[Federal Register Volume 85, Number 57 (Tuesday, March 24, 2020)]
[Notices]
[Pages 16628-16631]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2020-06166]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention


No Sail Order and Suspension of Further Embarkation

AGENCY: Centers for Disease Control and Prevention (CDC), Department of 
Health and Human Services (HHS).

ACTION: Notice.

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SUMMARY: The Centers for Disease Control and Prevention (CDC), a 
component of the Department of Health and Human Services (HHS), 
announces the issuance of a No Sail Order and Suspension of Further 
Embarkation on March 14, 2020 for all cruise ships that are not 
voluntarily suspending operation.

DATES: This action was effective March 14, 2020.

FOR FURTHER INFORMATION CONTACT: Jennifer Buigut, Division of Global 
Migration and Quarantine, Centers for Disease Control and Prevention, 
1600 Clifton Road NE, MS V18-2, Atlanta, GA 30329. Phone: 404-498-1600. 
Email: [email protected].

SUPPLEMENTARY INFORMATION: On March 14, 2020, the Director of the 
Centers for Disease Control and Prevention issued the following No Sail 
Order and Other Measures Related to Operations. A copy of the order is 
provided below and a copy of the signed order can be found at https://www.cdc.gov/quarantine/cruise/index.html.

U.S. Department of Health and Human Services Centers for Disease 
Control and Prevention (CDC) Order Under Sections 361 & 365 of the 
Public Health Service Act (42 U.S.C. 264, 268) and 42 Code of Federal 
Regulations Part 70 (Interstate) and Part 71 (Foreign): No Sail Order 
and Other Measures Related to Operations

Applicability

    This Notice of No Sail Order and Other Measures Related to 
Operations shall apply only to the subset of carriers \1\ described 
below and hereinafter referred to as ``cruise ships,'' except this 
Order shall not apply to any cruise ship that voluntarily suspends 
operations for the period of this Order:
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    \1\ Carrier is defined by 42 CFR 71.1 to mean ``a ship, 
aircraft, train, road vehicle, or other means of transport, 
including military.''
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    All commercial, non-cargo,\2\ passenger-carrying vessels operating 
in

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international, interstate, or intrastate waterways and subject to the 
jurisdiction of the United States with the capacity to carry 250 \3\ or 
more individuals (passengers and crew) with an itinerary anticipating 
an overnight stay onboard or a twenty-four (24) hour stay onboard for 
either passengers or crew.\4\
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    \2\ Given the substantial risk of person-to-person transmission 
of COVID-19, as opposed to transmission via indirect contact, this 
Order is currently limited to passenger, non-cargo vessels.
    \3\ Based on substantial epidemiological evidence related to 
congregate settings and mass gatherings, this Order suspends 
operation of vessels with the capacity to carry 250 individuals or 
more. Evidence shows that settings as small as nursing homes or 
movie theaters can proliferate the spread of a communicable disease. 
As the numbers of passengers and crew onboard a ship increases, 
certain recommended mitigation efforts such as social distancing 
become more difficult to implement. In light of the demonstrated 
rapid spread of this communicable disease in current cruise ship 
settings, application of this Order to vessels carrying 250 or more 
individuals is a prudent and warranted public health measure. 
Moreover, the management of current coronavirus cases in addition to 
existing seasonal care needs (e.g., influenza) has placed an extreme 
burden on the public health and healthcare systems and this Order 
will help avoid further stressing those systems.
    \4\ This order shall not apply to vessels operated by a U.S. 
Federal or State government agency. Nor shall it apply to vessels 
being operated solely for purposes of the provision of essential 
services, such as the provision of medical care, emergency response, 
activities related to public health and welfare, or government 
services, such as food, water, and electricity.
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General Background

