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A Review of VSP Cruise Ship Inspections (2022-2024)
David Best
Founder & CEO
[ Last update: ]
Abstract
The objective of this study was to verify the characteristics and results of Vessel Sanitation Program (VSP) inspections on cruise ships sailing in the United States, considering the risk categories, deficiencies raised, and scores awarded.
The findings of 231 VSP inspections carried out on 163 cruise ships between October 2022 and March 2024 were reviewed. The distribution of inspection scores was observed to range from a maximum of 100 to a minimum of 67, with a mean of 96.3 out of 100. A total of 6036 violations were identified across all inspections, with a mean of 26.1 violations reported per inspection.
Analysis revealed that a subset of 10 specific item categories were responsible for 72% (n=4347) of the total violations raised. Furthermore, research demonstrated a variability in the point deduction process, suggesting a degree of subjectivity embedded within the evaluative framework of the scoring system that warrants further investigation.
The study illustrates that VSP inspection scores should not be used as benchmarks for the comparison of hygiene standards between cruise ships. Rather, the deficiencies detailed within the inspection reports provide a more accurate measure of public health standards which can facilitate in identifying trends and highlighting key areas for improvement.
Keywords: Vessel Sanitation Program; inspections; cruise ships; public health
Table of Contents
Introduction
On March 14, 2020, the Centers for Disease Control and Prevention (CDC) issued a ‘No Sail Order’ which suspended cruise operations in the United States for an initial 30 days to prevent further transmission of the SARS-CoV-2 virus. This order was extended several times before cruise operations restarted—under a framework of specific COVID-19 requirements—in the summer of 2021. Routine cruise ship sanitation inspections, which had been suspended due to the pandemic, would not resume until October 2022. This study analyzes the inspections conducted upon recommencement of the program.
The CDC’s Vessel Sanitation Program (VSP) conducts unannounced operational inspections on cruise ships calling U.S. ports to verify adherence to hygiene standards set forth in the VSP Operations Manual (1). Cruise ships are typically inspected twice during the federal fiscal year, beginning on October 1st through September 30th. Vessels sailing outside of the United States for an extended period may not undergo biannual inspections; however, they are subject to inspection upon their return to U.S. waters.
Inspections ordinarily take six to eight hours depending on the size of the cruise ship, the number of inspectors, the length of time the vessel is in port, and the deficiencies identified. The weighted inspection scoring system used by VSP is based on a descending 100-point scale. The significance of each violation is assessed by the inspectors, with points being deducted in accordance with the item’s weighted value.
Each requirement in the VSP Operations Manual is assigned a value between one and five points based on its probability of increasing the risk of an acute gastroenteritis (AGE) outbreak. Items considered critical—those with a weight of three to five points—are designated in bold red underlined text. Noncritical items are those with a weight of one to two credit points.
At the end of an inspection, a draft report with a preliminary score is issued to the vessel to facilitate prompt remediation of the deficiencies raised. A validated report and final score is sent to the cruise line’s nominated representative within a few weeks after the inspection. A score of 85 or below is considered a failed inspection and results in an additional follow-up inspection shortly thereafter to review the status of deficiencies identified during the previous inspection.
Failing an inspection does not automatically result in a vessel being issued a “no-sail recommendation” from VSP unless there is an immediate threat to public health. An imminent health hazard is determined to be, but not limited to, one of the following situations:
A free halogen residual in the potable water distribution system less than 0.2 MG/L (ppm) and this deficiency is not corrected before the inspection ends
Inadequate facilities for maintaining safe temperatures for potentially hazardous food items
Inadequate facilities for cleaning and sanitizing food equipment
Inability to properly dispose of solid or liquid waste
An infectious disease outbreak where it is suspected that continuing operations may subject newly arriving passengers to disease
Within two weeks of receiving the final report, cruise lines are expected to submit their corrective-action statements to VSP detailing how each violation will be addressed to maintain compliance with the corresponding standard. VSP does not verify that the deficiencies have been corrected until the next periodic inspection or re-inspection. The reports, corrective-action statements, and scores, are published and available for public review on the VSP website (2).
Table 1 – Categorization of standards within the VSP 2018 Operations Manual by item number
Methods
The analysis in this study was based on a comprehensive review of cruise ship inspection records published on the CDC’s Vessel Sanitation Program website. The website’s ‘Advanced Cruise Ship Inspection Search’ function was employed to collect relevant data using the following specified search criteria:
‘Cruise Ships’: All Vessel Inspection Scores
‘Inspection Date Criteria’: From 01 October 2022 to 01 March 2024
‘Score Criteria’: All
The evaluation phase of the study was conducted in March 2024. A total of 231 inspection reports conforming to the analysis criteria were published at the time of review: all reports were included in the study. The categorization of deficiencies used in the analysis was in accordance with those outlined in the VSP 2018 Operations Manual (Table 1).
To ensure a consistent evaluation, any deficiency categorized with a ‘*’ rather than a specific item number in a report, was reassigned an appropriate item category number based on the standards detailed in the manual. This excludes two observations made during an inspection on the Seabourn Venture (4-Oct-23) as neither finding was in clear violation of an operational requirement.
Results
Cruise Ship Inspection Scores
The 231 VSP inspections reviewed in this study were conducted on 163 cruise ships, operated by 33 cruise lines over a period from October 1, 2022 through to March 1, 2024. The distribution of inspection scores was observed to range from a maximum of 100 to a minimum of 67, with a mean of 96.3 out of 100, suggesting a high level of compliance within the assessed parameters (Figure 1).
On 47 separate inspections, 44 cruise ships were awarded the highest possible score of 100: three vessels—Carnival Panorama, Celebrity Summit, and Disney Fantasy—each received a score of 100 on two consecutive inspections. The MSC Seaside was the only vessel to not pass its inspection, receiving a score of 67 on April 27, 2023.
It was observed that 67.5% (n=156) of inspections conducted were of vessels operated under the management of six principle cruise lines. This statistic represents a significant proportion of the total inspections performed, indicating a concentrated oversight within these specific companies:
Carnival Cruise Lines, Inc.: A total of 43 inspections with a mean score of 96.1
Royal Caribbean International: A total of 36 inspections with a mean score of 96.7
Norwegian Cruise Lines: A total of 26 inspections with a mean score of 97.3
Princess Cruises: A total of 21 inspections with a mean score of 95.1
Celebrity Cruises: A total of 16 inspections with a mean score of 98.5
Holland America Line: A total of 14 inspections with a mean score of 96.3
Figure 1 – Cruise ship inspection scores between October 2022 and March 2024
The Viking Octantis and Norwegian Sky, inspected on September 30 and October 11, 2023, respectively, had the lowest number of deficiencies reported during a single inspection with a count of six each. Conversely, the MSC Seaside had the highest number of deficiencies cited at 104.
In the context of a weighted inspection scoring system, it is presumed that a lower number of deficiencies typically correlates to a better result. Specifically, the identification of a reduced number of violations—particularly those of a critical or recurrent nature—is indicative of a superior adherence to regulatory standards and a decrease in associated health risks. However, when examining the data trends of VSP inspections, no significant relationship between the number of reported violations and the resultant score a ship received were observed (Figure 2).
Figure 2 – Minimum and maximum number of violations reported during one inspection by score
When a perfect score of 100 was awarded, the number of violations raised during a single inspection fluctuated between a low of six to a high of 26. Similar variations were detected within other scores, particularly those between a range of 99 to 94:
Score of 99: The Disney Dream (6-Apr-23) and Viking Star (28-Sep-23) had the lowest number of violations with 11, while the Allure of the Seas (26-Jan-24) had the highest with 34
Score of 98: The Serenade of the Seas (12-Aug-23) had the lowest number of violations with eight, while the Norwegian Jade (18-Feb-24) had the highest with 37
Score of 97: The Seabourn Quest (23-Mar-23) had the lowest number of violations with eight, while the Norwegian Prima (6-Oct-22) had the highest with 43
Score of 96: The Seven Seas Grandeur (27-Feb-24) had the lowest number of violations with 14, while the Marella Discovery (11-Mar-23) had the highest with 49
Score of 95: The Noordam (6-Oct-23) had the lowest number of violations with 15, while the Carnival Conquest (27-Oct-22) had the highest with 50
Score of 94: The Norwegian Encore (3-Jan-23) had the lowest number of violations with 12, while the Seabourn Odyssey (14-Jun-23) had the highest with 53
Deficiencies Identified during VSP Inspections
Over the course of the 231 inspections reviewed, at least one violation was observed in each of the 44 item categories. VSP inspectors identified a cumulative total of 6036 deficiencies, a mean of 26.1 violations per inspection. The distribution of reported violations across the item categories is presented in Table 2.
Table 2 – Total number of deficiencies reported by item category
The most prevalent area of non-compliance—representing 15% (n=902) of all violations—was associated with Item No. 33 which pertains to VSP food safety standards for the design, construction, maintenance, and cleanliness of decks, bulkheads, and deckheads within food areas on board a ship.
Analysis revealed that a violation of requirements attributed to this category was identified at least once on 89% (n=205) of all inspections. The predominant factors contributing to these violations included deck tiling in a poor state of repair, missing sealant, the accumulation of food debris and grease residues, and the presence of water condensate or leakages.
The least common finding, observed on only one occasion during an inspection of the Star Pride (7-Jan-23), was Item No. 4. This critical category, valued at five points, concerns the halogen residual concentrations within a vessel’s potable water distribution system. According to the inspection report, halogen levels exceeded the operational limit of 5 mg/L (ppm) due to a malfunctioning non-return valve in the chlorine injection system.
The inspectors elected not to deduct points for this particular violation, which would have resulted in a failed inspection as 10 points were subtracted from the vessel’s score for other deficiencies raised. This decision was likely influenced by several factors:
The event occurred between 5:00 AM and 6:00 AM
It was localized to a passenger area of the ship (Deck 8)
Exceeding the operational threshold of 5 ppm does not, in of itself, increase the likelihood of an AGE outbreak
Figure 3 illustrates the item categories with the greatest number of reported violations. The accumulative total of these violations constitute 72% (n=4347) of the total number of violations identified across all inspections reviewed. A significant majority of the item categories, eight out of 10, are related to food safety.
Of the eight food safety categories, seven are directly related to the cleanliness, maintenance, and operation of food facilities and equipment. The predominance of deficiencies in these areas may indicate various underlying reasons: that the categories are more prone to issues (suggesting a trend that requires attention); the standards for these items are particularly stringent; or, they are more heavily scrutinized by inspectors.
Food safety standards comprise the largest section of the VSP Operations Manual and contain the highest number of critical items at 10. As the seven item categories constitute a significant portion of the food safety requirements, it follows that a corresponding high incidence of violations might be reasonably anticipated in these areas.
Figure 3 – Ten most common item categories of deficiencies raised during inspections
Of the 44 item categories, 16 are designated as critical with a corresponding 3 to 5-point value. The critical item category with the greatest number of reported violations (n=459) was Item No. 39 (3-point value) which concerns the on board management of pests. The overwhelming majority of these violations were attributed to the presence of flies in food areas. The presence of pests was observed in almost 64% (n=147) of all inspections.
The subsequent four most frequently observed critical violations were:
Item No. 26 – 401 violations: Witnessed at least once during 163 inspections, VSP standards in this category pertain to the sanitizing of, and cleaning frequencies for, food-contact surfaces, equipment, and utensils. This category also includes requirements for materials used in their construction.
Item No. 16 – 125 violations: The highest 5-point valued deficiency reported concerns the regulation of temperature and time for potentially hazardous food, as well as requirements for informing consumers about the risks of eating raw or undercooked animal products. At least one violation was observed in 89 out of 231 inspections.
Item No. 11 – 99 violations: VSP requirements for reporting and managing communicable diseases—the second highest 5-point critical deficiency observed—were identified on 91 inspection reports. The majority of findings were related to delays in notifying on board medical staff about food employees exhibiting symptoms of acute gastroenteritis. Analysis revealed that VSP typically do not subtract points for such findings if there is documented evidence that the crew member was disciplined for reporting late.
Item No. 24 – 90 violations: Identified during 68 inspections, violations in this category primarily concern the sanitizing temperature of warewashing machines.
Point Deductions during VSP Inspections
Of the 231 inspections included within the study, VSP deducted an aggregate of 852 points from the consolidated scores awarded. The distribution of point deductions by item category is represented in Table 3.
Table 3 – Total sum of points deducted across all inspections by item category
A quantitative analysis of the point deductions revealed that 11 item categories accounted for 70.5% (n=601) of the total sum deducted (Figure 4). This indicates a concentrated pattern of point loss attributed to these categories that necessitates a deeper examination of contributing root causes.
According to the VSP website, points are deducted from a cruise ship’s inspection score when “there is a pattern of similar violations of the same criteria or when there is a single, significant violation” (3). Although weighted inspection scoring systems aim to be objective, the assessment of comparable violations or the definition of a significant violation can introduce subjectivity. More, the qualified judgement and risk estimations of inspectors may differ leading to variations in scoring.
Item No. 39, the category responsible for largest number of point deductions (n=90), is a good illustration of variability. Of a total of 10 inspections where nine or more separate pest management violations were reported, three points were consistently deducted from a vessel’s score. However, on inspections where eight or less violations of a similar nature were reported, points were not always deducted.
For example, eight of the total 32 deficiencies raised during an inspection of the Royal Princess (7-Aug-23) were related to issues concerning the presence of flies. These findings did not result in any points being deducted with the vessel awarded a final score of 99. Conversely, from a total of 20 deficiencies reported when the Celebrity Silhouette was inspected on January 12, 2023, three points were deducted for five pest violations (all attributed to the presence of flies) culminating in a final score of 97.
Figure 4 – Item categories responsible for the greatest sum of point deductions
The top 10 categories—irrespective of an item’s point value—that resulted in points being deducted are depicted in Figure 5. These categories comprised 70.7% (n=319) of all cases where point deductions were applied upon identification of corresponding violations.
The category responsible for the highest frequency of point deductions (n=78) was Item No. 33. Of the 30 inspections where eight or more violations were reported, points were consistently deducted: the Celebrity Silhouette (30-Nov-23) was an exception to this rule having no points deducted despite accruing eight violations.
On 83 inspections where the number of Item No. 33 violations raised on a single vessel ranged from four to seven, a point was deducted in approximately half of all instances (n=42). This variance in approach benefited seven cruise ships that received a perfect score of 100. Conversely, during the same period, five cruise ships—Carnival Glory, Carnival Spirit, Disney Magic, Royal Princess, and Sky Princess—received a one-point deduction for a similar range of violations, resulting in a final score of 99.
Figure 5 – Item categories that most frequently resulted in points being deducted
Discussion
The CDC established the Vessel Sanitation Program as a cooperative activity to “assist the cruise ship industry in fulfilling its responsibility for developing and implementing comprehensive performance-based systems to protect the health of the traveling public” (1). The operational inspections conducted by VSP are viewed as an opportunity to improve within this framework.
In a regulatory inspection process that prioritizes compliance with established standards, the objective is the minimization of violations. This goal supersedes the pursuit of an arbitrary score. Acknowledging the significance of critical and repeat violations, a weighted scoring system which quantifies degrees of compliance or contrasts in performance, should—over a large enough sample size—yield results that more precisely reflect the observed variances, thereby further enhancing the integrity of the inspection process.
Within the framework of the weighted scoring system VSP currently uses, it is imperative to analyze the deduction of points with consideration to the inherent design of the system. The current VSP model provides inspectors with the autonomy to apply their discretion in deducting points, a critical aspect of the evaluation process often not included in the description of violations found within official inspection records.
While this model is designed to assist cruise lines in prioritizing decisions that improve public health standards, it comes with one important caveat: its efficacy is contingent upon its consistent application and a thorough root-cause analysis being conducted to identify the underlying reasons for the violations. Only through such evaluation does a weighted inspection scoring model truly inform and guide the enhancement of public health.
Ultimately, the intent in analyzing VSP’s point deduction methodology was not to critique the informed discretion exercised by its inspectors. Rather, the objective was to highlight the prevalent misconception that a vessel’s VSP inspection score is the definitive measure of its public health standard.
Prospective enhancements to VSP’s scoring framework would be actualized through the establishment of a more explicit definition and rationale of the criteria governing point deductions to ensure an increased understanding for all stakeholders including cruise lines and the general public. However, the most significant advancement in the inspection process is anticipated when focus is redirected away from the numerical score awarded.
Research shows that the effectiveness of inspection scores in communicating risks to the public is widely contested and it is unclear how the public interprets the scores, irrespective of the calculation method (4). Numerous online articles inaccurately interpret the limited data provided by a ship’s VSP inspection score, correlating a lower result to an increased risk of illness (5). Furthermore, there is a tendency within the cruise industry to benchmark the performance of cruise ships based on their inspection scores.
Although VSP inspectors review relevant control records which predate the current inspection, a significant proportion of their evaluation focuses on deficiencies identified on the day of inspection itself. Consequently, the assessment of findings and their potential to increase the risk of an AGE outbreak is predominantly based on the level of risk present on the actual day of inspection.
Determining the gravity of findings both in respect of similarity and significance is subjective. Whereas risk is quantified as the product of likelihood and consequence, it cannot be inferred that a vessel with a lower score will be the source of a greater number of acute gastroenteritis cases. A recent study suggests that current VSP inspections “have no prognostic value with regard to future outbreaks of gastroenteritis on board cruise ships” (6). This assertion is supported by comparative analysis of cruise ship outbreak data and the inspection scores awarded.
During 2023, 14 AGE outbreaks on cruise ships sailing in U.S. waters were published on the VSP’s website (7). Of the implicated vessels, 10 had at least one operational inspection within the same calendar year. Seven of the 10 ships were awarded a score of 97 or higher, with two vessels achieving a perfect score of 100. Despite this accolade, they each experienced norovirus outbreaks.
In conclusion, it is inappropriate to use VSP cruise ship inspection scores as a basis for comparing the public health performance of different vessels, nor should the results be extrapolated beyond the actual inspection. The scores provide a momentary assessment of compliance with VSP hygiene requirements at the time of inspection rather than as an indicator of a vessel’s ongoing adherence to these standards. Furthermore, inspection scores are not a predictor of the probability of illness.
The true essence and significance of a VSP inspection lies not in the score a ship is awarded, but rather in the deficiencies identified during the process. As this study highlights, a notable concentration of the violations reported are within a limited spectrum of item categories. By further examining trends and ensuring a comprehensive root-cause analysis is conducted, the cruise industry can gain valuable insights on where improvements are required, priorities should be focused, and which strategies are most effective for preventing reoccurrences.
References
[1] CDC. Vessel Sanitation Program 2018 Operations Manual. Atlanta, GA: US Department of Health and Human Services, CDC; 2018. https://www.cdc.gov/nceh/vsp/default.htm
[4] Dundes L, Rajapaksa S. Scores and grades: a sampling of how college students and food safety professionals interpret restaurant inspection results. J Environ Health. 2001 Dec;64(5):14-9, 33-4. PMID: 11764676.
[6] Taylor CJ. Gastroenteritis outbreaks on cruise ships: are sanitation inspection scores a true index of risk? Int Marit Health. 2018;69(4):225-232. doi: 10.5603/IMH.2018.0037. PMID: 30589061.
