The joint action for preparedness and response at European entry points (ports, airports, and land borders), known as HEALTHY GATEWAYS, was developed within the framework of the 2017 Annual Work Programme and received funding from the European Union under the Third Health Programme (2014-2020). A total of 38 authorities (17 partners, 3 affiliated entities, and 18 collaborating entities) from 28 European countries participate in the HEALTHY GATEWAYS Joint Action Consortium. The Joint Action was launched on May 1, 2018, and had a duration of 36 months. In Spain, the Authority responsible for implementing this program is the Directorate General of External Health.
Article from CruisesNews magazine no. 53 – July 2020
But what exactly is International Health? Interestingly, it's the only health responsibility that falls exclusively under the State and is functionally dependent on the Ministry of Health. The functions it performs cover a wide range, from vaccinating international travelers (the most well-known function until the pandemic), to controlling and monitoring the health of international passenger traffic, and ensuring hygiene and sanitation in ports, international airports, border crossings, and international transport (currently the most in-demand function). It also includes monitoring and controlling hygiene and sanitation conditions in the international transport of goods (food, medicines, cosmetics, pesticides, chemicals, animals, etc.), as well as mortuary health services, and more.
What is EU Healthy Gateways?
The joint action of the European Union's Healthy Gateways aims to support cooperation and coordinated action among member states to improve their preparedness and response capacity at points of entry into the European Union. This includes ports, airports, and land borders, with the goal of preventing and combating cross-border health threats that can spread through the transport sector, in all its forms.
The HEALTHY GATEWAYS mission is to create procedures, guidelines, catalogs of good practices and action plans validated at the European level, which the health authorities of the member states will apply at an operational level in the field of transport, covering all types of health threats, as well as communicating risks to neighboring countries, and advising European and national political authorities on any public health risk.
The time spent on board by people infected with COVID-19 should always be minimized; they should be evacuated to land as soon as possible.
The HEALTHY GATEWAYS initiative will also support the rapid exchange of information in the event of cross-border health risks, using electronic systems established at points of entry and operating through digital communication networks to enable real-time alerts. Furthermore, this joint initiative will provide online and in-person training on contingency planning and event management (related to infections, vectors, chemical agents, environmental hazards, and other factors) at points of entry at the European, national, and local levels, as well as support hygiene inspections on ships and aircraft.
Furthermore, in the event of future public health emergencies of international concern (PHEIC), HEALTHY GATEWAYS will have an emergency mode to support the coherent response of Member States in accordance with recommendations issued by the WHO.
The problem of the lack of common European regulation:
The absence of a uniform regulatory framework for international tourists is hindering the recovery of European destinations and putting millions of jobs at risk. This was the stark warning from the World Travel & Tourism Council (WTTC), which is calling for coherent and coordinated travel rules to end the confusion caused by the existing disparities.
In a statement, it refers to “a bewildering array of rules and advice, which is delaying the recovery. Unnecessary and inconsistent border restrictions are discouraging tourists and hindering the resurgence of travel.” In the case of maritime tourism, specifically cruises, the reality is much harsher, as a ship can call at several different countries, which may have completely disparate regulations. A seven-day cruise from Barcelona, the best-selling itinerary in Spain, calls at least three countries (Spain, France, and Italy), regardless of the cruise line, and this number can reach four if Malta is included. For example, regarding something as basic as mask-wearing, the rules vary widely, from mandatory mask-wearing in Spain to mandatory mask-wearing only in public spaces in France, while Italy only requires its use indoors.
According to WTTC estimates, a 2.7% increase in the number of travelers would mean the recovery of one million tourism-related jobs. The report goes further, stating that “with the right coordinated measures, European governments could achieve up to 27% growth in travel, which would translate into ten million jobs.”.
Essential Prerequisites:
In Chapter 3, the document defines the prerequisites for the return of cruises to Europe. The first is to closely monitor the epidemiological situation. Shipowners are obligated to check the pandemic situation in both the source market and the destination. In accordance with the 2005 International Health Regulations, ports of call should have the capacity to provide an adequate public health emergency response: they will have to establish a public health emergency plan. This Port Authority plan must be compatible with the cruise ship's contingency plan, or even its infectious outbreak management plan. In turn, the shipowner's contingency plan for infections must expressly include the confirmed possibility of medical treatment on land, including possible air evacuation, and also provisions for the repatriation of passengers and crew, prioritizing ports with international air connections. The possibility of quarantine on land must also be guaranteed, including transportation, hotels or hospitals, etc., and coverage of its cost. Direct contacts must disembark "as soon as possible," and the quarantine will always be 14 days. Isolation of asymptomatic individuals on land must also be guaranteed. This effectively corrects the mistake made by Japanese authorities in imposing a quarantine on passengers and crew of the Diamond Princess, which had disastrous consequences.
