they feel better for at least 24 hours and remain without a fever in the absence of medications that can artificially knock a fever out.

Threlkeld says the shift is in response to a 90% decrease in mortality, a dramatic decrease in hospitalizations, and a recognition that a lot of people just aren’t testing themselves anymore.

“A lot of people don’t have the coverage to miss work without losing pay, and they can’t afford to do that. I can’t tell you how many times I’ve heard, ‘If you don’t test, you don’t have the disease,’” Threlkeld said. “[The CDC] hopes that we’ll get around that with less of a penalty, if you will, if you’re positive.”

The problem, of course, is more people are going to be out and about while still contagious with COVID.

The hope, according to Threlkeld, is that people will go back to testing themselves more, take advantage of vaccinations and medications like Paxlovid as well as follow recommendations like wearing a tight-fitting mask.

“It does, I think, put some of the impetus on people who are at high risk to protect themselves. We do know that can be done, and we do know that we don’t do it well enough,” he said.

Once you go back to normal activities, the CDC is encouraging you to take additional prevention strategies for the next five days.

That includes exposing yourself to fresh air, enhancing hygiene practices, wearing a tight-fitting mask, and avoiding people who are high-risk.

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In a pandemic milestone, the NIH ends guidance on COVID treatment

Pfizer's Paxlovid combines two antiviral drugs to fight the virus that causes COVID-19. Joe Raedle/Getty Images hide caption

Pfizer's Paxlovid combines two antiviral drugs to fight the virus that causes COVID-19.

These days, if you're sick with COVID-19 and you're at risk of getting worse, you could take pills like Paxlovid or get an antiviral infusion.

By now, these drugs have a track record of doing pretty well at keeping people with mild to moderate COVID-19 out of the hospital.

The availability of COVID-19 treatments has evolved over the past four years, pushed forward by the rapid accumulation of data and by scientists and doctors who pored over every new piece of information to create evidence-based guidance on how to best care for COVID-19 patients.

One very influential set of guidelines — viewed more than 50 million times and used by doctors around the world — is the COVID-19 Treatment Guidelines from the National Institutes of Health (NIH).

"I think everyone [reading this] will remember [spring of] 2020, when we did not know how to treat COVID and around the country, people were trying different things," recalls Dr. Rajesh Gandhi , an infectious diseases specialist at Massachusetts General Hospital and a member of the NIH's COVID-19 Treatment Guidelines Panel. Around that time, people were popping tablets of hydroxychloroquine and buying livestock stores out of ivermectin, when there was no proof that either of these drugs worked against infection by the coronavirus that causes COVID-19 ( later studies showed that they are ineffective ).

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It was early in the COVID-19 pandemic when the NIH convened a panel of more than 40 experts and put out its first guidelines, which became a reference for doctors around the world.

For the next few years, it was an "all hands on deck" endeavor, says Dr. Cliff Lane , director of the clinical research division at the National Institute of Allergy and Infectious Diseases (NIAID) and a co-chair of the panel.

Panel members met several times a week to review the latest scientific literature and debate data in preprints. They updated their official guidance frequently, sometimes two or three times a month.

End of an era

Lately, the development of new COVID-19 treatments has slowed to a drip, prompting the guideline group to rethink its efforts. "I don't know that there was a perfect moment [to end it], but ... the frequency of calls that we needed to have began to decrease, and then on occasion we would be canceling one of our regularly scheduled calls," says Lane. "It's probably six months ago we started talking about — What will be the end? How do we end it in a way that we don't create a void?"

The last version of the NIH's COVID-19 Treatment Guidelines was issued in February. The archives of the guidance — available online until August — document how scientific understanding and technological progress evolved during the pandemic.

Lane says specialty doctors groups — such as the American College of Physicians and the Infectious Diseases Society of America — will be the keepers of COVID-19 treatment guidance from now on. They're the usual stewards of best-practice guidelines anyway, he says.

At this transition point, panel members say the evolution of COVID-19 treatments offers lessons for dealing with new emerging infectious diseases.