    COVID-19 is a communicable disease caused by a novel (new) 
coronavirus, SARS-CoV-2, that was first identified as the cause of an 
outbreak of respiratory illness that began in Wuhan, China. The virus 
is thought to spread primarily by person-to-person contact through 
respiratory droplets produced when an infected person coughs or 
sneezes; it may also spread through contact with contaminated surfaces 
or objects. Manifestations of severe disease have included severe 
pneumonia, acute respiratory distress syndrome (ARDS), septic shock, 
and multi-organ failure. According to the World Health Organization 
(WHO), approximately 3.6% of reported COVID-19 cases have resulted in 
death globally. This mortality rate is higher among the elderly or 
those with compromised immune systems. Older adults and people who have 
severe chronic medical conditions like heart, lung, or kidney disease 
are also at higher risk for more serious COVID-19 illness. Early data 
suggest older people are twice as likely to have serious COVID-19 
illness.
    On January 30, 2020, the Director General of the WHO declared that 
the outbreak of COVID-19 constitutes a Public Health Emergency of 
International Concern under the International Health Regulations. The 
following day, the Secretary of the Department of Health and Human 
Services (HHS) declared that COVID-19 constitutes a public health 
emergency under the Public Health Service Act. To date, CDC has issued 
Level 3 Travel Health Notices recommending that travelers avoid all 
nonessential travel to China, Iran, South Korea, and most of Europe; 
the U.S. Department of State has issued a global Level 3 Health 
Advisory directing U.S. citizens to reconsider all travel abroad due to 
the global impact of COVID-19 and Level 4 Travel Advisories (Do Not 
Travel) for China, Iran, and certain parts of Italy. In addition, CDC 
has recommended that travelers, particularly those with underlying 
health conditions, avoid all cruise ship travel worldwide; the U.S. 
Department of State has similarly issued guidance that U.S. citizens 
should not travel by cruise ship at this time. As of March 11, 2020, 
the President of the United States has suspended entry to the U.S. by 
most foreign nationals who have recently visited China, Iran, and most 
of Europe due to COVID-19. On March 11, 2020, the WHO declared the 
COVID-19 outbreak a pandemic. As of March 13, 2020, there have been 
over 132,000 cases of COVID-19 globally in over 122 locations resulting 
in over 4,950 deaths; more than 1,620 cases have been identified in the 
United States, with new cases being reported daily and over 41 deaths 
due to the disease. A Presidential Declaration of National Emergency 
concerning COVID-19 was issued on March 13, 2020.
    Global efforts to slow transmission have included drastic control 
measures with substantial societal and economic impact. Countries such 
as Russia, Australia, the Philippines, Japan, Israel, and the United 
States have imposed stringent restrictions on travelers who have 
recently been in China. Similar travel restrictions have since been 
imposed on individuals from countries experiencing substantial 
outbreaks, including Iran, South Korea, and Europe. In many countries, 
including the United States, citizens, permanent residents, and their 
close relatives returning from areas known to have high rates of 
infection are being requested to self-quarantine for 14 days (a period 
estimated to encompass the incubation period for the virus) following 
return from countries with sustained community transmission. Despite 
these unprecedented global efforts at containment, cases of COVID-19 
have been shown to rapidly propagate, crossing international borders 
with ease. For example, the Islamic Republic of Iran has seeded at 
least 97 COVID-19 cases in 11 other countries, as reported by the WHO, 
and as of March 9, 2020, the Schengen Area of Europe has exported 201 
COVID-19 cases to 53 countries.
    In the United States, community transmission has occurred in 
Washington State, California, and New York. CDC is closely monitoring 
COVID-19 transmission and is supporting state and local health 
departments in conducting contact tracing investigations of confirmed 
COVID-19 cases identified in the United States. These investigations 
are complex and resource intensive; persons identified as infected or 
at-risk can require observation, movement restriction (such as 
isolation or quarantine), clinical evaluation, and care. Public health 
authorities in the United States are working concurrently to contain 
the spread of the disease and mitigate its impact.

