Healthy GateWays - Interim advice for preparedness and response to cases of COVID-19 on board ferries after lifting restrictive measures in response to the COVID-19 pandemic, Version 1, 24 June 2020

Healthy GateWays              Co-funded by the Health Programme of the European Union

Interim advice for preparedness and response to cases of COVID-19 on board ferries after lifting restrictive measures in response to the COVID-19 pandemic
Version 1
24 June 2020

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^{* The EU HEALTHY GATEWAYS Joint Action has received funding from the European Union, in the framework of the Third Health Programme (2014-2020). The content of this document represents the views of the author only and is his/her sole responsibility; it cannot be considered to reflect the views of the European Commission and/or the Consumers, Health, Agriculture and Food Executive Agency (CHAFEA) or any other body of the European Union. The European Commission and the Agency do not accept any responsibility for use that may be made of the information it contains.}
 

1. Introduction
In January 2020 the EU HEALTHY GATEWAYS joint action switched from operating under the inter-epidemic mode to operating in an emergency mode, at the request of the European Commission's Directorate-General for Health and Food Safety (DG SANTE). As stated in the Grant Agreement, the objective of the emergency mode is to support coherent response of EU MS according to Decision No 1082/2013/EU and the implementation of temporary recommendations issued by the World Health Organization (WHO). Under this emergency mode, EU HEALTHY GATEWAYS is available to respond to any specific requests from DG SANTE or EU MS to provide technical support, advice or ad-hoc training at points of entry as needed.
An ad-hoc working group was established with members from the EU HEALTHY GATEWAYS joint action consortium. The names and affiliations of the working group members who prepared this document are listed at the end of the document.
This advice includes measures for the prevention of transmission and spread of COVID-19 on board ferries.
The working group produced the following guidance, considering the Communication issued by the Commission “A European roadmap to lifting coronavirus containment measures” and “How to safely resume travel and reboot Europe's tourism in 2020 and beyond” [1-6] (https://ec.europa.eu/commission/presscorner/detail/en/ip_20_854), the temporary recommendations from the World Health Organization (WHO) (https://www.who.int/emergencies/diseases/novel-coronavirus-2019)[7-29] and the technical reports of the European Centre for Disease Prevention and Control [30-50] (ECDC) (https://www.ecdc.europa.eu/en/coronavirus/guidance-and-technical-reports) on COVID-19 (as of 23 June 2020). Furthermore, this guidance has been prepared considering the evidence currently available about SARS-CoV-2 transmission (human-to-human transmission via respiratory droplets or contact), but it also contains some proactive guidelines considering the lack of evidence to exclude other transmission modes (airborne or after touching contaminated environmental surfaces). It should be noted that SARS-CoV-2 has been found in faecal samples without any further information on how this finding is implicated in the mode of transmission.
The guidance provided on this document is based on the current situation of the pandemic and will be revised as needed after considering the epidemiological situation.

2. Purpose
This guidance is addressed to ferry companies, as well as competent public health authorities at ports.
The objective of these guidelines is to provide recommendations on preventive measures that ferries should implement to protect passengers, crew members and onshore personnel, as well as to create an environment of trust in the maritime transport of passengers by ferry. 
These guidelines should be adapted to each particular ship according to their own characteristics, traffic and any other factor that could be taken into consideration.