Turning points in treatment

In the spring of 2020, hospitals in parts of the U.S. were filling up with the first pandemic wave of COVID-19 patients. "We were just learning how the disease progressed. Our first guideline [ issued that April ] was, basically, we don't know what does and doesn't work," says Gandhi, of Massachusetts General Hospital. "But we did learn fairly quickly — mostly in hospitalized patients — what did work."

By June 2020, data supported a treatment plan for very ill patients: Use steroids like dexamethasone to stop the body's immune system from attacking itself, and combine them with antivirals, to stop the virus from replicating.

Then, about a year into the pandemic, came another turning point: solid evidence that early treatment with lab-made antibodies could help keep COVID-19 patients out of the hospital. "This was a somewhat unexpected and dramatic [positive] effect," Lane says, noting that previous attempts to develop antibody therapies against influenza were unsuccessful.

The way these drugs, called monoclonal antibodies, worked out "provided so much insight into the virus itself," says Dr. Phyllis Tien , of the University of California, San Francisco, and a member of the COVID-19 treatment panel. While initially successful, the antibodies targeted the coronavirus's fast-changing spike protein. New strains of the coronavirus would knock out each new antibody version in about a year .

This cat-and-mouse strategy didn't last.

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How monoclonal antibodies lost the fight with new covid variants.

By the end of 2021, the Food and Drug Administration authorized two pill courses that COVID-19 patients could try taking at home to get better: Merck's molnupiravir and Pfizer's Paxlovid, a combination of two antiviral drugs: ritonavir and nirmatrelvir.

"Both have, as I like to say, warts," says Carl Dieffenbach , director of the AIDS division at NIAID and part of the agency's program to develop antivirals for pandemics. "Molnupiravir's warts are that it works marginally," meaning the data shows that it isn't very effective. And while Paxlovid works pretty well, it can't be taken with a lot of common drugs. "[Many] doctors are uncomfortable or unwilling to manage ... [patients] who should take it, but are on a statin or some other drug through the process," Dieffenbach says.

Another antiviral drug, remdesivir , is also considered fairly effective for treating mild to moderate COVID-19, though it's harder for patients to access, as it's administered intravenously. The drug company Gilead tried to make it into a pill, but it didn't work .

Underuse of effective treatment

The hurdles that come with each of these outpatient treatments have contributed to low usage rates among the patients they're intended to help, says Jenny Shen , a research scientist at the CUNY Institute for Implementation Science in Population Health.

Shen's research found that at the height of the pandemic, just 2% of COVID-19 patients reported getting molnupiravir and 15% reported getting Paxlovid, among those considered to be eligible for the drugs.

The study uses data from 2021-2022 — a time when the federal government bought these drugs from manufacturers and provided them free to states, health centers and pharmacies. Shen notes that rates of use have likely further declined since late 2023, after the drugs got transitioned to the commercial market , since they're "not as free as before" and, in many cases, require copayments.

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Coronavirus faq: is paxlovid the best treatment is it underused in the u.s..

Another part of the problem is that doctors can be reluctant to prescribe these outpatient treatments, since they can be difficult to manage if a patient has other health problems, Shen says.

Yet another challenge is that many patients with risk factors just don't believe they'll get very sick. "A dilemma we have observed is that patients want to see how severe their disease may become," but in waiting, they become ill beyond the point where the treatment would help, Shen says.

Even now, when some 13,000 people are getting hospitalized with COVID-19 each week, more patient education on how the drugs work and when they're most effective could help those who are sick make better-informed decisions, she says.

There's one more COVID-19 drug in late-stage clinical trials that could be promising, says Dieffenbach. It's a pill course by the Japanese company Shionogi that's getting tested for its efficacy against both acute and long COVID. "I'm waiting to see how this all turns out," he says, "But then that's it. That's what's in the pipeline" for the near future.

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Department of Health announces updated guidance for COVID-19 and other respiratory illnesses

For immediate release : March 18, 2024   (24-030) 

Contact : DOH Communications  

The new recommendations streamline guidance across multiple illnesses

OLYMPIA – The Washington State Department of Health (DOH) announced updated guidance for what to do when someone is sick with COVID-19, flu, respiratory syncytial virus (RSV), and other respiratory viruses. While much of DOH’s new guidance is similar to recent updates announced by the Centers for Disease Control (CDC), DOH’s new guidance offers additional recommendations on how to prevent spreading respiratory illnesses after someone becomes infected, as well as how to protect people with weakened immune systems and others at higher risk of severe illness.