Risk of Transmission on Cruise Ships

    Cruise ships often involve the movement of a number of people in 
closed and semi-closed settings. Cruises vary in size, with larger 
cruises involving populations of more than 4,000 passengers and crew. 
Like other close-contact environments, cruise ships facilitate 
transmission of COVID-19.
    There are several features of cruise ships that increase the risk 
of COVID-19 transmission. A hallmark of cruise travel is the number and 
variety of person-to-person contacts an individual passenger may have 
daily. The dynamics of passenger-to-passenger, passenger-to-crew, crew-
to-passenger, and crew-to-crew intermingling in a semi-closed setting 
are particularly conducive to SARS-CoV-2 spread, resulting in high 
transmission rates. Cruises include frequent events that bring 
passengers and crew close together, including group and buffet dining, 
entertainment events, and excursions. Cruise ship cabins are small, 
increasing the risk of transmission between cabinmates. Close 
quartering is a particular concern for crew, who typically eat and 
sleep in small, crowded spaces. Infection among crew members may lead 
to transmission on sequential cruises on the same vessel because crew 
members may continue working and living onboard the ship from one 
cruise to the next. Crew from one ship may in turn serve onboard 
multiple different ships for subsequent voyages, which also has the 
potential to amplify transmission.
    Transmission of COVID-19 on cruise ships may also be amplified by

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difficulty decontaminating numerous surfaces in common areas. 
Contamination of frequently touched surfaces, such as door handles and 
faucets in public toilet rooms, elevator buttons, handrails in stairs 
and passageways, and utensils/dispensing mechanisms (for beverages) in 
self-service buffets, etc., is also likely to be a significant factor 
in transmission. Less obvious examples of frequently touched surfaces, 
include playing cards, slot machine levers, and chips in the casino; 
computer keyboards in the internet caf[eacute]; books, puzzles, and 
games in the library; gym equipment; counters and surfaces in gift 
shops; and the cruise card used by passengers to pay/register for 
everything on board and exit/enter the ship in port. The high volume of 
people on board a cruise ship and wealth of high-touch surfaces make 
successful control of this method of transmission very difficult.
    Moreover, the nature of cruise travel presents additional 
opportunities for spread of the disease to ports of calls and 
passengers' home communities. During a cruise, disembarkation of 
passengers at sequential ports of call under uncontrolled conditions 
may lead to disease transmission in those ports. Once a cruise 
concludes, passengers residing in different countries or throughout the 
United States may require air transportation or other types of common 
carriers to return home. Return of disembarked infected passengers to 
their communities could lead to widespread, interstate disease 
transmission.
    Quarantine and isolation measures are difficult to implement 
effectively onboard a cruise ship and only occur after an infection has 
already been identified onboard a cruise. If ships are at capacity, it 
may not be feasible to fully separate ill and well persons onboard the 
ship, particularly among the crew. Because crew are required to 
continue working to keep a ship safely operating, effective quarantine 
for crew is particularly challenging.

Already Observed Impact of Cruise Ship Travel in General and in the 
U.S.

    Cruise ship travel has already been associated with a number of 
COVID-19 clusters and outbreaks, including on the Diamond Princess 
(Asia) and the Grand Princess (California to Mexico, California to 
Hawaii). The threat of spread is not limited to larger cruise ships. An 
outbreak onboard a Nile River cruise with 171 passengers and crew (29 
of which were American citizens) resulted in 45 confirmed COVID-19 
cases (3 of which are American citizens). Many of these passengers 
returned home before any notifications about COVID-19 were provided, 
potentially spreading the disease to their home communities. Evidence 
of COVID-19 transmission onboard six similar Nile River cruise ships, 
each carrying approximately 100 passengers, illustrates that even ships 
with moderate numbers of passengers and crew onboard carry a 
substantial risk of disease transmission and outbreak.
    The initial stages of the COVID-19 epidemic were marked by the 
outsized role of a single cruise ship, the Diamond Princess in 
Yokohama, Japan, which for a period of 18 days was the setting for the 
largest number of cases outside the original epicenter in China. The 
outbreak of COVID-19 onboard the Diamond Princess demonstrates the 
speed and extent of disease transmission that can occur onboard cruise 
ships. Despite quarantine and isolation efforts, more than 700 cases of 
infection with the virus that causes COVID-19 were identified among 
Diamond Princess passengers and crew during the three weeks following 
the identification of one case of COVID-19 in a person who was 
symptomatic before leaving the ship. There are several cases of severe 
disease associated with the Diamond Princess, including at least six 
deaths. Additionally, approximately half of the infected passengers did 
not report symptoms at the time their infections were diagnosed.
    On March 4, 2020, Placer County, California officials reported the 
death of a passenger who had been onboard the Grand Princess cruise 
ship during a voyage from February 11-21, 2020 (Sailing A) and was a 
confirmed COVID-19 case. As of March 7, 2020, there were 22 presumptive 
positive cases of COVID-19 among persons who were onboard Sailing A. 
The Grand Princess left San Francisco for a second sailing on February 
21 (Sailing B). Sixty-eight passengers and most of the crew from 
Sailing A were also on Sailing B. While testing of those who were 
onboard Sailing B continues, to date, 22 crew and 8 passengers have 
tested positive for COVID-19. As a result of the outbreak onboard the 
Grand Princess, the Federal government engaged in a massive effort to 
disembark and quarantine American passengers from the ship on four 
military bases to help prevent further transmission to the passengers' 
home communities. Passengers from Sailing A were from more than 30 U.S. 
states and 25 countries; Sailing B included passengers from over 50 
countries. More than 70 persons from this voyage have reported symptoms 
and require assessment and evaluation and additional confirmed cases in 
multiple states/countries are anticipated.