3. Contingency planning for the prevention and control of COVID-19
Ferry operators should have in place written contingency plans (outbreak management plan) for the prevention and control of possible² cases of COVID-19 that all crew on board should have good knowledge of and readiness to implement. In the written contingency plan (outbreak management plan) a COVID-19 task force commanded by the master of the ship should be defined.
Where applicable, medical facilities and/or medical staff (ship’s doctor or the master of the ship or a medically trained officer) on board ferries should be assessed and reinforced so as to be able to manage COVID-19 cases as described in section 6 of the current document. Supplies and equipment to be available on board are described in paragraph 5.5 of the current document.
Further information for passenger ships on international voyages about the recommended medical facilities, medication and medical staff competency are described in the “European Manual for Hygiene Standards and Communicable Disease Surveillance on passenger ships” available here http://www.shipsan.eu/Home/EuropeanManual.aspx.
“Designated crew members” mentioned in this document refers to the designated functions in each ship’s contingency plan (outbreak management plan) for the prevention and control of COVID-19 under the guidance of the master of the ship. The master of the ship should keep the company’s land-based personnel informed for the operation of the above mentioned plan and should keep a relevant record book/log.
The plan should include the measures that should be implemented for the prevention and control of COVID-19 cases and procedures for the isolation of possible cases of COVID-19 as these are described in the following paragraphs. Training of crew members for the implementation of the contingency plan (outbreak management plan) should be ensured as this is described in the guidance documents published by the World Health Organization and EU HEALTHY GATEWAYS:
https://www.who.int/publications-detail/operational-considerations-for-managing-covid-19-cases-or-outbreaks-on-board-ships-interim-guidance and https://www.healthygateways.eu/Novel-coronavirus#Interim
Ferry operators should take into consideration when developing the contingency plans (outbreak management plans) IMO Circular Letter No.4204/Add.16 (6 May 2020) - Coronavirus (COVID 19) -"COVID-19 related guidelines for ensuring a safe shipboard interface between ship and shore-based personnel”available here: 
http://www.imo.org/en/MediaCentre/HotTopics/Documents/COVID%20CL%204204%20adds/Circular%20Letter%20No.4204-Add.16%20-%20Coronavirus%20(Covid%2019)%20- %20Covid-19%20Related%20Guidelines%20For%20Ensuring%20A%20Safe%20Shipboard.pdf
The contingency plan (outbreak management plan) should include the following as applicable:
A. Preventive measures
• Physical distancing measures
• Personal hygiene rules
• Personal Protective Equipment (PPE) use
• Health monitoring of symptoms for transport staff and where applicable passengers and
record keeping
• Procedures for responding to a possible case (temporary isolation, arrangements for providing the preliminary medical examination by the ship’s doctor or the master of the ship or a medically trained officer as applicable)
• Standard Operating Procedures (SOP’s) for cleaning and disinfection covering all types of surfaces and materials and defining the disinfectants and the methods to be used
• SOPs for laundry of linen and clothing
• SOPs for cleaning and disinfection of body fluid spills in the environment
• Food safety management
• Potable water safety management
• Recreational water safety management
• Ventilation of indoor areas
• Communication plan including reporting public health events to the competent authorities
• Data management of health or screening documents (e.g. Passenger Locator Forms, Maritime Declaration of Health) in accordance with Regulation (EU) 2016/679 on the protection of natural persons with regard to the processing of personal data and on the free movement of such data (GDPR) and national regulations on the processing of personal data and medical confidentiality.
B. Measures for the response and management of a possible case
• Isolation/separation plan of the possible case
• Communication with competent authorities at ports
• Collaboration with the national competent authorities for contact tracing and quarantine of contacts ashore
• Cleaning and disinfection procedures of contaminated spaces, objects and equipment (daily and final cleaning and disinfection)
• Waste management procedures
• Communication strategy for contacting the contacts of a confirmed COVID-19 case among the travelers retrospectively 

4. Options for measures to prevent COVID-19 infectious tourists from boarding
4.1. Pre-boarding screening for all passengers on board ferries on international voyages
All rules and conditions decided by a country for passengers will have to be implemented during the pre-embarkation screening at foreign ports before boarding of these passengers on board ships on international voyages. Companies are advised to be familiar with those requirements before allowing passengers to access the ship in order to avoid problems upon arrival.

4.2. Training and raising crew member awareness
Ferry operators should provide training and instructions to their crew members regarding the recognition of the signs and symptoms of COVID-19. In particular, information should be provided to all crew members for the immediate reporting of signs and symptoms indicative of COVID-19 to their designated supervisor/manager or medical staff for themselves, other crew members or passengers. Crew members should be adequately consulted, equipped, trained and instructed on how to carry out their duties while minimising risks to their own health, and also the health of their co-workers and passengers [3]. This should include, for example, information on how to adequately use personal protective equipment, maintain hygiene and minimise unnecessary contacts with others.
Crew members that develop signs and symptoms indicative of COVID-19 will have to immediately leave their post and follow guidance provided in paragraph 6.
Crew members should be reminded of the procedures that are to be followed when a crew member displays signs and symptoms indicative of COVID-19 or when a passenger reports on such symptoms. Crew members should minimize the visits ashore as much as possible in order to reduce contacts with people.

4.3. Measures before boarding during ticket purchasing
4.3.1. Exclusion policy by the EUMS
EU Member States that have developed an exclusion policy with regards to transport and COVID-19 should inform the travelling public about the policy through their travel agents, travel companies, conveyance operators and other businesses operating in the tourism sector. This policy can exclude symptomatic or potentially exposed travellers from travelling. In this respect, any person experiencing symptoms compatible with COVID-19, or anyone who has been in contact with a confirmed case of COVID-19 would not be accepted on board conveyances and at tourist accommodation sites. If a country has decided to include any other pre-requisite such as laboratory testing (e.g. a molecular test before departure) as part of the exclusion policy for tourists, this should also be communicated to incoming tourists. EU MS when deciding about laboratory testing as a condition for travel should take into consideration the limitations, including the effectiveness, cost and the availability of tests. Molecular tests cannot detect incubating travellers, where it is still possible for infection to occur after the laboratory testing has been performed.
Digital methods for as many processes as practicable should be applied at the terminal, such as on-line purchasing, issuing of boarding passes, automatic passport and id scanners, to reduce the time that passengers spend in the terminal and to avoid congestion.
Restrictions or special measures to prevent potential exposure could be applied to tourists belonging to high risk groups. They could be advised to avoid remote destinations away from urban centres where health care capacities are not available or are basic, and where the transportation network is infrequent.

4.3.2. Promoting a contactless environment
Ferry companies and travel agencies should prioritise and promote the electronic sales of tickets while ensuring accessibility to ticket sales for people having no access to electronic means or who are unable to use such electronic means. As far as practicable, a contactless environment should be favoured.

4.3.3. Pre-travel information by travel agencies and ferry companies
Travel agencies should provide pre-travel information to customers about health issues with their travel package. In this context, information regarding the symptoms of COVID-19, the exclusion policy implemented by the country, health risks especially for vulnerable groups and the importance of preventive measures should be provided in advance of travel. These materials should be available in the national language, English and, where needed, other languages based on the most common language profiles of the passengers using the respective conveyance. If it is decided to distribute the information to the passengers in a printed format/leaflet then it should be done in a manner to avoid direct hand contact between two persons or to avoid many different persons touching the leaflets.
The information should include:
• boarding screening measures where applied;
• symptoms compatible with COVID-19, including sudden onset of at least one of the following: cough, fever, shortness of breath, loss of taste/smell;
• exclusion policy and likelihood of being denied boarding e.g. if they have developed symptoms or have been in contact during the last 14 days with a COVID-19 patient or any other rule according to the country policy or company policy;
• health risks for vulnerable groups and the recommendation to consult a doctor and if necessary avoid travel of all individuals belonging to those groups in accordance with the recommendations made by public health competent authorities in EUMS, e.g. people over 65 years of age or of any age with severe chronic diseases (cardiovascular disease, diabetes, respiratory diseases) and immunocompromised individuals;
• hygiene measures (hand washing with soap and water or hand hygiene with alcohol-based hand-rub solutions, respiratory (coughing and sneezing) etiquette, disposal of used tissues, use of face mask³, physical distancing, elimination of handshaking, avoiding touching the nose, eyes and mouth without previously washing hands[39] etc.);
• actions to take in case of relevant symptoms develop;
• rules and health measures implemented on board the ship (e.g. use of face masks, physical distancing, fines policy for non-compliance etc.);
• need to immediately report to transport staff if they develop cough, fever, shortness of breath, loss of taste/smell during travel;
• need to immediately seek medical care if developing fever, cough, difficulty breathing loss of taste/smell and sharing previous travel history with the health care provider.
As mentioned, travel companies and travel agents should provide clear information to travellers about the likelihood to be refused boarding according to the exclusion policy adopted by the country.
Examples of reasons for refusing boarding are:
a) if passengers have symptoms indicative of COVID-19
b) if passengers have been in contact with a confirmed case of COVID-19 according to the Pre-boarding health declaration questionnaire
c) in case passengers do not respect the local measures in place for preventing transmission (e.g. physical distancing, use of face masks etc.)
d) if during a journey a possible case of COVID-19 is detected on board a ship, then for the rest of the journey and until the ship reaches its final destination, boarding of new passengers at the intermediate stops may not be allowed but only disembarkation.
Ferry operators and tour operators should provide all relevant information on their websites and in the electronic reservation systems, about the exclusion policy, as well as any pre-requisites and the country specific rules during boarding and travel. It is suggested to explore the possibility to have a number of means to provide this information, so intending passengers have a number of opportunities to consider (e.g. to be obligatory to read the information in order to complete the reservation). Passengers could be redirected to national authorities’ website for further information about COVID- 19 (e.g. symptoms, high risk persons and national rules).
Passengers should provide a telephone number and an email address during the purchasing process. The company should keep this information for 1 month and make available to the port health authority if requested. 

4.4. Options for measures during boarding
4.4.1. Physical distancing
It is advised that physical distancing in accordance with national policy (e.g. 1,5 meters) should be applied at waiting areas and during boarding by adopting special marking and controlled entry measures. Dedicated lanes or separating different passenger flows should be considered.
Crew members could oversee the process and compliance with the physical distancing measures.
The transport of persons with disabilities and reduced mobility as well as elderly should be given priority. Crew members who, in line with the EU rules on passenger rights, provide assistance to persons with disabilities and reduced mobility as well as elderly, should be provided with the necessary PPE.

4.4.2. Pre-boarding screening
Pre-boarding screening efforts could be considered by the competent authorities in each country to assess incoming travellers for any symptoms or previous exposure to COVID-19 on vessels sailing on international or national voyages. The competent authorities in EUMS will decide who will implement the pre-boarding screening and develop the implementation protocol. The following pre-boarding screening measures could be considered: a) pre-boarding health questionnaire asking about symptoms and/or exposure and b) temperature screening.
If a country decides that the ferry companies implement the pre-boarding screening then in cases where boarding will not be allowed as a result of the pre-boarding screening, the ferry operator should inform the competent public health authorities at the port about the specific case that was not allowed boarding due to symptoms development or exposure. Competent authorities at the port will then conduct an initial assessment and further manage the ill or exposed passenger and its contacts.

4.4.2.1. Completion of the pre-boarding health declaration questionnaire
If a country decides to use a pre-boarding health questionnaire it is advised to be issued before boarding all ships on a voyage of more than 30 minutes duration (including all segments/legs of the itinerary) at the port of departure so as to detect any passengers that have been exposed to the new coronavirus (COVID-19). If a questionnaire will be used to assess the presence of symptoms and previous exposure to the disease, this can be provided at the time of booking to be completed within 48 hours before travel in case of web-based completion or delivered to the designated staff while boarding (web-based completion of the questionnaire would be a preferable option). An example of this questionnaire is presented in Annex 1.
The designated staff will collect and review all completed questionnaires. In case they detect passengers that have presented symptoms or have been exposed to COVID-19 patients in one of the ways described in the Questionnaire of Annex 1 during the last 14 days, it is advised to deny boarding. 

4.4.2.2. Temperature screening
Countries should take into consideration the advantages and limitations of temperature screening while deciding on the pre-boarding measures. Temperature screening during boarding could detect passengers that have developed fever from any etiology. This method cannot rule out the boarding of persons that have been detected with the SARS-CoV-2 virus. For example, it will not identify mild symptoms, asymptomatic, incubating travellers or those concealing symptoms (e.g. antipyretics). Hence, only a small percentage of cases could be detected via measurement of travellers’ body temperature during boarding.
Further information about the advantages and limitations of entry-exit screening is provided here:
https://www.healthygateways.eu/Portals/0/plcdocs/EU HEALTHY GATEWAYS 2019 nCoV EUMS E-E screening 6 2 2020 V1b.pdf?ver=2020-02-11-094124-737
If a country decides to implement temperature screening then this could be implemented for large vessels with a long duration of voyage (>6 hours), including ferry boats and cruise-ferries for all crew and passengers.
Temperature screening should be performed remotely with the use of non-contact infrared thermometers. These thermometers must be approved as diagnostic tools for fever and must be used according to the manufacturer's instructions.
In case of detection of a person with a temperature of >38°C, boarding will not be allowed.

4.4.2.3. Boarding refusal
A standard policy should exist about denying boarding to any exposed or symptomatic possible case among passengers and crew as described in paragraph 4.3. To encourage honest reporting of exposure and symptoms the ticket cancelation policy should take into consideration the Commission’s recommendation of 13.5.2020 on vouchers offered to passengers and travellers as an alternative to reimbursement for cancelled package travel and transport services in the context of the COVID-19 pandemic available here: https://ec.europa.eu/info/files/covid-19-recommendation-vouchers-offered-passengers-and-travellers-alternative-reimbursement-cancelled- package-travel-and-transport-services en
According to the above and in accordance with the exclusion policy adopted by each country, boarding may be denied especially if during the pre-boarding entry screening it is identified that:
i. passengers had symptoms indicative of COVID-19 or
ii. if the answers to the pre-boarding health declaration questionnaire show that the person had contact with a COVID-19 case
If boarding will not be allowed then local rules for the subsequent use or not of the ticket will apply.
If boarding will not be allowed for the reasons specified in cases (i) and (ii) above the competent health authority will be informed to apply the local procedures for laboratory testing/quarantine/isolation and will ensure that travel will not be allowed for 14 days or if the passenger was ill he/she will have to bring an official document signed by a medical doctor confirming that all discharge criteria are fulfilled as set by countries rules or by ECDC on the guidance document titled “Discharge criteria for confirmed COVID-19 cases - When is it safe to discharge COVID-19 cases from the hospital or end home isolation?” available here: https://www.ecdc.europa.eu/sites/default/files/documents/COVID-19-Discharge-criteria.pdf

4.4.3. Passenger Locator Form
It should be considered to use Passenger Locator Forms (PLF) for ships on international voyage to ensure that contact information of passengers is available, in order to facilitate contact tracing if a case of COVID-19 is detected. Passenger Locator Forms could be disseminated before boarding or during boarding and collected by transport staff or public health authority staff before or during disembarkation. The company should keep the PLF for 2 months and make available to Public Health Authority if requested. Electronic completion of Passenger Locator Forms before boarding could be used in the future. The passenger locator form for ships is available at Annex 2.

4.4.4. Information package for passengers
During boarding and during the journey information should be clearly communicated to passengers (e.g. electronic posters, recorded messages) on the symptoms of the disease, preventive measures and instructions for immediate reporting to crew members if they develop symptoms during travelling.

5. Measures for preventing and limiting transmission of COVID-19 on board ferries
5.1. Physical distancing
To ensure that measures related to physical distancing on board ships are maintained, it is advised that ferry ship operators reduce the maximum number of passengers on board ships where this is necessary. The capacity reduction decision should be based on the epidemiological situation of the country and should be re-assessed and re-considered at two-week intervals or on a monthly basis. Hence, ferry ship operators are advised to estimate the maximum number of passengers per ship as these are described in paragraph 5.2 of the current document.
It is advised to consider allowing passengers on short ferry routes to stay in the car or truck if overall safety can be sufficiently ensured. In case passengers are recommended or requested to remain in their vehicles on board ferries during short voyages (e.g. less than one hour), such a measure should apply on open decks only, unless additional safety precautions are taken in line with applicable EU rules [3]. Where needed, capacity of decks should be adjusted to ensure safety and personnel trained in fire suppression should be present. 
When conditions allow for it, use as far as practicable the open spaces of the vessel.
Unnecessary movement of passengers on board conveyances should be avoided.
Where there are permanent non-moving seats either indoors or outdoors there should be a special marking on where passengers/co-travelers are allowed to sit and where not, in order to maintain physical distance with other passengers/group of people. In case of a family/same household or group of co-travellers, crew should be instructed to facilitate appropriate seating distancing.
It is advised to ensure that on all internal and external areas of the ship the physical distancing in accordance with national policy (e.g. 1.5 meters) is maintained in combination with the use of face masks. Designated crew members could oversee the process and compliance with the physical distancing measures in all areas.
Special floor markings must be considered at all possible passenger congestion points, such as reception areas, bars, restaurants, shops, and public toilets to ensure that the physical distance in accordance with national policy is maintained (e.g. 1.5 meters). For the protection of crew members the use of protective panels should be considered at places such as reception areas or at bars and restaurants.
In public toilets the minimum number of passengers should enter so as to maintain the physical distancing in accordance with national policy (e.g. 1.5 meters) between passengers.
It is suggested not to use elevators. If their use is deemed necessary, the maximum number of persons allowed should be reduced. If escalators are available, then the use of elevators should not be allowed even with reduced number of persons (except for the persons with reduced mobility, the elderly, baby prams or for food service). Procedures should be put in place to limit elevator occupancy, signage and monitoring. Stations with alcohol-based hand-rub solutions (containing at least 60% ethanol or 70% isopropanol) should be available outside all elevators.
To ensure physical distancing measures are maintained during disembarkation it is advised that disembarkation is done sequentially per deck and seat number or other appropriate system.

5.2. Maximum number of passengers allowed on board
It should be considered to estimate the maximum number of passengers on board each ship so as to be able to ensure physical distancing measures on board are implemented.
Rules can be made so that vessels can operate with reduced numbers of persons on board to ensure physical distancing at all parts on the ship. The capacity reduction should be re-assessed and re-considered based on the epidemiological situation at two-week intervals or on a monthly basis.
For passengers not belonging to the same household, numbered seating could be considered to be positioned in a way to respect the rule of one seat occupied and the adjacent, front, rear and diagonal seat remains empty (i.e. A radius of 1 seat around the 
passenger). Special markings on where a passenger is allowed to sit and where not should be considered, in order to maintain physical distance amongst different group of co-travelers.
For cabins it could be considered to place one passenger per cabin if it is a solitary individual or to occupy the cabin as normal if it is for a family booking or co-habitants or persons with reduced mobility and their assistant. Up to four individuals could share the same cabin only if they can provide proof of a group booking.
Cabins should be adequately ventilated and should remain empty with the door open for at least one hour prior to the use by the next passengers. In case a cabin empties it should not be used by other passengers on the same itinerary.
Measures should be taken to control the capacity at common areas such as toilets, corridors, elevators, bars and restaurants etc.

5.3. Hand hygiene and respiratory etiquette
Hand hygiene should be applied by passengers and crew members with soap and water. If hands are not visibly soiled, an alternative alcohol-based hand-rub solution may be used. The use of gloves does not replace hand hygiene.
Stations with alcohol-based hand-rub solutions (containing at least 60% ethanol or 70% isopropanol) should be available at all entrances of the conveyances and other areas such as toilets, check-in areas, bars and restaurants.
Ferry companies should provide information to passengers and crew members on hand hygiene related issues and where necessary the appropriate facilities and equipment:
- Hand washing techniques (use of soap and water, rubbing hands for at least 20 seconds etc.). The use of gloves does not replace hand hygiene and could in certain circumstances lead to an increased risk of contamination.
- When hand washing is essential (e.g. before boarding and after disembarkation from conveyances, after assisting an ill traveller or after contact with environmental surfaces they may have contaminated (e.g. handrails), before putting on or removing the face mask, before putting on or removing gloves, after using the toilet, before touching our face etc.)
- When the use of antiseptic is advised and how this can be done
- Respiratory etiquette during coughing and sneezing with disposable tissues or clothing
- Avoid touching the eyes, nose or mouth.
- Avoiding close contact with people suffering from acute respiratory infections
- Appropriate waste disposal
- Use of PPE (non-medical face masks medical face masks and gloves)
Respiratory etiquette should be implemented: the nose and mouth should be covered with paper tissue when sneezing or coughing and then the tissue should be disposed of immediately in a no touch bin and meticulous hand hygiene should be performed by using water and soap or an alcohol-based hand rub solution. If paper tissues are not available, coughing or sneezing into the elbow is recommended. For this reason, it is important to have available in different areas around the ferry relevant supplies (e.g. tissues or paper towels and disposable gloves, no touch bins etc.). Information about the respiratory etiquette and hand hygiene should be provided to passengers via recorded communications, leaflets, infographics, electronic posters etc.

5.4. Preventing droplet transmission by the use of face masks⁴
Competent authorities should consider advising passengers and crew on board ferries operating nationally or internationally, who are not ill or showing symptoms compatible with COVID-19 to wear a face mask, taking into consideration their national epidemiological aspects and the international spread of disease. Ferry operators should follow national advice. It is advised to be considered by competent authorities in EUMS to make mandatory the use of a face mask when entering indoor areas of transport hubs for passengers and staff. For countries that have chosen to implement such a policy, this should be communicated in advance of travel.
Information about the correct use of face masks should be provided to passengers via audio messages, leaflets, infographics, electronic posters etc. When using face masks, the following should be also applied: physical distancing of 1.5m (or otherwise in accordance with national policy), hand hygiene, respiratory etiquette, limiting direct contact with surfaces and avoiding touching the face and the mask.
There is advice available for using face masks in the community by ECDC here: https://www.ecdc.europa.eu/en/publications-data/using-face-masks-community- reducing-covid-19-transmission
and by EU HEALTHY GATEWAYS joint action here:
https://www.healthygateways.eu/Portals/0/plcdocs/EUHG PPE Travellers 17 04 2020 F .pdf?ver=2020-04-23-140238-597
and by WHO here:
https://apps.who.int/iris/bitstream/handle/10665/332293/WHO-2019-nCov-IPC Masks- 2020.4-eng.pdf?sequence=1&isAllowed=y
Crew members may be excluded from the mandatory use of a mask in certain circumstances and in specific areas in which there is no risk of droplet transmission from person to person (between crew members and between crew members and passengers) and from contamination of the environment with respiratory droplets from asymptomatic persons. This will have to be decided after conducting a risk assessment by the company (an example would be the engine room when the physical distancing is maintained). In this case a written risk assessment will be available assessing the risk and listing the areas and instances where the use of a face mask might not be necessary. The company should make the updated risk assessment available to competent authorities at ports.
Adequate personal protective equipment should be provided and distributed to all crew members along with instructions for their proper use and appropriate disposal. Information on personal protective equipment for crew members depending on their duties on board and their proper use is available from EU HEALTHY GATEWAYS available here:
https://www.healthygateways.eu/Portals/0/plcdocs/EUHG PPE Overview 24 04 2020 F. pdf?ver=2020-04-27-141221-467

5.5. Supplies and equipment
Adequate medical supplies and equipment should be available on board the ship in appropriate quantities compared to the number of passengers/crew on board to respond to a case or an outbreak among crew.
Adequate supplies of disinfectants, personal protective equipment and hand hygiene supplies should also be carried on board ships as well as body temperature devices.
Special procedures should be put in place to minimize contact between crew members and suppliers and other workers from the port.
Further details about supplies specific to COVID-19 can be found at: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance (please see disease commodity package)
Further recommendations for the type of PPE required according to the job position and the setting can be found here:
https://www.healthygateways.eu/Portals/0/plcdocs/EUHG PPE Overview 24 04 2020 F. pdf?ver=2020-04-27-141221-467

5.6. Ventilation and air-conditioning
Ferries should be adequately ventilated.
The ventilation of all spaces of the ship should be operated 24/7 and the use of timers or CO2 detectors that control the ventilation rate should be avoided; the ventilation rate should be such as to provide as much outside air as possible. The minimum required air exchanges per hour for each space on the ship should be respected and if possible the air exchanges should be further increased in order to reduce the risk of transmission.
All of the air handling units (AHUs) should be switched from recirculation to 100% outside air by closing the recirculation dampers (via the Building Management System or manually). In case it is not possible to completely stop the recirculation of the air, the ship should explore disinfecting the return air by using HEPA filters or other technologies (e.g. UV germicidal irradiation). 
There is no need to change heating, cooling and humidification set points. The fan coils (units with local/cabin level circulation) should either be switched off or operate so that the fans are continuously on. When possible, direct air flow should be diverted from groups of passengers. Exhaust ventilation systems of toilets should always be kept on, and should create negative pressure.
In case any of the AHUs have heat recovery equipment (such as enthalpy wheels or plate heat exchangers), they should be inspected in order to ensure that leakages between the supply and the exhaust air are under control. If leaks are suspected in the heat recovery sections, pressure adjustment or bypassing (some systems may be equipped with bypass) can be an option, in order to avoid a situation where higher pressure on the extract side will cause air leakages to the supply side. Pressure differences can be corrected by dampers or by other reasonable arrangements.
All maintenance works related to the HVAC system, including changing the central outdoor air and extract air filters, should be conducted according to the usual maintenance schedule. Duct cleaning should be avoided during the COVID-19 pandemic. Regular filter replacement and maintenance work shall be performed with common protective measures including respiratory protection.
The medical facilities, as well as the designated isolation spaces, should be connected to separate AHU than the rest of the spaces of the ship.
If aerosol-generating procedures are essential to be performed in the medical facilities of the ship, then the area should be under negative pressure and achieve at least 12 air changes per hour if this is feasible.
Information on ventilation and heating is provided by ECDC on the technical report titled Heating, ventilation and air-conditioning systems in the context of COVID-19 available here: https://www.ecdc.europa.eu/sites/default/files/documents/Ventilation-in-the-context-of-COVID-19.pdf

5.7. Cleaning and disinfection guidelines
The personnel in charge of cleaning and disinfecting the cabins or isolation rooms occupied by possible cases must be trained, protected and must follow rigorous protocols.
EU HEALTHY GATEWAYS has produced suggested procedures for cleaning and disinfection of ships during the pandemic of COVID-19 (VERSION 2 - 20/04/2020), which can be found here: https://www.healthygateways.eu/Portals/0/plcdocs/EU HEALTHY GATEWAYS COVID-19 Cleaning Disinfection ships 21 4 2020 F.pdf?ver=2020-04-21-154731-953
This document includes advice about specifications for the training of cleaning staff and use of PPE, information about the cleaning equipment and materials to be used, and a summary of antimicrobial agents effective against coronaviruses. It further outlines suggested procedures for cleaning and disinfection for different areas of the ships. 

5.8. Passenger facilities on board ships e.g. bars, restaurants, dining areas and food management
Food hygiene rules must be strictly followed. It is advised to avoid having self-service buffet for passenger, but that food be delivered by staff to customers closed in packages. Disposable cutlery, salt and pepper should be used. If disposable cutlery cannot be used then these should be washed and disinfected at > 77 °C for at least 30 seconds, or at 82 °C or with chlorine solution of 200ppm at minimum temperature of 24°C with contact time 7 seconds and then air dried.
Trays, napkins, soft drinks, straws etc. should be handed over by the staff to the customers and the customers should not collect them themselves.
It is preferable that dining tables are used outdoors respecting physical distance measures. If dining tables are used indoors, then physical distancing measures should be respected as well.

5.9. Health monitoring of crew
Continuing health monitoring for all staff working can allow for early detection of symptomatic COVID-19 cases. Daily contactless temperature measurement and immediately reporting to supervisors any mild or severe symptoms compatible with COVID-19 is of high importance. Any staff with a temperature at or over >38°C should immediately self-isolate, be provided appropriate PPE and inform their designated supervisor/manager or medical staff if available. In the event of a possible COVID-19 case on board, the frequency of contactless temperature measurement of staff could be increased (e.g. twice per day).

6. Managing COVID-19 cases on board
6.1. Management of a possible case
As soon as a possible case is detected the contingency plan (outbreak management plan) should be activated.
The master or the designated officer in the absence of a doctor on board shall carry out a clinical examination of the patient in accordance with the training received and report their findings to the medical teleconsultation centre (TMAS at sea or local rescue at dockside).
Following preliminary medical examination, if it is determined that there is a possible case of COVID-19 on board, the patient should be isolated in an isolation cabin with negative pressure if available or in a designated cabin, room or quarters and infection control measures should be continued until disembarkation and transfer of the patient to the hospital ashore. Advice for management of possible cases can be found in the EU HEALTHY GATEWAYS Interim advice for ship operators for preparedness and response to the outbreak of COVID-19, available at: https://www.healthygateways.eu/Novel-coronavirus 

6.2. Management of contacts
Management of contacts will take place according to the national policies by the national competent authorities.
Advice for contact definition and management can be found in the following links:
• EU HEALTHY GATEWAYS, Interim advice for ship operators for preparedness and response to the outbreak of COVID-19, available at: https://www.healthygateways.eu/Novel-coronavirus
• ECDC, Contact tracing: Public health management of persons, including healthcare workers, having had contact with COVID-19 cases in the European Union - second update https://www.ecdc.europa.eu/en/covid-19-contact-tracing-public-health-management
• WHO, Operational considerations for managing COVID-19 cases/outbreak on board ships https://www.who.int/publications/i/item/operational-considerations- for-managing-covid-19-cases-outbreak-on-board-ships

6.3. Disembarkation
As soon as a possible case is detected on board a ferry and for the duration of the journey until arrival at the final destination, new passengers should not be allowed to board at intermediate destinations, but disembarkation should be allowed.
Possible cases should not come into contact with other people while disembarking and should therefore disembark in such a way that they encounter only a minimum number of crew members and no passengers. They could take a different route and/or disembark with a time lag (10 minutes). Possible cases should carry their luggage and personal belongings if they are in a fit state to do so. Wearing a surgical mask is recommended. Possible cases should be informed of the precautions to be taken for themselves and their entourage.
The competent authorities at the destination will provide advice on the management of the possible case and their contacts.

6.4. Reporting
In accordance with the International Health Regulations (2005), the officer in charge of the ship must immediately inform the competent authority at the next port of call about any possible case of COVID-19.
For ships on international voyage, the Maritime Declaration of Health (MDH) should be completed and sent to the competent authority in accordance with the local requirements at the port of call.
Ship operators must facilitate application of health measures and provide all relevant public health information requested by the competent authority at the port. The officer in charge of the ship should immediately alert the competent authority at the next port of call regarding the possible case to determine if the necessary capacity for transportation, isolation, laboratory diagnosis and care of the possible case/cluster of cases of COVID-19 is available at the port. The ship may be asked to proceed to another port in close proximity if this capacity is not available, or if warranted by the medical status of the possible case/cluster of cases of COVID-19. It is important that all arrangements are conducted as quickly as is feasible to minimise the stay of symptomatic possible case/cases on board the ship.
_____

^{² Possible case: any person with at least one of the following symptoms: cough, fever, shortness of breath, sudden onset of anosmia, ageusia or dysgeusia. Additional less specific symptoms may include headache, chills, muscle pain, fatigue, vomiting and/or diarrhoea (source: Case definition for coronavirus disease 2019 (COVID-19), as of 29 May 2020. https://www.ecdc.europa.eu/en/covid-19/surveillance/case-definition).
³ “Face masks” is a generic term which covers both medical and non-medical masks. Medical face mask (also known as surgical or procedure mask): medical device covering the mouth, nose and chin ensuring a barrier that limits the transition of an infective agent between the hospital staff and the patient. They are used by healthcare workers to prevent large respiratory droplets and splashes from reaching the mouth and the nose of the wearer and help reduce and/or control at the source the spread of large respiratory droplets from the person wearing the face mask. Medical face mask comply with requirements defined in European Standard EN 14683:2014.
Non-medical face masks (or ‘community’ masks): include various forms of self-made or commercial masks or face covers made of cloth, other textiles or other materials such as paper. They are not standardized and are not intended for use in healthcare settings or by healthcare professionals (European Centre for Disease Prevention and Control. Using face masks in the community. Stockholm: ECDC; 2020.) https://www.ecdc.europa.eu/sites/default/files/documents/COVID-19-use-face-masks-community.pdf
⁴ “Face masks” is a generic term which covers both medical and non-medical masks. Medical face mask (also known as surgical or procedure mask): medical device covering the mouth, nose and chin ensuring a barrier that limits the transition of an infective agent between the hospital staff and the patient. They are used by healthcare workers to prevent large respiratory droplets and splashes from reaching the mouth and the nose of the wearer and help reduce and/or control at the source the spread of large respiratory droplets from the person wearing the face mask. Medical face mask comply with requirements defined in European Standard EN 14683:2014.
Non-medical face masks (or ‘community’ masks): include various forms of self-made or commercial masks or face covers made of cloth, other textiles or other materials such as paper. They are not standardized and are not intended for use in healthcare settings or by healthcare professionals (European Centre for Disease Prevention and Control. Using face masks in the community. Stockholm: ECDC; 2020.) https://www.ecdc.europa.eu/sites/default/files/documents/COVID-19-use-face-masks-community.pdf}

Annexes
Annex 1
Pre-boarding health declaration questionnaire
(The questionnaire is to be completed by all adults before embarkation)
 

Questions

Annex 2
Passenger Locator Forms (PLF) for ferries
Regulation (EU) 2016/679 on the protection of natural persons with regard to the processing of personal data and on the free movement of such data (GDPR) should be taken into consideration.
The form is available in Word format from the following link:
https:/www.healthygateways.eu/Translated-Passenger-Locator-Forms

Working group members
Barbara Mouchtouri¹, Martin Dirksen-Fischer², Mauro Dionisio³, Miguel Davila-Cornejo⁴, Elina Kostara¹, Leonidas Kourentis¹, Lemonia Anagnostopoulou¹, Jan Heidrich⁵ and Christos Hadjichristodoulou¹
1. Laboratory of Hygiene and Epidemiology, Faculty of Medicine, University of Thessaly, Larissa, Greece
2. Institute for Hygiene and Environment of the Hamburg State Department for Health and Consumer Protection, Hamburg, Germany
3. Italian Ministry of Health, Rome, Italy
4. Ministry of Health, Social Services and Equality, Madrid, Spain
5. Institute for Occupational and Maritime Medicine, Hamburg, Germany
For any questions or support related to the points of entry, please email Questo indirizzo email è protetto dagli spambots. È necessario abilitare JavaScript per vederlo.
Input was provided by Interferry and European Community Shipowners' Associations (ECSA).

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^{Fonte: portsofgenoa.com}