Evaluating infectious disease outbreak potential and mitigation effectiveness on cruise ships.

The cruise ship sector is a major part of the tourism industry, and an estimated over 30 million passengers are transformed worldwide each year. Cruise ships bring diverse populations into proximity for many days, facilitating the transmission of respiratory illnesses. The objective of this study is to develop a modeling framework to inform the development of viable disease risk management policies and measures to control disease outbreaks on cruises. Our model, parameterized and calibrated using the data of the COVID-19 outbreak on the Diamond Princess cruise ship in 2020, is used to assess the impact of the mitigation measures such as mask wearing, vaccination, on-board and pre-traveling testing measures. Our results indicate mask wearing in public places as the cheapest and most affordable measure can drop the number of cumulative confirmed cases by almost 50%. This measure along with the vaccination by declining the number of the cumulative confirmed cases by more than 94% is the most effective measure to control outbreaks on cruises. According to our findings, outbreaks are more predominant in the passenger population than the crew members, however, the protection measures are more beneficial if they are applied by both crew members and passengers. Regarding the testing measure, pre-traveling testing is more functional than the on-board testing to control outbreaks on cruises.

Using a bottom-up method to assess cruise ship activity impacts on emissions during 2019-2020 in China.

COVID-19 has had a serious impact on the development of the global shipping industry, especially since the impact on the cruise tourism industry was unprecedented. This study took cruise ships sailing in China ECA, China Exclusive Economic Zone (EEZ), Yangtze River main line, and Xijiang River main line Chinese waters as an example to analyze the key changes in cruise ship emissions during the pandemic. Automatic identification system (AIS) data, vessel static data, and emission control regional data are used to conduct a comprehensive analysis of cruise ship emissions from multiple perspectives such as a port-to-regional comparison. As such, a vessel emission model (i.e., a bottom-up method) is constructed in this research for predicting China ECA and EEZ cruise ship emissions. Compared with 2019, the cruise activities sailing in China's Emission Control Area (ECA) are mainly at berth, and the emissions of cruise ships have dropped significantly, with SOx emissions reduced by 59.11%. In addition, this study also calculates the carbon emissions of China's regional cruises, supplementing China's cruise carbon pool. The research results suggest that cruise operators may improve fuel efficiency, decrease vessel speed, improve routing and scheduling, and enhance fleet management in order to further mitigate the negative effects of the cruise tourism industry on the marine environment.

Large outbreak of typhoid fever on a river cruise ship used as accommodation for asylum seekers, the Netherlands, 2022.

On 6 April 2022, the Public Health Service of Kennemerland, the Netherlands, was notified about an outbreak of fever and abdominal complaints on a retired river cruise ship, used as shelter for asylum seekers. The diagnosis typhoid fever was confirmed on 7 April. An extensive outbreak investigation was performed. Within 47 days, 72 typhoid fever cases were identified among asylum seekers (n = 52) and staff (n = 20), of which 25 were hospitalised. All recovered after treatment. Consumption of food and tap water on the ship was associated with developing typhoid fever. The freshwater and wastewater tanks shared a common wall with severe corrosion and perforations, enabling wastewater to leak into the freshwater tank at high filling levels. Salmonella Typhi was cultured from the wastewater tank, matching the patient isolates. In the freshwater tank, Salmonella species DNA was detected by PCR, suggesting the presence of the bacterium and supporting the conclusion of contaminated freshwater as the probable source of the outbreak. Outbreaks of uncommon infections may occur if persons from endemic countries are accommodated in crowded conditions. Especially when accommodating migrants on ships, strict supervision on water quality and technical installations are indispensable to guarantee the health and safety of the residents.