The Director Has Reason To Believe That Cruise Ship Travel May Continue 
To Introduce, Transmit, or Spread COVID-19

    Cruise ship travel markedly increases the risk and impact of the 
COVID-19 disease outbreak within the United States. Disembarkation of 
passengers at sequential ports may lead to disease transmission in 
those ports. Return of disembarked infected passengers to their 
communities could lead to widespread disease transmission. Cases that 
have been confirmed to date may have led to secondary transmission, 
including in a healthcare worker.
    Furthermore, the passenger population of cruises often includes a 
substantial number of older adults, meaning there is higher risk for 
COVID-19 morbidity and mortality. Industry trade publications report 
that 51% of cruise ship passengers are over the age of 50. The median 
age of passengers onboard the Grand Princess Sailing B, for example, 
was 66 and 1,200 passengers on the ship were over age 70. Given these 
demographics, many cruise passengers are at high risk for severe 
disease if they become infected.
    Beyond the risk to these individuals, the intensive care 
requirements for cruise ship passengers with severe disease stresses a 
healthcare system already overburdened and facing a shortage of beds 
needed for influenza and other seasonal and critical healthcare 
conditions. The addition of further cruise ship cases place healthcare 
workers at substantial increased risk. Specifically, these cases divert 
medical resources away from persons with other medical problems and 
other COVID-19 cases, consuming precious diagnostics, therapeutics, and 
protective equipment. Ongoing concerns with cruise ship transmission 
also draw valuable resources away from the immense Federal, state, and 
local effort to contain and mitigate the spread of COVID-19. Safely 
evacuating, triaging, quarantining, and repatriating cruise ship 
passengers involves complex logistics, incurs financial costs at all 
levels of government, and diverts resources away from larger efforts to 
suppress or mitigate the virus.

Coordination Efforts With the Cruise Ship Industry

    To address the continued and significant risks and burdens posed by 
ongoing cruise ship operations, CDC and other Federal agencies have 
engaged with representatives from

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Cruise Lines International Association (``CLIA''), the leading industry 
trade group. To that end, CLIA members and certain individual cruise 
lines have voluntarily taken steps to try to mitigate the impact of the 
spread of COVID-19. On March 13, 2020, CLIA and their associated 
members announced that all member cruise lines would voluntarily 
suspend cruise ship operations from U.S. ports of call for 30 days as 
public health officials and the Federal government continue to address 
COVID-19. The Federal government recognizes the enormity and importance 
of this action taken by CLIA and the commitment it demonstrates to 
protecting the health of both cruise ship passengers and the public at 
large. Following the example set by CLIA members, additional cruise 
lines have also voluntarily suspended operations from U.S. ports of 
call. Although the CLIA members and the additional cruise lines 
implementing a voluntary suspension of operations represent a large 
majority of the cruise industry, not all cruise lines or ships have 
announced a voluntary suspension of operations or that they will follow 
the important example set by CLIA members. This Order is intended to 
cover and specifically apply to those cruise lines or ships that do not 
undertake a voluntary suspension of operations. As a result, this Order 
specifically excludes from applicability any cruise line or ship that 
voluntarily suspends operations for the period of this Order, as CLIA 
members have done.