The lack of a uniform regulatory framework for cruises hinders their recovery from European destinations such as the Mediterranean or the Baltic.
The ship's contingency plan will ensure the ability to conduct COVID-19 tests either on board or ashore, as well as crew training (including drills) and a commitment to immediately report any potential cases to the next port of call using the Shipsan Information System (SIS).
But the most important requirement of the COVID-19 Guidelines is that the contingency plan involves a reduction in passenger capacity. Ships must be able to isolate 5% of passengers and 5% of crew in single cabins when it is not possible to disembark those who need to be quarantined or isolated, for 24 hours after the first case of COVID-19 is detected. When it is possible to disembark passengers and crew within those first 24 hours, isolation space on board will be required for only 1% of passengers and 1% of crew. This will be very important for itinerary planning. On a transatlantic cruise on a 2,000-cabin ship, capable of accommodating 4,000 passengers in lower berths, 100 cabins will need to be designated for this purpose, and 200 fewer passengers will have to be boarded. On a cruise on the same ship from Barcelona to the Mediterranean, 20 cabins will need to be designated for this purpose.
The ratio of one bather per 4 m2 of pool water surface is established, with capacity control (point 7.20).
Finally, section 11 of Chapter 3 is dedicated to cruise ship inspections. The EU Healthy Gateways will create a common inspection script for all member states, with shared criteria based on joint training for all inspectors in this area. A database will also be created containing the results of all inspections, similar to that of the US CDC, to avoid duplicate inspections and to publicize the results.
COVID-19 Prevention Measures:
Chapter 4 outlines universal criteria for pandemic prevention on board cruise ships. The first is exclusion, establishing common criteria. Any passenger or crew member with symptoms should not board, nor should anyone who has been in contact with a COVID-19 positive individual in the last 14 days, or anyone who tests positive for COVID-19 via PCR or SARS-CoV-2. The EU Healthy Gateways suggests that this exclusion policy should be standardized across the industry, specifically addressing CLIA.
Risk groups are another important factor. A medical certificate will not be required for those over 65 or those with chronic cardiovascular disease, diabetes, or weakened immune systems, but they should consult a doctor to determine if they are fit to travel. The guidelines recommend activities for risk groups separate from the rest of the passengers and suggest having ventilators on board. All information regarding exclusions must be publicly available and described on the shipowner's website, in the booking confirmation, or even sent specifically by mail.
Response to COVID-19 Outbreaks on Board:
Chapter Five of the guide focuses primarily on the communication strategy in the event of an outbreak on board. This strategy must be clear, defining the content of the messages, the communication channels, and the timelines. It also stipulates that all crew members must be able to recognize the symptoms of COVID-19 and that this training must be repeated every 30 days. Furthermore, it mandates that crew members be informed that if they have symptoms of the pandemic, they cannot work but must continue to be paid. Finally, they are obligated to report any suspicions regarding the health status of a colleague.
There must be stockpiles of PPE (personal protective equipment) on board and clear disinfection protocols. Medical personnel on board must also receive specific training in sample collection.
Passengers should receive information about required PPE on and off the ship, and about the possibility of not boarding if they show symptoms of COVID-19 at the terminal.
Goodbye to mini-bars? The EU Healthy Gateways Guide recommends removing any items that cannot be disinfected between uses: menus, magazines, coffee/tea containers, and mini-bar products (unless served from dispensers). This rule also applies to coffee makers and kettles.
This chapter draws attention to the ship's contingency plan. It introduces the role of the responsible officer in the event of a pandemic, a position that some shipowners, such as NCL, have already announced they will incorporate into their ship's role. This plan must include information on physical distancing, PPE, hygiene rules, cleaning/disinfection procedures, laundry, food and water management, ventilation, and so on. It must also outline specific measures in the event of COVID-19, such as isolation, quarantine, disinfection, communication, etc. Finally, section 5.1.3 states that RT-PCR tests, medications, PPE, and disinfectant must be available on board to combat a potential positive case.
Onboard Prevention Measures
: Chapter 7, the most extensive, is dedicated to COVID-19 prevention onboard the cruise ship. It begins with health precautions: daily temperature checks for all crew members, PCR testing for the entire crew, either already onboard or before re-embarking, and subsequent random PCR testing every two weeks. The protection of the most vulnerable groups is addressed in sections 7.2 and 7.3. Passengers are required to be organized into closed groups (referred to as "cohorts"), which will share meals, activities, excursions, etc. Interaction between "cohorts" is minimized. Embarkation, meals, excursions, etc., must be scheduled by group. These groups could be based on age, which would complicate matters for families by separating the elderly and children.
CLIAs and cruise lines were involved in the development of the guide and will continue to work with EU Healthy Gateways to assess its suitability and feasibility as a pan-European framework.