“This updated respiratory virus isolation guidance reflects that we're in a better place now in the COVID-19 pandemic,” said Dr. Tao Sheng Kwan-Gett, Chief Science Officer, DOH. “But while life is returning to normal in many ways, we must remember that for many in our community with chronic conditions and weakened immune systems, respiratory virus infections such as COVID-19, flu, and RSV remain a deadly threat. Each week, more than a dozen people in our state lose their lives to COVID-19 each week. We must not rest until that number is zero.”

One of the most significant guidance changes is how long someone should stay home and away from others after contracting COVID-19, flu, RSV, or other respiratory viruses. While previous COVID-19 guidance recommended people isolate for at least 5 full days after symptoms appeared, the new guidance recommends people return to normal activities when their symptoms are getting better overall and they have not had a fever (without having to use fever-reducing medication) for at least 24 hours. It is important to remember that people can still be contagious even when their symptoms have improved:

• People with COVID-19 can be contagious for 5-10 days after their illness begins.
• People with flu can be contagious for up to 5-7 days after their illness begins.
• People with RSV can be contagious for 3-8 days after their illness begins.

Because people can remain contagious even after they feel better, DOH recommends taking extra precautions during the first 5 days of returning to normal activities after COVID-19, flu, RSV, or other respiratory viruses. This includes wearing a mask , taking steps to improve air flow and filtration , frequent hand washing , regular cleaning , physical distancing , and, if possible, testing when you will be around other people indoors.

DOH’s new respiratory illness guidance also offers recommendations to prevent spreading infection to people at higher risk of getting very sick , such as older adults and people with weakened immune systems. These recommendations include staying away from high-risk people:

• For 10 days after symptoms of infection start, or for people who never develop symptoms, for 10 days since testing positive for COVID-19, OR
• Until receiving a negative result from a COVID-19 antigen test , (for people who previously tested positive)

While DOH’s new COVID-19 and respiratory illness guidance is meant to provide baseline recommendations, Washington residents are asked to follow any local health jurisdiction, workplace, business, or school policies that may provide more protective guidance specific to their setting or community. Employers must follow Washington State Department of Labor & Industries COVID-19 requirement in the workplace. Additionally, the new DOH guidance does not apply to health care settings. People who are staying, working, or visiting in a health care setting, long-term care facility, or residential care setting should follow the guidance in COVID-19 Infection Prevention in Health Care Settings , and the flu guidance for health care settings and long-term care facilities provided by the CDC . 

The DOH website is your source for a healthy dose of information. Find us on Facebook, Instagram , and follow us on X (formerly Twitter) . Sign up for the DOH blog,  Public Health Connection . 

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CDC shortens COVID-19 isolation period. What to know about new guidelines

The Centers for Disease Control and Prevention is updating its COVID-19 guidance so people who test positive for the virus will no longer be directed to isolate at home for five days.

On Friday, top health officials announced a new policy focusing on actions people can take to reduce spreading a variety of common respiratory viruses, such as influenza, respiratory syncytial virus (RSV) and COVID-19. Those actions include staying at home when sick, staying up to date with vaccines, practicing good hygiene and improving indoor air quality.

The change marks the first time the agency has revised its coronavirus guidelines since 2021. It is intended for people and employers, not for hospitals or nursing homes that have separate guidance, the CDC said.

CDC officials called the change a streamlined approach that’s easier for people to understand and more in line with circulating respiratory viruses that spread the same way and have similar symptoms. 

The announcement reflects progress made in reducing hospitalizations and deaths from COVID-19 over the last two years, CDC Director Mandy Cohen said in a Friday news conference. Still, she emphasized continued use of vaccines and treatments.

“We're in a different situation, but we must use the tools that work to protect against respiratory viruses,” she told reporters. “That’s why our updated guidance emphasizes some core prevention actions to protect against severe illness from respiratory viruses.”

