The Vessel Sanitation Program (VSP) at the Centers for Disease Control and Prevention (CDC) assists
the cruise ship industry to prevent and control the introduction, transmission, and spread of
gastrointestinal illnesses (GI) on cruise ships. VSP operates under the authority of the Public Health
Service Act (42 U.S.C. Section 264 Quarantine and Inspection Regulations to Control Communicable
We accomplish this mission by:
inspecting cruise ships, including both periodic, unannounced operational sanitation inspections and scheduled construction inspections;
monitoring gastrointestinal illnesses and investigating or responding to outbreaks;
training cruise ship employees on public health practices;
providing health education and reliable and current public health information to the cruise ship
industry, the traveling public, public health professionals, state and local health authorities, and
Which cruise ships are in our jurisdiction?
Cruise ships under our jurisdiction:
carry 13 or more passengers, and
have a foreign itinerary with U.S. ports.
How does VSP operate?
The program operates by the public health standards that can be found in the
VSP Operations Manual
(pdf). These criteria target the control and prevention of gastrointestinal illnesses on cruise ships
and are primarily based on standards found in the FDA Food Code and the World Health Organization’s
Guide to Ship Sanitation. The
VSP Operations Manual is periodically updated to reflect new technologies,
current food science, disease patterns and trends, and emerging pathogens.
Periodic Operational Sanitation Inspections
Why are periodic operational sanitation inspections conducted?
CDC inspectors conduct operational sanitation inspections to determine how well ships are operating
and maintaining sanitation standards in accordance with the
VSP Operations Manual
(pdf). Inspectors provide public health guidance to cruise ship staff when standards are out of
compliance and at the end of the inspection, write a report describing inspection findings and
recommendations. Inspections are conducted while a ship is in a U.S. port.
What do CDC inspectors examine during a periodic sanitation inspection?
Depending on the size of the ship, one to four inspectors will examine a ship to determine if it
complies with the public health standards found in the
VSP Operations Manual. The major areas that CDC
inspects include the following parts of the ship:
medical facilities: for gastrointestinal illness surveillance documentation and medical logs;
potable water systems: for source to storage, distribution, protection and any cross-connection,
and the disinfection process;
swimming pools and whirlpool spas: for filtration, disinfection, general maintenance, and safety;
galleys and dining rooms: for food protection during sourcing, provisioning, storage, preparation,
and service. Employee health and personal hygiene are evaluated as well as facility equipment
maintenance and dishwashing;
child activity centers: for properly equipped diaper changing stations, toilets, and handwashing
stations; facility disinfection; infection control for ill children;
hotel accommodations: for routine cleaning sequences and infection control procedures during
outbreaks of gastrointestinal illness, including the use of appropriate disinfectants and outbreak
ventilation systems: for maintenance and cleaning of air handling systems; and
common areas of the ship: for integrated pest management strategies, general cleanliness, and
At the conclusion of each inspection, CDC inspectors meet with ship management to discuss inspection
violations and provide them with a draft report. Within 2 weeks of the inspection, CDC sends a final
copy of the inspection report to the corresponding cruise line.
How frequently are ships inspected?
Cruise ships under VSP’s jurisdiction are subject to two inspections each year. If a ship sails
outside of the United States for an extended period of time, it may not be inspected twice a year but
will be inspected again when it returns to the United States.
Do ships know when the inspection will occur?
The twice-yearly inspections are unannounced.
Where do sanitation inspections occur?
All sanitation inspections occur while ships are in U.S. ports. CDC does not conduct sanitation
inspections in other countries.
How are cruise ships scored?
Cruise ships are scored on a 100-point scale. Inspection criteria, defined in the
VSP Operations Manual,
are assigned a point value (the major areas are listed above); when the criteria are violated,
inspection points are deducted from the score. Points are deducted from that score based on
significance. An 85 or below is considered a failing score. All scores are
on the VSP Web site.
Are ships required to correct violations from the inspection?
Yes. Some of the violations are corrected during the inspection while others may take longer to
correct. Although ships are responsible for correcting all violations, some critical violations must
be corrected immediately. Each ship must submit a Corrective Action Statement that states how the
violations were corrected.