Just as on land, physical distancing is essential. Marking distances, controlling capacity, carrying out the mandatory evacuation drill in stages, by groups, as well as meals or optional excursions, are all recommendations repeated in the EU Healthy Gateways guide.
Point 7.7 repeatedly recommends the use of masks for passengers and crew in any area where interaction may occur and it is difficult to maintain the minimum 1.5 meters of social distance: maritime station, coaches, elevators, infirmary, and on tenders and lifeboats.
Section 7.8 addresses ventilation. The aim should be 100% outside air, or at least the maximum possible amount. Ventilation in all occupied spaces on the ship must operate continuously, avoiding CO2 level controls that restrict it. Direct airflow should be diverted away from passengers whenever possible. Toilet exhaust fans must operate continuously. The medical facility and quarantine areas must have independent climate control. A minimum of 10 air changes per hour must be guaranteed. If it is not possible to eliminate air recirculation, the ship must improve the efficiency of its filters or use germicidal ultraviolet lamps.
Cleaning and disinfection also play a prominent role: the guide urges increased cleaning frequency in common areas, such as restaurants and elevators, to the point that a COVID-19 cleaning protocol, version 2 of April 20, 2020, has been published, covering everything from crew training to cleaning products, etc. In cabins (section 7.10), the guide proposes increased cleaning and ventilation, eliminating, for example, the presence sensor for air conditioning operation, or the interlock between opening the balcony door and activating the air conditioning. Menus, decorative items, coffee machines, and even the minibar are removed. The television and air conditioning remotes must be disinfected daily. Towels must be changed twice a day, and there must be a hand sanitizer dispenser in the cabin.
The Guide mentions the possibility of expanding the catering service in the cabins to avoid overcrowding, but this would require increased cleaning. Furthermore, it indicates that once the meal is finished, the trays must be placed in the corridor… so their cleaning will also need to be increased, not to mention that navigating through them could become an obstacle course.
Section 7.11 details food safety. Precautions must be taken from the moment supplies are loaded in port, such as disinfecting pallets, maintaining a social distance of 1.5 meters between chairs, etc. Buffets and self-service areas are expressly prohibited. Only if their elimination is not feasible will the crew serve passengers in individual portions. Salt, pepper, and other condiments will be served in disposable containers, contrary to the cruise industry's recent shift to bulk products for environmental reasons and to reduce plastic waste. Passengers and crew will never share utensils. Individual dining options, including room service, are recommended, but the general practice will be in closed groups, with multiple seating times to limit interaction. Cooks must wear face masks, and hand sanitizer dispensers will be available at the entrance to each dining area.
To reduce personal interaction, the use of online bookings, purchases, etc., via contactless cards or wristbands will be encouraged. Settlement of expenses for the last night on board will always be done online. The reception area must be reconfigured to ensure social distancing. Installing protective screens at all counters is recommended. The reception team will be able to provide all types of information about the virus, as well as PPE, and identify passengers with COVID-19 symptoms. Boutiques will not have fitting rooms.
The guidelines suggest using only outdoor children's play areas, with limited capacity, physical distancing, and thorough cleaning. In casinos, they require changing the configuration of gaming tables and slot machines to ensure 1.5 meters of physical distance. There will be a maximum number of players per table and access control. The casino bar must be closed. And chips and slot machines must be disinfected after each use.
In the gym, cardio machines must be spaced two meters apart, with mandatory use of hand sanitizer before and after. A user log must be kept, and machines must be disinfected after each use. In the spa, the use of screens and appropriate PPE is recommended.
Regarding water management, the guide emphasizes Legionella prevention, maintaining water seals, aerosol prevention, and so on. It prohibits indoor pools but allows covered outdoor pools, so popular with cruise lines like MSC, Holland America, etc. It mandates individual showers and requires a 1.5-meter distance between sun loungers—in any direction—always with your own towel and disinfection after each use. Imagine how expensive a sun lounger will be on a day's sailing in the Mediterranean in August! All furniture that presents disinfection problems must be removed. A ratio of one bather per 4 m² of pool water surface is established, with capacity control. Jacuzzis may only be used together by passengers from the same cabin.
Shipping companies could consider testing all passengers boarding. However, testing should not create a false sense of security, as it has limitations, and therefore the EU Healthy Gateways Guide rules it out.
The guide has a section dedicated to elevators, whose use it optimistically advises against. However, it also includes some more pragmatic measures, such as reduced capacity, capacity controls, cleaning of control panels, and voice control. For other spaces, it suggests reducing furniture to avoid overcrowding, to a maximum of 4 people per 10 square meters. It prohibits business centers and discourages the use of public restrooms.