In February, the Washington Post first reported on the CDC's plans to change the guidance.

What guidance does

Friday's guidance, CDC officials said, is meant to target respiratory viruses more broadly because the flu, RSV and COVID-19 all have similar symptoms such as cough and fever; have similar means of spread; and require the same protection strategies.

The CDC is recommending that people who test positive for the coronavirus should base their isolation period on clinical symptoms. The CDC doesn't recommend testing as a standard for deciding when someone is no longer contagious, in part, because CDC surveys show fewer people use at-home tests if they have symptoms, according to Dr. Brendan Jackson, who leads respiratory virus response for CDC's National Center for Immunization and Respiratory Disease. The CDC's decision is more streamlined to tell people to stay home if they are sick.

Americans can return to public life if they have been fever-free for at least 24 hours and symptoms are improving, regardless of a positive test, agency officials told reporters on Friday. When they return to normal activities, the CDC recommends people use preventative strategies for the next five days. This includes limiting close contact with others, enhancing hygiene like hand-washing, improving ventilation, masking and testing as needed. 

Officials said the federal action followed similar updated guidance from California and Oregon, which were the first states to announce new COVID-19 guidelines in early January that also did away with specific isolation times. 

Dr. Lara Jirmanus, a clinical instructor at Harvard Medical School, said people may struggle to interpret this new guidance.

Exclusive: Health is political, Americans are divided. How new CDC head aims to fix that.

“This guidance is going to be confusing to people because when they hear it, they're going to hear, ’the CDC now says COVID is not a big deal,’” said Jirmanus, a primary care doctor in Cambridge, Massachusetts. “That's not true. It's a deadly and disabling virus.”

She added people who are repeatedly infected increased their risk of developing long COVID, a potentially disabling condition that inflicts millions of Americans. Infants not yet eligible for vaccination remain at risk, as well.

Recent weekly reporting periods indicate nearly 19,000 people are hospitalized and more than 1,000 die from COVID-19 each week. However, Jackson, of the CDC, said COVID-19 figures are now approximately the same as those for the flu and far lower than early in the pandemic.

“These data reinforced that COVID-19 is still an important public health threat, but it is not the emergency that it once was,” Jackson said. “Its health impacts increasingly resemble those of other respiratory virus viral illnesses.”

How public should respond

Anyone who has a respiratory illness ‒ a cough, stuffy nose, often a fever ‒ should assume they have either COVID-19, the flu, or RSV, all of which kill tens of thousands of vulnerable Americans a year, said Dr. Paul Offit, a pediatrician and infectious disease specialist at the Children's Hospital of Philadelphia.

He recommends that people at risk for severe disease from COVID-19, including those who are pregnant, immunocompromised, or over 65, get tested quickly if they develop these symptoms so they can benefit from the very effective available treatments, Paxlovid and the antiviral Molnupiravir.

Anyone not at high risk should just assume they have one of these highly contagious infections and should wear a mask to protect the vulnerable, Offit said.

Dr. William Schaffner, an infectious disease specialist at Vanderbilt University School of Medicine, said he's one of the few people in his Nashville, Tennessee, region still masking in public. He and his wife are caring for a family member undergoing chemotherapy for cancer and he doesn't want to bring anything home.

He agrees that a policy change was needed to bring it more in line with what people are already doing. "These new guidelines will be welcomed."

State health officials cheered the new guidance as a practical yet important step.

"The thing that I heard across the board from our members is it's time to really try to align COVID with other respiratory illnesses," said Marcus Plescia, chief medical officer of the Association of State and Territorial Health Officials.  "It's in step of where we need to be going and where our society is going anyway."

Dr. Anand Parekh, chief medical adviser for the Bipartisan Policy Center, said most members of the public likely aren't following the previous isolation guidelines anyway.

"We're not going to prevent COVID anymore ‒ people are going to get COVID," he said. But, he added, what's important is preventing hospitalizations, severe illness and deaths in the face of a virus that "is much more transmissible than the flu or than a regular rhinovirus that gives you the common cold."

Western states moved first

The CDC's shift mirrors  updated guidance from California and Oregon , which were the first states to announce new COVID-19 guidelines in early January that also did away with specific isolation times.