Findings and Immediate Action

    Accordingly, and consistent with 42 CFR 71.32(b), the Director of 
CDC (``Director'') finds evidence to support a reasonable belief that 
cruise ships are or may become infected or contaminated with a 
quarantinable communicable disease.\5\ This reasonable belief is based 
on information from epidemiologic and other data regarding the nature 
and transmission of COVID-19 on cruise ships from the recent outbreaks 
onboard the Diamond Princess, Grand Princess, and other cruise ships. 
As a result, cruise ship passengers may be infected with or exposed to 
COVID-19 by virtue of having been onboard a cruise ship at a time when 
cases of COVID-19 are being reported in significant numbers globally 
and specifically on cruise ships, when testing is available. The 
Director also finds that cruise ship travel may exacerbate the global 
spread of COVID-19. The scope of this pandemic is inherently and 
necessarily a problem that is international and interstate in nature, 
and cannot be controlled sufficiently by the cruise ship industry or 
individual state or local health authorities. Accordingly, under 42 CFR 
70.2, the Director determines that measures taken or likely to be taken 
by state and local health authorities regarding COVID-19 onboard cruise 
ships are inadequate to prevent the further interstate spread of the 
disease.
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    \5\ COVID-19 is a communicable disease for which quarantine is 
authorized under Section 361 of the Public Health Service Act (42 
U.S.C. 264) and 42 CFR 70.1, 71.1, as listed in Executive Order 
13295, as amended by Executive Orders 13375 and 13674.
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    The Director further determines that this Order provides public 
health authorities, in concert with the cruise ship industry, the 
necessary pause in operations to develop and implement an appropriate 
and robust plan to prevent and mitigate the spread of COVID-19, and 
acts to prevent the spread of the disease and ensure cruise ship 
passenger and crew health.
    Therefore, in accordance with Sections 361 and 365 of the Public 
Health Service Act (42 U.S.C. 264, 268) and 42 CFR 70.2, 71.32(b), for 
all cruise ships not voluntarily suspending operations for the period 
described below, it is ordered:
    1. Cruise ship operators shall be allowed to disembark passengers 
and crew members at ports or stations only as directed by the United 
States Coast Guard (USCG), in consultation with HHS/CDC personnel and, 
as appropriate, as coordinated with Federal, state, and local 
authorities.
    2. Cruise ship operators shall not reembark any crew member, except 
as approved by USCG, in consultation with HHS/CDC personnel, until 
further notice.
    3. Cruise ship operators shall not embark any new passengers or 
crew, except as approved by USCG, or other Federal authorities as 
appropriate, in consultation with HHS/CDC personnel.
    4. Cruise ship operators shall not commence or continue operations 
(e.g., shifting berths, moving to anchor, or discharging waste), except 
as approved by USCG, in consultation with HHS/CDC personnel, until 
further notice.
    5. While in port, the cruise ship operator shall observe health 
precautions as directed by HHS/CDC personnel.
    6. The cruise ship operator shall comply with all HHS/CDC, USCG, 
and other Federal agency instructions to follow CDC recommendations and 
guidance for any public health actions relating to passengers, crew, 
ship, or any article or thing on board the ship, as needed, including 
by making ship's manifests and logs available and collecting any 
specimens for COVID-19 testing.
    7. This order does not prevent the periodic reboarding of the ship 
by HHS/CDC personnel and/or USCG and/or other Federal, state, or local 
agencies or the taking on of ships' stores and provisions under the 
supervision of HHS/CDC personnel and/or USCG.
    8. This order does not prevent the ship from taking actions 
necessary to maintain the seaworthiness or safety of the ship, or the 
safety of harbor conditions, such as movement to establish safe 
anchorage, or as otherwise directed by USCG personnel.
    CDC may modify this order by an updated publication in the Federal 
Register or by posting an advisory to follow at www.cdc.gov.

Authority

    The authority for these orders is Sections 361 and 365 of the 
Public Health Service Act (42 U.S.C. 264, 268) and 42 CFR 70.2, 
71.32(b).

    Dated: March 19, 2020.
Robert R. Redfield,
Director, Centers for Disease Control and Prevention.
[FR Doc. 2020-06166 Filed 3-23-20; 8:45 am]
BILLING CODE 4163-18-P