Finally, regarding optional excursions, it clearly states that the same level of protection must be maintained on the excursion as on board, although the author seems unaware that some passengers opt for external optional excursions… for which the shipowner is not responsible. Guides (and any external personnel) must adhere to the cruise line's contingency plan. Temperature checks must be taken for all passengers before and after the excursion, and hand sanitizer and masks must be available. The use of tenders for disembarkation is discouraged, but if necessary, they must be disinfected after each use. Closed groups are again encouraged.
Managing Positive Cases on Board:
When a positive COVID-19 case is declared on board, the pandemic officer will make it official. The infected person will be isolated in a single, exterior cabin, used only for this purpose, located as close as possible to the onboard medical facility. Contact with the positive case will be strictly limited to what is necessary, and all personnel will be provided with the required PPE. The guidelines also provide criteria for assessing whether the cruise should be shortened or suspended. They also include instructions on testing infected individuals, as well as situations in which tests may produce false positives. The criteria for conducting contact tracing are also described. Section 8.3 is particularly important in the Mediterranean, as it outlines the criteria for deciding, after a positive case, whether passengers embarking via interporting are allowed to board, after consulting with the Port Health Authorities of the affected countries.
It also clarifies the obligation to immediately report to the competent authority of the next port of call after declaring a positive result. This authority must always be contacted in case it becomes necessary to activate quarantine measures, laboratories, etc., as previously outlined in the Contingency Plan.
Finally, the guide addresses the retrospective investigation of positive cases. It outlines criteria for investigating infections, using methods such as closed-circuit television, smart cards or bracelets worn by passengers on board, the ship's app or other apps developed for this purpose, and completing a contact tracing form after passengers disembark the cruise ship.
Cruise terminals:
Interaction between the ship and land should be limited to terminal workers, police, etc. A minimum physical distance of 1.5 meters must be ensured within the terminal, but also at taxi stands, coaches, etc. The guide even mentions the possibility of limiting the number of taxis and coaches to prevent overcrowding.
It also recommends creating separate routes, queues, or flows, using, for example, multiple jetways, to avoid overcrowding. Terminal workers will wear appropriate PPE, and mask use will be mandatory. They will also have their temperature taken as frequently as passengers and undergo regular COVID-19 testing.
CLIA welcomed the document. “The primary concern of CLIA and each of its member cruise lines is the health and safety of their passengers and crew. This guidance from public health authorities in Europe provides a useful resource for cruise ship owners as they prepare to resume operations,” commented CLIA Europe Secretary General Tom Boardley.
Signage should emphasize hand hygiene and precautions when coughing or sneezing. The terminal should be cleaned and disinfected using the same protocol as the receiving vessel, which is relatively straightforward given that cruise lines are also the largest operators of maritime terminals for cruise ships. Ventilation in the terminal should be increased, and drafts avoided. An isolation room should be added to the terminals. If a positive case is declared in the terminal, everyone must wear a mask and immediately notify Port Health Authorities.
Regarding passengers, it is recommended that luggage, especially handles and straps, be disinfected before boarding. Frequent and intensive handwashing is also advised for baggage handlers.
Measures to be taken during boarding:
All embarkations have a certain degree of chaos, and the guide dedicates Chapter 6 to their regulation. During boarding, a double temperature check must be implemented: an initial and a secondary check. The first is carried out by non-medical personnel, but trained to recognize symptoms of the pandemic. If necessary, a secondary temperature check, accompanied by a questionnaire, is performed by Port Health or qualified medical personnel. The guide mentions the possibility of testing all passengers, but then cites the limitations of these tests and concludes that antibody tests should not be used to exclude anyone from a cruise.
All forms for boarding should preferably be electronic, avoiding any contact.
What is the EU Healthy Gateway COVID-19 guide?
The EU Healthy Gateways issued its COVID-19 guide to restart cruise operations. Released on July 1, 2020, the European Union's Healthy Gateways COVID-19 guide, aimed at cruise ship owners and port authorities, contains many expected protocols and some new ideas, such as dividing people into cohorts and organizing activities by age group.
This guide outlines a strategy for reducing the risks of COVID-19 among cruise ship passengers and crew. It covers the entire process, from booking the voyage until passengers and crew have returned home. National regulations regarding the entry of cruise passengers into their home ports, including border crossings at train stations and airports to board cruise ships in port, must also be considered in cruise line plans.
The COVID-19 Guidelines aim to reduce interaction between people by creating closed groups. But this strategy is particularly important for crew members.
The guidelines propose shorter cruises, either nonstop or with a limited number of stops, and recommend a phased approach to restarting operations, always with short itineraries, such as three to seven days, along with a limited number of stops, or even a return to nonstop cruises. Shipowners should first assess the availability and capacity of the ports/countries included in the itinerary, and agreements should be established to accept potential cases of COVID-19, confirmed or not, so that they can disembark from the cruise ship. Uninfected passengers should also have the option to disembark.