In California's order, issued on Jan. 9, the changes were attributed to the reduced impact of COVID-19 compared to past years, the availability of treatment and the changing expectations to keep people most at-risk safe while posing minimal disruptions to the public.

Those who experience no apparent symptoms are no longer required to isolate at all, according to the state policies.

“We are now at a different point in time with reduced impacts from COVID-19 compared to prior years due to broad immunity from vaccination and/or natural infection, and readily available treatments available for infected people,” the director of the California Department of Public Health Dr. Tomás Aragón said in the  state order .

Looking ahead

The concern remains for people returning to work while contagious, which is often the case for people who can’t afford to take time off.

Cohen said the CDC is encouraging companies to allow employees to stay home when they’re sick, regardless of whether it's COVID-19 or another respiratory viral illness.

The decision also comes as the CDC earlier this week recommended a booster shot of the latest COVID-19 vaccine for people ages 65 and older . Cohen said it’s important to get vaccinated, with an updated COVID-19 and flu shots expected this fall.

Karen Weintraub contributed to this report.

Watch CBS News

A man got 217 COVID-19 vaccinations. Here's what happened.

By Caitlin O'Kane

Edited By Paula Cohen

Updated on: March 6, 2024 / 11:32 AM EST / CBS News

A 62-year-old man in Germany intentionally got 217 doses of  COVID-19 vaccines within 29 months. The vaccinations occurred outside of a clinical study, and after hearing about the "hypervaccinated" man, medical researchers in Germany reached out to him to run tests.

The researchers first learned about the man, who they say got the vaccines "deliberately and for private reasons," when a public prosecutor in Magdeburg, Germany, opened a fraud investigation, according to a paper  published in The Lancet Infectious Diseases  medical journal on Monday. The prosecutor confirmed 130 of the vaccinations and ultimately did not file criminal charges against the man.

The researchers sent a proposal to the man and the prosecutor saying they wanted to investigate the potential impact on his immune system from getting so many of the shots.

The man voluntarily gave them blood and saliva samples and the researchers compared his antibody levels to a control group of 29 people who had three doses of mRNA COVID-19 vaccines , according to the study. 

They were able to measure the man's antibody levels after his 214th vaccination and found them highest on that day and again three days after his 215th vaccination. His contraction kinetics — the cell response to the antibodies — mirrored those of the control group. His 217th vaccination showed just a modest increase in antibodies.

They checked the levels of a variety of types of cells involved in immune system responses, and while some were boosted as his vaccinations increased, many levels were in line with the control group.

The researchers say the man appeared to suffer no significant side effects despite the extreme number of doses.

"In summary, our case report shows that SARS-CoV-2 hypervaccination did not lead to adverse events and increased the quantity of spike-specific antibodies and T cells without having a strong positive or negative effect on the intrinsic quality of adaptive immune responses," the study reads. "While we found no signs of SARS-CoV-2 breakthrough infections in [the man] to date, it cannot be clarified whether this is causally related to the hypervaccination regimen."

"Importantly, we do not endorse hypervaccination as a strategy to enhance adaptive immunity," they note.

Staying up to date with  COVID-19 vaccinations  is recommended for everyone ages 6 months and older in the U.S. There are three types of COVID-19 vaccines available in the U.S. — two mRNA vaccines from Moderna and Pfizer, and a protein subunit vaccine from Novavax — and there is no preferential recommendation of one over the other, according to the CDC.  The CDC has a table with information  on the number of recommended doses based on your past vaccinations.

The CDC recently amended its COVID-19 guidelines, shortening the 5-day isolation period and updating its guidance on masks and testing. The new recommendations offer a "unified, practical approach to addressing risk" from COVID as well as other infections like the flu and RSV, the agency said.

• COVID-19 Vaccine

Caitlin O'Kane is a New York City journalist who works on the CBS News social media team as a senior manager of content and production. She writes about a variety of topics and produces "The Uplift," CBS News' streaming show that focuses on good news.

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• Testing for COVID-19

COVID-19: testing from 1 April 2024

Explains testing from 1 April 2024 onwards and sets out the purpose of ongoing testing, who will be eligible to access testing and when tests should be used.