What happens if a ship fails an inspection?
Ships that fail inspections are re-inspected within a reasonable time period of the failure. If a
ship fails an inspection because of an imminent public health risk, VSP may recommend that the ship not
sail. Imminent public health risks include the following violations:
inability to properly chlorinate potable water;
inability to keep food within safe temperatures;
inadequate facilities for cleaning and sanitizing equipment;
inability to properly dispose of solid or liquid waste; and
an infectious disease outbreak where continuing normal operations may subject newly arriving
passengers to disease.
Consultation for Construction and Renovation Inspections
When do construction and renovation inspections occur?
At the request of the cruise industry, CDC provides consultation during the construction and
renovation of cruise ships. We conduct plan reviews to analyze the ship’s design to eliminate
environmental health risks and to incorporate modifications that create healthy environments. CDC
involvement may include:
reviewing construction/renovation plans;
performing shipyard inspections; and
performing final construction inspections.
What’s involved in a construction/renovation inspection?
equipment and facilities: for standards, parts, and placements and hygiene requirements;
food areas: for buffet lines, galleys, provision rooms, refrigerators, bar areas, and dining rooms;
warewashing and waste management: for proper setup and handling;
swimming pools and whirlpool spas: for drains, pumps, filters, safety, and disinfection; and
water systems: for bunkering, storage, distribution, disinfection, and cross-connections/backflow
After an inspection, we may recommend that the ship include more handwashing stations, change the
location of these stations, or install backflow prevention devices on hairwashing stations connected to
the potable water line in the ship’s spa.
At the conclusion of each review or inspection, the cruise line and/or construction company is
provided with a report that indicates recommended changes to the ship’s design.
Gastrointestinal Illness Surveillance and Outbreak Investigations
Syndromic Surveillance of Gastrointestinal Illnesses
To assist the cruise ship industry to prevent and reduce gastrointestinal illnesses on cruise ships,
CDC maintains an electronic surveillance system that tracks cases of gastrointestinal illnesses. We
monitor the system to observe illness patterns.
How does the surveillance system work?
Cruise ship medical staff or other designated personnel are required to maintain a log of reported
cases of gastrointestinal illnesses. Cases are self-reported by passengers and crew. Medical staff send
a report to VSP that indicates the number of cases.
When are gastrointestinal illnesses reported to VSP?
Cruise ship staff are required to send GI illness case reports to VSP during the following
before arriving to a U.S. port from a foreign port. This report is required even when there are
no cases. It is made 24–36 hours before arriving to the United States;
if the case count of ill passengers or crew changes after making the initial notification in the
when 2% or more of the passengers or crew are ill with gastrointestinal illness. This report must be
sent at any time the vessel is in the United States or within 15 days of arriving to a U.S. port; and
when unusual symptoms are reported to the ship’s medical staff.
What does VSP do with the reports?
We monitor reports of gastrointestinal illness to:
determine if a high number of people are sick;
determine if unusual cases occur; and
analyze illness patterns over time.
Prior to the occurrence of an outbreak, cruise lines are required to develop an Outbreak Prevention
and Response Plan (OPRP). The OPRP must indicate trigger points that initiate a ship’s response to cases
of illness. It must identify overall outbreak management strategies and include detailed infection
control procedures for each area of the vessel.
When an outbreak occurs, we request logs and records, including gastrointestinal illness
surveillance logs, so that we can closely examine the reported cases. The surveillance logs include
information such as specific symptoms and the date and time that the illness occurred. By reviewing the
logs, we are able to determine the following:
amount of illness throughout the ship;
distribution of illness among the passengers and crew;
when the illness first began;
distribution of illness during each day of the voyage; and
When does VSP conduct an outbreak investigation?
VSP conducts outbreak investigations on ships that are sailing in the United States or are within 15
days of arriving to a U.S. port and when one of the following is true:
2% or more of the passengers or crew have reported being sick with symptoms of gastrointestinal
an unusual illness symptom(s) or occurrence(s) is reported; or
an outbreak has occurred, and the ship has difficulty in getting the outbreak under control.
Where are outbreak investigations conducted?
Outbreak investigations may be conducted either in the office or on a cruise ship. The following
describes what occurs during each investigation.