A SARS-CoV-2 Omicron outbreak among crew members on a cruise ship in Germany in early 2022.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreaks on cruise ships have rarely been investigated. In early 2022, we were informed about a SARS-CoV-2 outbreak on a cruise ship calling Port of Hamburg after 10 infections among crew members were detected. We conducted an outbreak investigation in collaboration between ship owners, the ship physician and Hamburg's Institute for Hygiene and Environment, to identify risk factors and to achieve containment. The aim was to identify risk factors for SARS-CoV-2 infection and SARS-CoV-2 variants in a cohort of 165 crew members. MATERIALS AND METHODS: For this purpose, we collected data on age, sex, nationality, boarding-time, cabin use (single/shared), work place, and vaccination status of the study participants. Cases were defined as individuals who tested SARS-CoV-2 positive at least once in daily screenings during the outbreak period (10 days) by polymerase chain reaction or antigen test. We investigated risk factors for infection by descriptive, univariable and multivariable analysis. We performed whole genome sequencing to identify SARS-CoV-2 variants. RESULTS: We verified 103 SARS-CoV-2 positive cases (attack rate [AR] 62.4%); 39/41 sequenced samples were BA.2.3 Omicron subtype, one BA.1 and one BA.1.1. Among boostered crew members, AR was 38% vs. 65% among those vaccinated once or twice. Among those who stayed < 30 days on board, AR was 31% vs. 72% among those staying on board longer. Among Europeans, the AR was 53% vs. 71% in non- -Europeans. Adjusting for age and sex, cases were more likely to have received no booster vaccine (odds ratio [OR]: 2.66, 95% confidence interval [CI]: 0.99-7.13), to have spent more time on board (≥ 30 days, OR: 6.36, 95% CI: 2.81-14.40 vs. < 30 days) and to have a non-European nationality (OR: 2.14, 95% CI: 1.08-4.27). The outbreak stopped shortly after offboard isolation of cases. CONCLUSIONS: This investigation confirms the importance of a booster vaccine against COVID-19. Longer stays onboard could facilitate social mixing. Further studies could investigate the impact of social, cultural/ behavioural patterns and public health access on the infection risk. Physical distancing together with screening and isolation can contain SARS-CoV-2 outbreaks on cruise ships.

Influenza: seasonality and travel-related considerations.

RATIONALE FOR REVIEW: This review aims to summarize the transmission patterns of influenza, its seasonality in different parts of the globe, air travel- and cruise ship-related influenza infections and interventions to reduce transmission. KEY FINDINGS: The seasonality of influenza varies globally, with peak periods occurring mainly between October and April in the northern hemisphere (NH) and between April and October in the southern hemisphere (SH) in temperate climate zones. However, influenza seasonality is significantly more variable in the tropics. Influenza is one of the most common travel-related, vaccine-preventable diseases and can be contracted during travel, such as during a cruise or through air travel. Additionally, travellers can come into contact with people from regions with ongoing influenza transmission. Current influenza immunization schedules in the NH and SH leave individuals susceptible during their respective spring and summer months if they travel to the other hemisphere during that time. CONCLUSIONS/RECOMMENDATIONS: The differences in influenza seasonality between hemispheres have substantial implications for the effectiveness of influenza vaccination of travellers. Health care providers should be aware of influenza activity when patients report travel plans, and they should provide alerts and advise on prevention, diagnostic and treatment options. To mitigate the risk of travel-related influenza, interventions include antivirals for self-treatment (in combination with the use of rapid self-tests), extending the shelf life of influenza vaccines to enable immunization during the summer months for international travellers and allowing access to the influenza vaccine used in the opposite hemisphere as a travel-related vaccine. With the currently available vaccines, the most important preventive measure involves optimizing the seasonal influenza vaccination. It is also imperative that influenza is recognized as a travel-related illness among both travellers and health care professionals.

Can ship travel contain COVID-19 outbreak after re-opening: a Bayesian meta-analysis.

Large gatherings of people on cruise ships and warships are often at high risk of COVID-19 infections. To assess the transmissibility of SARS-CoV-2 on warships and cruise ships and to quantify the effectiveness of the containment measures, the transmission coefficient (ß), basic reproductive number (R0), and time to deploy containment measures were estimated by the Bayesian Susceptible-Exposed-Infected-Recovered model. A meta-analysis was conducted to predict vaccine protection with or without non-pharmaceutical interventions (NPIs). The analysis showed that implementing NPIs during voyages could reduce the transmission coefficients of SARS-CoV-2 by 50%. Two weeks into the voyage of a cruise that begins with 1 infected passenger out of a total of 3,711 passengers, we estimate there would be 45 (95% CI:25-71), 33 (95% CI:20-52), 18 (95% CI:11-26), 9 (95% CI:6-12), 4 (95% CI:3-5), and 2 (95% CI:2-2) final cases under 0%, 10%, 30%, 50%, 70%, and 90% vaccine protection, respectively, without NPIs. The timeliness of strict NPIs along with implementing strict quarantine and isolation measures is imperative to contain COVID-19 cases in cruise ships. The spread of COVID-19 on ships was predicted to be limited in scenarios corresponding to at least 70% protection from prior vaccination, across all passengers and crew.

An empirical and modelling approach to the evaluation of cruise ships' influence on air quality: The case of La Paz, Mexico.

Maritime activity has diverse environmental consequences impacts in port areas, especially for air quality, and the post-COVID-19 cruise tourism market's potential to recover and grow is causing new environmental concerns in expanding port cities. This research proposes an empirical and modelling approach for the evaluation of cruise ships' influence on air quality concerning NO2 and SO2 in the city of La Paz (Mexico) using indirect measurements. EPA emission factors and the AERMOD modelling system coupled to WRF were used to model dispersions, while street-level mobile monitoring data of air quality from two days of 2018 were used and processed using a radial base function interpolator. The local differential Moran's Index was estimated at the intersection level using both datasets and a co-location clustering analysis was performed to address spatial constancy and to identify the pollution levels. The modelled results showed that cruise ships' impact on air quality had maximum values of 13.66 µg/m3 for NO2 and 15.71 µg/m3 for SO2, while background concentrations of 8.80 for NOx and 0.05 for SOx (µg/m3) were found by analysing the LISA index values for intersections not influenced by port pollution. This paper brings insights to the use of hybrid methodologies as an approach to studying the influence of multiple-source pollutants on air quality in contexts totally devoid of environmental data.

Transmission of SARS-CoV-2 Associated with Cruise Ship Travel: A Systematic Review.

Background: Maritime and river travel may be associated with respiratory viral spread via infected passengers and/or crew and potentially through other transmission routes. The transmission models of SARS-CoV-2 associated with cruise ship travel are based on transmission dynamics of other respiratory viruses. We aimed to provide a summary and evaluation of relevant data on SARS-CoV-2 transmission aboard cruise ships, report policy implications, and highlight research gaps. Methods: We searched four electronic databases (up to 26 May 2022) and included studies on SARS-CoV-2 transmission aboard cruise ships. The quality of the studies was assessed based on five criteria, and relevant findings were reported. Results: We included 23 papers on onboard SARS-CoV-2 transmission (with 15 reports on different aspects of the outbreak on Diamond Princess and nine reports on other international cruises), 2 environmental studies, and 1 systematic review. Three articles presented data on both international cruises and the Diamond Princess. The quality of evidence from most studies was low to very low. Index case definitions were heterogeneous. The proportion of traced contacts ranged from 0.19 to 100%. Studies that followed up >80% of passengers and crew reported attack rates (AR) up to 59%. The presence of a distinct dose−response relationship was demonstrated by findings of increased ARs in multi-person cabins. Two studies performed viral cultures with eight positive results. Genomic sequencing and phylogenetic analyses were performed in individuals from three cruises. Two environmental studies reported PCR-positive samples (cycle threshold range 26.21−39.00). In one study, no infectious virus was isolated from any of the 76 environmental samples. Conclusion: Our review suggests that crowding and multiple persons per cabin were associated with an increased risk of transmission on cruise ships. Variations in design, methodology, and case ascertainment limit comparisons across studies and quantification of transmission risk. Standardized guidelines for conducting and reporting studies on cruise ships of acute respiratory infection transmission should be developed.

Optimization of Cockpit Ventilation for Polar Cruise Ships in Combination with Windscreen Defogging and Cabin Comfort Considerations.

Polar cruise ships are exposed to extreme external conditions during voyages, resulting in cockpit windscreens that are prone to fogging and frosting, seriously affecting the driver's vision and even threatening navigation safety. However, the current research mainly focuses on cabin comfort, ignoring the coupling of defogging and comfort. Accordingly, this paper combines cockpit-windshield-defogging design and cockpit comfort considerations, and proposes 108 orthogonal-ventilation design parameters based on the four basic ventilation methods. The effects of different air supply parameters on comfort and anti-fog characteristics are investigated by using fluid dynamics simulation methods. The entropy weight-TOPSIS algorithm is employed to find the optimal ventilation parameters. The results show that the "Down-supply up-return type vertical jet" air supply method corresponding to an air supply velocity of 1 m/s, an air supply temperature of 297 K, and an air supply relative humidity of 30% has the smallest Euclidean distance di+ from the positive ideal solution, and the largest Euclidean distance di- from the negative ideal solution; thus, it obtains a higher ci and the highest priority. This air supply method provides the best thermal comfort for the drivers, as well as the best anti-fogging and defogging effect. The results can be useful to provide suggestions for the future design of the air-conditioning systems in polar cruise ships.

A Hybrid Multi-Target Path Planning Algorithm for Unmanned Cruise Ship in an Unknown Obstacle Environment.

To solve the problem of traversal multi-target path planning for an unmanned cruise ship in an unknown obstacle environment of lakes, this study proposed a hybrid multi-target path planning algorithm. The proposed algorithm can be divided into two parts. First, the multi-target path planning problem was transformed into a traveling salesman problem, and an improved Grey Wolf Optimization (GWO) algorithm was used to calculate the multi-target cruise sequence. The improved GWO algorithm optimized the convergence factor by introducing the Beta function, which can improve the convergence speed of the traditional GWO algorithm. Second, based on the planned target sequence, an improved D* Lite algorithm was used to implement the path planning between every two target points in an unknown obstacle environment. The heuristic function in the D* Lite algorithm was improved to reduce the number of expanded nodes, so the search speed was improved, and the planning path was smoothed. The proposed algorithm was verified by experiments and compared with the other four algorithms in both ordinary and complex environments. The experimental results demonstrated the strong applicability and high effectiveness of the proposed method.

Risk factors, immune response and whole-genome sequencing of SARS-CoV-2 in a cruise ship outbreak in Norway.

OBJECTIVE: To improve understanding of SARS-CoV-2-transmission and prevention measures on cruise ships, we investigated a Norwegian cruise ship outbreak from July to August 2020 using a multidisciplinary approach after a rapid outbreak response launched by local and national health authorities. METHODS: We conducted a cross-sectional study among crew members using epidemiologic data and results from SARS-CoV-2 polymerase chain reaction (PCR) of nasopharynx-oropharynx samples, antibody analyses of blood samples, and whole-genome sequencing. RESULTS: We included 114 multinational crew members (71% participation), median age 36 years, and 69% male. The attack rate was 33%; 32 of 37 outbreak cases were seropositive 5-10 days after PCR. One PCR-negative participant was seropositive, suggesting a previous infection. Network-analysis showed clusters based on common exposures, including embarkation date, nationality, sharing a cabin with an infected cabin-mate (adjusted odds ratio [AOR] 3.27; 95% confidence interval [CI] 0.97-11.07, p = 0.057), and specific workplaces (mechanical operations: 9.17 [1.82-45.78], catering: 6.11 [1.83-20.38]). Breaches in testing, quarantine, and isolation practices before/during expeditions were reported. Whole-genome sequencing revealed lineage B.1.36, previously identified in Asia. Despite extensive sequencing, the continued transmission of B.1.36 in Norway was not detected. CONCLUSIONS: Our findings confirm the high risk of SARS-CoV-2-transmission on cruise ships related to workplace and cabin type and show that continued community transmission after the outbreak could be stopped by implementing immediate infection control measures at the final destination.

Unique Evolution of SARS-CoV-2 in the Second Large Cruise Ship Cluster in Japan.

In the initial phase of the novel coronavirus disease (COVID-19) pandemic, a large-scale cluster on the cruise ship Diamond Princess (DP) emerged in Japan. Genetic analysis of the DP strains has provided important information for elucidating the possible transmission process of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on a cruise ship. However, genome-based analyses of SARS-CoV-2 detected in large-scale cruise ship clusters other than the DP cluster have rarely been reported. In the present study, whole-genome sequences of 94 SARS-CoV-2 strains detected in the second large cruise ship cluster, which emerged on the Costa Atlantica (CA) in Japan, were characterized to understand the evolution of the virus in a crowded and confined place. Phylogenetic and haplotype network analysis indicated that the CA strains were derived from a common ancestral strain introduced on the CA cruise ship and spread in a superspreading event-like manner, resulting in several mutations that might have affected viral characteristics, including the P681H substitution in the spike protein. Moreover, there were significant genetic distances between CA strains and other strains isolated in different environments, such as cities under lockdown. These results provide new insights into the unique evolution patterns of SARS-CoV-2 in the CA cruise ship cluster.

A review of COVID-19 transmission dynamics and clinical outcomes on cruise ships worldwide, January to October 2020.

BackgroundCruise ships provide an ideal setting for transmission of SARS-CoV-2, given the socially dense exposure environment.AimTo provide a comprehensive review of COVID-19 outbreaks on cruise ships.MethodsPubMed was searched for COVID-19 cases associated with cruise ships between January and October 2020. A list of cruise ships with COVID-19 was cross-referenced with the United States Centers for Disease Control and Prevention's list of cruise ships associated with a COVID-19 case within 14 days of disembarkation. News articles were also searched for epidemiological information. Narratives of COVID-19 outbreaks on ships with over 100 cases are presented.ResultsSeventy-nine ships and 104 unique voyages were associated with COVID-19 cases before 1 October 2020. Nineteen ships had more than one voyage with a case of COVID-19. The median number of cases per ship was three (interquartile range (IQR): 1-17.8), with two notable outliers: the Diamond Princess and the Ruby Princess, which had 712 and 907 cases, respectively. The median attack rate for COVID-19 was 0.2% (IQR: 0.03-1.5), although this distribution was right-skewed with a mean attack rate of 3.7%; 25.9% (27/104) of voyages had at least one COVID-19-associated death. Outbreaks involving only crew occurred later than outbreaks involving guests and crew.ConclusionsIn the absence of mitigation measures, COVID-19 can spread easily on cruise ships in a susceptible population because of the confined space and high-density contact networks. This environment can create superspreader events and facilitate international spread.

Protecting Victims or Protecting the Brand? Secondary Victimization and Cruise Ship Crime.

It is now widely recognized that victims of crime in general, and victims of sexual offences in particular, commonly experience secondary victimization resulting from dismissive, poor, and sometimes retraumatizing treatment when they encounter the formal criminal justice system. However, little is known about victims' experiences when initially reporting crime outside of the formal justice system, for example crime that occurs during cruise ship holidays. The cruise industry is the fastest growing tourism sector. The total number of passengers onboard cruise ships internationally was expected to reach 30 million in 2019. There is limited reliable data about how many people experience crime onboard cruise ships, though crime victimization does occur. While victimization onboard cruise ships has received some attention, there is a dearth of evidence about when and how victims report crime, how victims are treated when they report their experience of crime to cruise ship companies, or the justice outcomes. Nor does the available data address whether victims of crime from diverse social groups are treated differently by cruise companies. Drawing on qualitative accounts produced by primary and secondary victims of crime onboard cruise ships, it is argued that as well as the known challenges that victims face, the addition of brand protection can compound cruise ship victims' experiences of secondary victimization. Secondary victimization refers to additional, or compounded harms experienced because of social or systemic responses to their experience of crime. There are three key implications of these findings: greater understanding of crime victims' experiences should be developed via refined, mandatory reporting of crime onboard cruise ships, and robust qualitative research; cruise ship staff need improved specialized training in responding to victims of crime, and legislation should be considered mandating an independent authority onboard cruise ships to receive, investigate and monitor victimization reports and responses.

Cruise Ship Travel in the Era of Coronavirus Disease 2019 (COVID-19): A Summary of Outbreaks and a Model of Public Health Interventions.

BACKGROUND: Cruise travel contributed to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission when there were relatively few cases in the United States. By 14 March 2020, the Centers for Disease Control and Prevention (CDC) issued a No Sail Order suspending US cruise operations; the last US passenger ship docked on 16 April. METHODS: We analyzed SARS-CoV-2 outbreaks on cruises in US waters or carrying US citizens and used regression models to compare voyage characteristics. We used compartmental models to simulate the potential impact of 4 interventions (screening for coronavirus disease 2019 (COVID-19) symptoms; viral testing on 2 days and isolation of positive persons; reduction of passengers by 40%, crew by 20%, and reducing port visits to 1) for 7-day and 14-day voyages. RESULTS: During 19 January to 16 April 2020, 89 voyages on 70 ships had known SARS-CoV-2 outbreaks; 16 ships had recurrent outbreaks. There were 1669 reverse transcription polymerase chain reaction (RT-PCR)-confirmed SARS-CoV-2 infections and 29 confirmed deaths. Longer voyages were associated with more cases (adjusted incidence rate ratio, 1.10, 95% confidence interval [CI]: 1.03-1.17, P < .003). Mathematical models showed that 7-day voyages had about 70% fewer cases than 14-day voyages. On 7-day voyages, the most effective interventions were reducing the number of individuals onboard (43.3% reduction in total infections) and testing passengers and crew (42% reduction in total infections). All four interventions reduced transmission by 80.1%, but no single intervention or combination eliminated transmission. Results were similar for 14-day voyages. CONCLUSIONS: SARS-CoV-2 outbreaks on cruises were common during January-April 2020. Despite all interventions modeled, cruise travel still poses a significant SARS-CoV-2 transmission risk.

Epidemiology of Coronavirus Disease Outbreak among Crewmembers on Cruise Ship, Nagasaki City, Japan, April 2020.

In April 2020, a coronavirus disease (COVID-19) outbreak occurred on the cruise ship Costa Atlantica in Nagasaki, Japan. Our outbreak investigation included 623 multinational crewmembers onboard on April 20. Median age was 31 years; 84% were men. Each crewmember was isolated or quarantined in a single room inside the ship, and monitoring of health status was supported by a remote health monitoring system. Crewmembers with more severe illness were hospitalized. The investigation found that the outbreak started in late March and peaked in late April, resulting in 149 laboratory-confirmed and 107 probable cases of infection with severe acute respiratory syndrome coronavirus 2. Six case-patients were hospitalized for COVID-19 pneumonia, including 1 in severe condition and 2 who required oxygen administration, but no deaths occurred. Although the virus can spread rapidly on a cruise ship, we describe how prompt isolation and quarantine combined with a sensitive syndromic surveillance system can control a COVID-19 outbreak.

Requerimientos para la operación de cruceros y medidas para los pasajeros: síntesis rápida de evidencia / Requirements for the operation of cruise ships and measures for passengers: rapid evidence synthesis

ANTECEDENTES Y OBJETIVO A raíz de la pandemia por COVID-19 y con el objetivo de limitar su propagación, el Gobierno de Chile ha implementado diferentes medidas para identificar tempranamente casos nuevos, aislar rápidamente los casos confirmados e indicar cuarentena a sus contactos estrechos. Los protocolos o definiciones epidemiológicas se han ido adecuando en la medida que aumenta el conocimiento respecto al comportamiento del SARS-CoV-2 y a la contingencia epidemiológica. Actualmente, el Ministerio de Salud se encuentra evaluando las condiciones que exigirá a cruceros para operar en aguas chilenas. En consecuencia, el equipo del Reglamento Sanitario Internacional del Departamento de Epidemiología solicita esta síntesis con el objetivo de describir los requisitos de la operación de cruceros y medidas para los pasajeros establecidas en diferentes países. METODOLOGÍA Primero se elaboró un listado de los países con mayor concurrencia de pasajeros de cruceros. Posteriormente, se identificaron organismos internacionales de referencia en materias de salud pública y asuntos marítimos. Luego de establecer los países y organizaciones de interés, se buscó en sus páginas gubernamentales. Se complementó con una búsqueda no estructurada de buscadores web no científicos. Se incluye información de 10 países: Estados Unidos, España, Italia, México, Reino Unido, China, Bahamas, Jamaica, Australia e Israel. 4 organismos internacionales RESULTADOS Las condiciones aplicadas por los países o las recomendadas realizadas por organismos internacionales son las siguientes: -Cruceros: monitoreo y reporte de la situación epidemiológica; protocolos de la naviera para la prevención y mitigación de riesgo sanitario; fortalecimiento de insumos y de profesional médico a bordo; adquisición de seguros médicos en caso de brotes; adquisición de seguros o acuerdos con residencias para aislamiento o cuarentena; entrenamiento, requisitos y protección a la tripulación; distanciamiento y reducción del número de pasajeros al 50% de la capacidad máxima. -Pasajeros: ausencia de síntomas o de indicación de aislamiento, uso de mascarilla, distanciamiento físico, realización de test para COVID-19 y presentar certificado de vacunación en caso de poseerlo. -Algunos países mantienen cerradas las actividades de cruceros en sus costas, otros las han restringido a viajes domésticos y otros no las han iniciado por decisión de las propias navieras.