The role of testing

Throughout the coronavirus (COVID-19) pandemic, the government has prioritised protecting the most vulnerable and those in high-risk settings. Government-funded testing will continue to focus on these groups. In March 2023, the Government announced further changes towards managing COVID-19 like other respiratory illnesses. New changes from 1 April 2024 are the next stage in delivering this approach.

The ongoing success of the vaccination programme, increased access to treatments and high immunity among the population have allowed the government to scale back testing in England. From April onwards, testing will be provided to individuals at highest risk from COVID-19, continuing to support diagnosis for care and access to treatments.

From 1 April 2024, routine provision of free COVID-19 lateral flow device ( LFD ) tests for the management of outbreaks in higher risk settings will come to an end in England. However, free polymerase chain reaction ( PCR ) testing to determine the cause of an acute respiratory infection outbreak in higher risk settings, where deemed appropriate by a local UK Health Security Agency ( UKHSA ) health protection team ( HPT ), will remain to test for a wide range of respiratory viruses.

The cohort of people eligible for COVID-19 treatments can still access free COVID-19 LFDs from their local pharmacy. These people, who are at highest risk of getting seriously ill, are encouraged to test to gain timely access to treatments. A full list of those who are eligible, and information on how to access tests, is available on the NHS website: https://www.nhs.uk/COVIDtreatments

Routine asymptomatic COVID-19 LFD testing on discharge from hospital into care or hospice settings will also end to align with the approach for other respiratory illnesses, though NHS Trusts will have local discretion to re-introduce this or other forms of testing as clinically appropriate following risk assessment, involving local authority public health teams, UKHSA HPTs and care providers as necessary in decision making.

Within healthcare settings, limited testing, including symptomatic testing of staff working on inpatient wards focused on treating profoundly immunocompromised individuals, will continue in line with locally derived protocols to protect those most at risk. Symptomatic testing of patient-facing hospice staff who work closely with people who are severely immunocompromised will also continue as outlined in guidance, in line with similar NHS settings.

Where symptomatic testing is recommended, this should be based on the  current list of COVID-19 symptoms .

All other residents, service users, patients and staff who are symptomatic should follow guidance for the general population on what to do if they have symptoms of a respiratory infection or a positive COVID-19 test , and the guidance on actions we can all take to help reduce the risk of catching COVID-19 and passing it on to others .

Testing recommended in NHS settings

In addition to the recommended testing identified, local healthcare organisations, with appropriate advice (including from Medical Directors, Nursing Directors or Directors of Infection Prevention and Control), may exercise local discretion to continue testing for specific individuals or cohorts in line with broader infection prevention and control measures. This includes emergency admission, elective pathway and transfer of care admissions, for example to a ward caring for patients who are severely immunosuppressed.

Together with the care home or hospice setting, hospitals should assess the risk in the period before planned discharge, seeking advice on proposed changes to testing arrangements from local authority public health teams or UKHSA HPTs , if needed. Following discussion with care home providers and any advice from public health teams or HPTs , hospitals may decide to undertake an LFD test, for example if there is a local outbreak within the hospital setting. This test should be provided and done by the hospital.

Testing recommended in care services (adult social care and hospices)

Guidance on a range of infection prevention and control measures in adult social care has now been combined with acute respiratory infection guidance in the guidance for infection prevention and control in adult social care: acute respiratory infection .

Testing recommended in other non-healthcare settings

These settings include prisons, immigration retention or removal centres, asylum reception centres, asylum hostel accommodation and reception centres, homelessness settings (including night shelters, hostels, hotels, and other temporary accommodation), domestic abuse refuges and respite rooms.

The risk of harm from COVID-19 for children and young people is very low.

Children and young people ( CYP ) settings do not require continued access to testing in residential special educational needs and disability ( SEND ) settings or the  CYP  secure estate ( CYPSE ).

Settings are encouraged to follow guidance on GOV.UK:

• Health protection in children and young people settings, including education
• Preventing and managing outbreaks of acute respiratory illness ( ARI ) in the  CYPSE

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