In the office: CDC staff evaluate ship records, including gastrointestinal illness surveillance
logs; establish daily contact with cruise line officials to determine if proper sanitation practices are
being applied; assess current outbreak management practices; and make recommendations for outbreak
management. Cruise ship staff collect clinical specimens, such as stool samples, or environmental
specimens, such as water samples, and send them to a land-based laboratory to test for possible cause(s)
of the outbreak.
On-site investigations: In addition to the in-office investigation listed above,
CDC staff board the cruise ship to do one or more of the following:
epidemiological assessment: examine the distribution of gastrointestinal illnesses, interview
passengers and crew members, and distribute and analyze questionnaires;
targeted environmental health assessment: based on preliminary findings from the
epidemiological review, investigate specific areas on the vessel to check for exposure and routes of
transmission of the illness; and
laboratory assessment: cruise ship staff collect clinical specimens, such as stool
samples, or environmental specimens, such as food, and send them to a land-based laboratory to test for
the possible cause(s) of the outbreak.
What does VSP require cruise lines to do during outbreaks?
Cruise lines are required to activate their Outbreak Prevention and Response Plan (mentioned above
under Preventing Outbreaks) and make every effort to gain control of the outbreak. Some control measures
increase daily cleaning and disinfection frequencies;
stop high-risk activities, such as self-service buffet tables and handshaking;
isolate ill people;
collect clinical and/or environmental specimens for analysis; and
provide daily updates to VSP that include case counts and reports of what the ship has done to establish control.
Additionally, VSP may request cruise lines to do the following:
alert passengers and staff of the illness;
provide information about proper handwashing;
notify new passengers about the outbreak prior to embarkation;
notify port authorities; and
establish cleaning and disinfection procedures in ports.
Where can I find information about a specific outbreak?
An increase in the number of norovirus outbreaks in 2006 and 2007 in the United States occurred at
the same time as the appearance of two new types of norovirus, called GII.4 Minerva and GII.4 Laurens,
respectively. These types of norovirus caused 79% of the outbreaks, but it's not clear if the increase
in outbreaks is directly related to how these new types of norovirus were spread, to their ability to
cause illness, or to another unknown factor (Centers for Disease Control and Prevention.
Activity --- United States, 2006--2007. Morbidity and Mortality Weekly Report August 24, 2007; 56;
How do I protect myself from norovirus?
To protect yourself from norovirus are the following:
engage in proper
handwashing techniques throughout your voyage, but especially after using the
bathroom and before eating;
avoid any food or water that you think may be contaminated;
avoid raw or undercooked shellfish, unnecessary direct hand contact with surfaces such as toilet
room door handles, and unnecessary close contact with symptomatic ill persons; and
We offer a 2.5-day training course to teach cruise ship supervisors the public health practices that
are specified in the
VSP Operations Manual. During the course, attendees have the opportunity to ask
specific questions about our requirements and how they relate to their work.
What practices do cruise ship personnel learn during the course?
Training is based on public health practices that are specified in the
VSP Operations Manual. The
courses that are taught include:
GI illness Surveillance and Outbreak Investigations;
Foodbourne Illnesses: Causes and Prevention;
Equipment and Facilities (related to food and other areas);
Hazard Analysis Critical Control Points (what they are and how to apply them);
General Environmental Health Maintenance (proper maintenance in child activity centers and ventilation systems);
Potable Water (protection and handling of);
Swimming Pool and Whirlpool Spas (maintenance of);
Integrated Pest Management;
Housekeeping and Infection Control;
Waterborne Illnesses (both potable and recreational); and
Where can I find more information?
Specific information about training sessions, including when and where they’re held, can be found
on the VSP Web site under Training.
Specific information is available on the VSP Web site and by request of interested individuals.
Cruise Ship Travelers
The cruising public can take a proactive
approach to staying healthy on their vacation by finding
out a ship’s sanitation score, learning about proper handwashing techniques, learning about disease
threats including norovirus, and much more.
Cruise ship employees can find information about inspection scores, variance requests, training
dates, outbreak investigation summaries and operational inspection requirements, and ship construction
For more information
If you’re looking for more information, please contact us by any of the following methods: