[Federal Register Volume 85, Number 140 (Tuesday, July 21, 2020)]
[Notices]
[Pages 44085-44094]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2020-15810]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention


No Sail Order and Suspension of Further Embarkation; Second 
Modification and Extension of No Sail Order and Other Measures Related 
to Operations

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 U.S. Department of Health and Human Services (HHS), 
announces a second modification and extension of the No Sail Order and 
Other Measures Related to Operations that was issued on April 15, 2020. 
This Order applies to cruise ships defined as commercial, non-cargo, 
passenger-carrying vessels with the capacity to carry 250 or more 
individuals (passengers and crew) and with an itinerary anticipating an 
overnight stay onboard or a 24-hour stay onboard for either passengers 
or crew, that are operating in international, interstate, or intrastate 
waterways, subject to the jurisdiction of the United States. This Order 
shall additionally apply to cruise ships operating outside of U.S. 
waters if the cruise ship operator intends for the ship to return to 
operating in international, interstate, or intrastate waterways, 
subject to the jurisdiction of the United States during the period that 
this Order is in effect.

DATES: This action was effective July 16, 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: This Order renews the No Sail Order and 
Other Measures Related to Operations signed by the CDC Director on 
March 14, 2020, as further modified and extended effective April 15, 
2020, subject to the modifications and additional stipulated conditions 
as set forth in this Order.
    This Order shall remain in effect until the earliest of (1) the 
expiration of the Secretary of Health and Human Services' declaration 
that COVID-19 constitutes a public health emergency; (2) the CDC 
Director rescinds or modifies the order based on specific public health 
or other considerations; or (3) September 30, 2020.
    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 (HHS)

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)

Second Modification and Extension of No Sail Order and Other Measures 
Related to Operations

Executive Summary

    The coronavirus disease 2019 (COVID-19) pandemic continues to 
spread rapidly around the world with no treatment or vaccine, with over 
12.5 million confirmed cases and over 560,000 confirmed deaths 
worldwide as of July 12, 2020. On July 12, 2020, 230,000 new COVID-19 
cases were reported, the largest single-day tally worldwide since the 
epidemic began. It took 3 months to reach the first million cases of 
COVID-19, but during one week in June 2020, 1 million new cases were 
reported worldwide.
    Since HHS/CDC's original No Sail Order, signed on March 14, 2020, 
which restricted the embarkation of passengers, CDC has worked to 
control COVID-19 on cruise ships that remained at sea, while protecting 
against further introduction and spread of COVID-19 into U.S. 
communities. As of July 10, 2020, CDC has expended an estimated 38,000 
person-hours on the cruise ship COVID-19 response since March 14, 
2020--in addition to the thousands of hours invested by other HHS 
components, other U.S. government agencies, and state and local 
authorities. CDC continues to have regular conversations by phone and 
email with cruise lines, often daily.
    Cumulative CDC data from the period of March 1 to July 10, 2020 
reveal a total of 2,973 COVID-19 or COVID-like illness cases on cruise 
ships, in addition to 34 deaths. These data have also revealed a total 
of 99 outbreaks on 123 different cruise ships, meaning that 80% of 
ships within U.S. jurisdiction were affected by COVID-19 during this 
time frame. In addition, 9 ships still have ongoing or resolving COVID-
19 outbreaks on board.
    The challenges described in this document highlight the need for 
further action prior to cruise ships' resuming

[[Page 44086]]

passenger operations. CDC supports the decision by the Cruise Line 
International Association (CLIA) and its members to voluntarily extend 
the suspension of operations for passenger cruise ship travel. However, 
because not all cruise ship operators subject to the No Sail Order are 
members of CLIA or have made similar commitments, CDC is extending its 
No Sail Order to ensure that passenger operations do not resume 
prematurely.

Previous Orders and Incorporation by Reference

    This Order renews the No Sail Order and Other Measures Related to 
Operations signed by the CDC Director on March 14, 2020,\1\ as further 
modified and extended effective April 15, 2020 \2\--subject to the 
modifications and additional stipulated conditions as set forth in this 
Order.
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    \1\ No Sail Order and Suspension of Further Embarkation. 
www.federalregister.gov/documents/2020/03/24/2020-06166/no-sail-order-and-suspension-of-further-embarkation. Last accessed June 24, 
2020.
    \2\ No Sail Order and Suspension of Further Embarkation; Notice 
of Modification and Extension and Other Measures Related to 
Operations. www.federalregister.gov/documents/2020/04/15/2020-07930/no-sail-order-and-suspension-of-further-embarkation-notice-of-modification-and-extension-and-other. Last accessed June 24, 2020.
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    This Order shall remain in effect until the earliest of (1) the 
expiration of the Secretary of Health and Human Services' declaration 
that COVID-19 constitutes a public health emergency; (2) the CDC 
Director rescinds or modifies the Order based on specific public health 
or other considerations; or (3) September 30, 2020.
    The findings and other evidence relied upon in issuing the March 14 
and April 15, 2020 Orders are incorporated herein by reference. Any 
ambiguity between the March 14, and April 15, 2020 Orders, as modified 
by the current Order, shall be resolved in favor of the current Order.

Statement of Intent

    This Order shall be interpreted and implemented in a manner as to 
achieve the following paramount objectives:
     Preserving human life;
     Preserving the health and safety of cruise ship crew 
members, port personnel, and communities;
     Preventing the further introduction, transmission, and 
spread of COVID-19 into and throughout the United States;
     Preserving the public health and other critical resources 
of Federal, State, and local governments;
     Preserving hospital, healthcare, and emergency response 
resources within the United States; and
     Maintaining the safety of shipping and harbor conditions.

Applicability

    This Modification and Extension of No Sail Order and Other Measures 
Related to Operations shall apply only to the subset of carriers \3\ 
described below and hereinafter referred to as ``cruise ships'':
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    \3\ Carrier is defined by 42 CFR 71.1 to mean, ``a ship, 
aircraft, train, road vehicle, or other means of transport, 
including military.''

    All commercial, non-cargo,\4\ passenger-carrying vessels with 
the capacity \5\ to carry 250 \6\ or more individuals (passengers 
and crew) and with an itinerary anticipating an overnight stay 
onboard or a twenty-four (24) hour stay onboard for either 
passengers or crew that are operating in international, interstate, 
or intrastate waterways, subject to the jurisdiction of the United 
States.\7\
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    \4\ 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.
    \5\ A ship's capacity shall be determined based on the number of 
persons listed in the U.S. Coast Guard Certificate of Inspection 
issued in accordance with 46 CFR 2.01-5 and that was in effect on 
the date of the signing of this current Order.
    \6\ Based on substantial epidemiologic 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 on board a ship increase, 
certain recommended mitigation efforts such as social distancing 
become more difficult to implement. In light of the demonstrated 
rapid spread of COVID-19 in cruise ship settings, application of 
this Order to vessels carrying 250 or more individuals is a prudent 
and warranted public health measure. Moreover, during the early part 
of 2020, management of COVID-19 cases in addition to care needs 
resulting from the seasonal influenza epidemic placed an extreme 
burden on public health and healthcare systems and this Order will 
help avoid further stressing those systems.
    \7\ 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.

    This Order shall additionally apply to cruise ships operating 
outside of U.S. waters if the cruise ship operator intends for the ship 
to return to operating in international, interstate, or intrastate 
waterways, subject to the jurisdiction of the United States during the 
period that this Order is in effect.

Definitions

    The following definitions shall apply for the purposes of this 
Order:
    COVID-19 means the disease caused by the coronavirus SARS-CoV-2.
    ``Operations,'' ``Operate,'' and ``Operating'' means any action by 
a cruise ship operator (e.g., shifting berths, moving to anchor, 
discharging waste, making port, or embarking or disembarking passengers 
or crew) to bring or cause a cruise ship to be brought into or transit 
in or between any international, interstate, or intrastate waterways, 
or maintaining a ship in layup status,\8\ subject to the jurisdiction 
of the United States.
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    \8\ Layup means reducing cruise ship operations to those levels 
needed to maintain essential machinery and equipment so that the 
ship may be returned to service.
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    ``Operator'' means the Master of the vessel (cruise ship) and any 
other crew member responsible for cruise ship operations and 
navigation, as well as any person or entity (including a corporate 
entity) that authorizes or directs the use of a cruise ship (e.g., as 
owner, lessee, or otherwise). A cruise ship operator may be either the 
cruise ship captain or the cruise line to which the cruise ship 
belongs, or both. The term ``Operator'' as used in this Order further 
incorporates the terms ``company,'' ``designated person,'' and 
``responsible person'' as defined in 33 CFR Sec.  96.120.

Events Necessitating the March 14 and April 15, 2020 Orders

    On January 20, 2020, the Diamond Princess cruise ship departed 
Yokohama, Japan. On January 25, 2020, a symptomatic passenger departed 
the ship in Hong Kong, where he was later confirmed to have COVID-19. 
Upon the ship's return to Yokohama, Japanese authorities quarantined 
all passengers and crew on board the ship. Among the 3,711 Diamond 
Princess passengers and crew, 712 (19.2%) were subsequently confirmed 
to have COVID-19, 37 required intensive care, and nine died. Following 
this outbreak, two voyages of the Grand Princess cruise ship were 
ultimately associated with 159 confirmed COVID-19 cases, including 
eight deaths.\9\
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    \9\ Moriarty LF, Plucinski MM, Marston BJ, et al. Public Health 
Responses to COVID-19 Outbreaks on Cruise Ships--Worldwide, 
February-March 2020. MMWR Morb Mortal Wkly Rep 2020;69:347-352. 
https://www.cdc.gov/mmwr/volumes/69/wr/mm6912e3.htm. Last accessed 
June 25, 2020.
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    Because of these events, and the increased risk of transmission on 
cruise ships, on March 14, 2020, the CDC Director issued a No Sail 
Order and Other Measures Related to Operations directing cruise ships 
not voluntarily suspending operations to comply with certain measures. 
This followed a March 13, 2020, announcement by CLIA, the leading 
industry trade group, that its members would voluntarily suspend cruise 
ship operations. On March 17, 2020, CDC issued a Level 3 Travel

[[Page 44087]]

Health Notice warning all travelers to defer cruise travel worldwide 
based on widespread ongoing transmission of COVID-19.\10\ Despite the 
announcement by CLIA, the application of the March 14, 2020 Order, and 
the Level 3 Travel Health Notice, cruise ships continued to be 
associated with COVID-19 outbreaks. Between March 14 and April 15, 
2020, COVID-19 outbreaks were reported on several additional cruise 
ships. These included the Costa Cruises ships Costa Magica and Costa 
Favolosa; Holland America Line's Zaandam; the Celebrity Eclipse; the 
Disney Wonder; and Princess Cruises' Coral Princess.
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    \10\ CDC Travel Health Notice, COVID-19 and Cruise Ship Travel, 
at: https://wwwnc.cdc.gov/travel/notices/warning/coronavirus-cruise-ship (originally posted, March 17, 2020). Last accessed June 25, 
2020.
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    COVID-19 outbreaks on cruise ships required 27 notifications by CDC 
to international, state, and local health departments for over 11,000 
cruise ship passengers requiring contact tracing, which resulted in 
countless hours of work for numerous already-burdened public health 
officials. This number exceeded that of the number of contacts 
identified from flight investigations since the beginning of the 
pandemic. Medical evacuation efforts necessitated by these outbreaks 
required resource intensive operations that involved multiple small 
boats to ferry contagious crew to shore and high levels of coordination 
between Federal, State, and local public health, maritime, and other 
governmental authorities. Response efforts drew valuable resources away 
from the immense Federal, State, and local efforts to contain and 
mitigate the spread of COVID-19. State and local public health 
officials further stated that they faced an increasing burden 
supporting cruise ships attempting to make port with ill passengers or 
crew and struggled to repatriate passengers and crew while also 
protecting the limited medical assets available to their communities. 
The intensive care requirements for infected passengers and crew in 
need of life-saving critical care also greatly stressed an already 
overtaxed healthcare system that at the time was facing shortages of 
masks, test kits, beds, and ventilators needed to respond to COVID-19.
    Accordingly, to protect public health and safety and prevent the 
further introduction, transmission, and spread of COVID-19 into and 
throughout the United States, the CDC Director issued an Order 
modifying and extending the previous March 14, 2020 Order, which became 
effective on April 15, 2020.

Events Since the Issuance of the April 15, 2020 Extension

    Under the April 15, 2020 Extension, as a condition of obtaining 
controlled free pratique to continue to engage in cruise ship 
operations in any international, interstate, or intrastate waterways 
subject to the jurisdiction of the United States, cruise ship 
operations were limited, and cruise lines were required to submit plans 
to prevent, mitigate, and respond to the spread of COVID-19 on board to 
ensure a safe work environment and disembarkation for crew members. The 
No Sail Order (NSO) response plans had to minimize to the greatest 
extent possible any impact on U.S. government operations or the 
operations of any State or local government, or the U.S. healthcare 
system. While working with cruise ship operators to ensure the 
completeness and accuracy of these response plans, CDC allowed crew 
members to disembark from cruise ships in U.S. waters and return home 
if cruise ship operators attested to complying with requirements to 
disembark crew members in such a manner as to minimize the risk to 
other travelers and communities. Among other requirements, safe 
disembarkation meant not using commercial transport for disembarking 
crew, screening disembarking crew members for illness, ensuring that 
crew members with known exposure to COVID-19 traveled separately from 
those with no known exposure, providing face masks or cloth face 
coverings to disembarking crew members or confirming that they had 
their own face coverings, and instructing disembarking crew members to 
stay home for 14 days and continue to practice social distancing after 
reaching their final destination. This disembarkation process proved 
cumbersome and labor intensive; it is still ongoing even now with over 
14,000 crew remaining onboard, due in part to limited charter flight 
availability, cruise lines' cost burdens, and some destination 
countries' refusing to accept returning crew.
    Following the April 15, 2020 Extension, CDC published its Interim 
Guidance for Mitigation of COVID-19 Among Cruise Ship Crew During the 
Period of the No Sail Order to assist cruise ship operators in 
preventing, detecting, and medically managing confirmed and suspected 
SARS-CoV-2 infections and exposures among crew members.\11\ During this 
period, CDC also further assisted cruise ship operators with 
humanitarian medical evacuations for people in need of lifesaving 
support. As of July 10, 2020, CDC has worked with cruise ship operators 
to assist in the disembarkation and safe return home of approximately 
8,825 crew members, including 314 U.S. citizens and residents.
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    \11\ CDC, Interim Guidance for Mitigation of COVID-19 Among 
Cruise Ship Crew During the Period of the No Sail Order at: https://www.cdc.gov/quarantine/cruise/management/interim-guidance-no-sail-order.html
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    Under the April 15, 2020 Extension, CDC established an enhanced 
surveillance process to provide a more complete picture of COVID-19 
activity on cruise ships. CDC required weekly submission of the 
``Enhanced Data Collection (EDC) During COVID-19 Pandemic Form.'' The 
EDC form was used to conduct surveillance for COVID-19 among crew who 
remained on board cruise ships based on cumulative reports of acute 
respiratory illness (ARI),\12\ influenza-like illness (ILI),\13\ 
pneumonia, and other clinical indicators. As of July 10, 2020, EDC 
reports have shown a total of 4,590 polymerase chain reaction (PCR) 
tests performed, 281 (6%) of which were positive, 18 hospitalizations, 
2 instances of mechanical ventilation, and 9 medical evacuations for 
crew on ships within U.S. jurisdiction since April 15, 2020. CDC 
recommended that ships' surveillance include routine testing for SARS-
CoV-2 infection, including intermittent testing of a random sample of 
symptomatic and asymptomatic crew members.
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    \12\ Acute Respiratory Illness (ARI) is defined as the presence 
of cough, sore throat, or rhinorrhea in the absence of fever.
    \13\ Influenza-like Illness (ILI) is defined as fever (100.4 
[deg]F [38 [deg]C]) plus either cough or sore throat in the absence 
of another diagnosis.
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    In addition to reviewing the NSO response plans, CDC continued to 
update its Interim Guidance as new information became available; 
provided technical expertise to ships with ongoing outbreaks; created 
cruise ship-specific websites to inform crew members, the public, and 
partners; and reviewed hundreds of attestations for safe disembarkation 
and transfer of crew members.
    CDC also established a ``COVID-19 Color Coding System'' for ships 
applicable to cruise ship operators with an appropriate NSO response 
plan for crew management. Classification of ships under this system 
requires cruise company officials to sign an acknowledgment of the 
completeness and accuracy of their NSO response plans upon completion 
of CDC review of the plan. CDC additionally provides a provisional 
color status for ships belonging to cruise lines that do not yet

[[Page 44088]]

have a complete and accurate plan. CDC assesses the status of a ship by 
reviewing surveillance data from the weekly EDC form.
     ``Green'' ship status means that a ship has no confirmed 
cases of COVID-19 or COVID-like illness for 28 \14\ consecutive days 
among crew members onboard. In addition, cruise ship operators must 
sign an attestation that if the ship received ship-to-ship transfers, 
the crew members came from a ship with no cases of COVID-19 or COVID-
like illness within the 28 days before the transfer occurred and that 
land-based crew embarking the ship were immediately quarantined for 14 
days. Ships achieving ``Green'' status may use commercial travel to 
disembark crew members and may lessen onboard restrictions to allow 
crew to resume some daily interactions with fellow crew members, 
including social gatherings, group meetings, and use of group settings 
such as crew bars and gyms.
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    \14\ The 28-day period for COVID-19 is based on the public 
health standard of 2 incubation periods, which is commonly used to 
determine that a communicable disease of public health concern is no 
longer circulating in a location.
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     ``Yellow'' ship status means that a previously designated 
``Green'' ship reported one or more COVID-like illness cases onboard 
and that testing for COVID-19 is pending. If crew with COVID-like 
illness are not tested by PCR or if results are not available within 1 
week of the case being reported, then the ship's status changes to 
``Red.'' Ships with a ``Yellow'' status are required to resume all 
preventive measures, with the exception of requiring crew members to 
remain in cabins as much as possible during non-working hours, and are 
no longer eligible for commercial travel of disembarking crew.
     ``Red'' ship status means that one or more cases of 
laboratory-confirmed COVID-19 or COVID-like illness have occurred 
onboard within the past 28 days, that ship-to-ship transfers occurred 
from a ship that was not ``Green,'' that embarking crew were not 
immediately quarantined for 14 days, or that the ship failed to submit 
one or more weekly EDC forms during the past 28 days. Ships with a 
``Red'' status must follow all preventive measures, including requiring 
crew members to remain in cabins as much as possible during non-working 
hours, until the ship's status changes to ``Green.''
    The status of the cruise ship operator NSO response plans and the 
color-coding status for individual ships are updated weekly at https://www.cdc.gov/coronavirus/2019-ncov/travelers/crew-disembarkations-commercial-travel.html.

Difficulty of Cruise Ship Operators in Submitting Appropriate Response 
Plans

    As of April 29, 2020, CDC had received NSO response plans from 
seven cruise ship operators representing approximately 110 cruise ships 
or about 95% of cruise ships subject to the April 15, 2020 Extension. 
These operators included Carnival Corporation,\15\ Royal Caribbean 
Cruise Line, Norwegian Cruise Lines, Disney Cruise Lines, Virgin 
Voyages, Windstar Cruises,\16\ and Bahamas Paradise Cruise Lines. MSC 
Cruises submitted an NSO response plan on May 7, 2020, covering three 
of its ships.
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    \15\ On May 24 and again on June 3, 2020, Carnival Corporation 
communicated to CDC that none of its operating companies had any 
ships in U.S. waters, nor did they expect to have any ships 
returning to U.S. waters before the end of the NSO period. 
Accordingly, CDC has held its review of the Carnival response plan 
in abeyance.
    \16\ While Windstar Cruises initially submitted an NSO response 
plan for one of its ships, it later withdrew its ships from U.S. 
waters and stated it had no intention of returning those ships to 
U.S. waters during the period of the NSO. Accordingly, CDC has held 
its review of the Windstar response plan in abeyance.
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    In order to manage the public health crisis occurring at sea, 
including analyzing epidemiologic data, reviewing and responding to NSO 
response plan submissions, and managing the safe disembarkation of 
crew, CDC created a Maritime Unit (MU) staffed with 30 subject matter 
experts. The MU developed an email box staffed 7 days a week to handle 
the volume of cruise-related inquires received by CDC during the 
pandemic and established daily communications with cruise lines. For 
the plan review process, two MU team members were assigned to review 
each plan and communicate with the submitting cruise line. The work-
intensive plan review process has involved assessing hundreds of 
documents from each cruise line to determine if they completely and 
adequately addressed the elements of an appropriate plan described in 
the April 15, 2020 Extension. Most plans needed two complete reviews 
and revisions, with one plan requiring seven rounds of revisions.
    The plans as initially submitted by the cruise lines were 
incomplete and did not fully meet all the requirements of the April 15, 
2020 Extension. Areas of major concern included insufficient details 
for monitoring crew onboard; unspecified quantities of personal 
protective equipment, medical and laboratory supplies, and fever-
reducing medications; incomplete plans to disembark asymptomatic crew 
safely; missing shoreside and onboard testing agreements, supplies, and 
protocols; not isolating symptomatic crew; failing to close self-
service buffets, salons, gyms, and recreational water facilities; lack 
of ability to provide the required level of medical care; and 
implementing social distancing and other restrictions only when 
physically present in U.S. waters. CDC has provided feedback to assist 
cruise lines in determining how best to address these concerns.
    By July 10, 2020, cruise ship operators had reduced the number of 
cruise ships they proposed to operate in U.S. waters to approximately 
49 ships, with some operators choosing to temporarily withdraw all 
ships remaining in U.S. waters. As of July 10, 2020, one cruise ship 
operator representing only one cruise ship operating in U.S. waters had 
an NSO response plan meeting all the elements described in the April 
15, 2020 Extension: Bahamas Paradise Cruise Line.

Examples of Potential Non-Compliance With the Extended No Sail Order

    The difficulty of cruise ship operators in submitting appropriate 
NSO response plans was compounded by several instances of potential 
non-compliance with the requirements of the April 15, 2020 Extension. 
On April 29, 2020, CDC sent a Notice of Potential Non-Compliance with 
the No Sail Order to Holland America Line in response to attempts by a 
crew member to disembark from the Oosterdam without cruise line 
officials' attesting that precautions to protect public health had been 
taken. This attempted disembarkation without appropriate precautions 
required CDC, U.S. Coast Guard, U.S. Customs and Border Protection, 
California Department of Public Health, Los Angeles County Health 
Department, and Los Angeles Police Department to leverage valuable 
resources and work together to enforce the NSO. In response, Holland 
America Line stated that the incident was the result of confusion 
between Oosterdam administrative personnel and local port agents. As a 
corrective measure, Holland America Line spoke to the local agents at 
the Port of Los Angeles and instructed them not to approve further 
disembarkations unless specifically instructed by shoreside management.
    On May 11, 2020, CDC sent a ``Dear Colleague'' letter to cruise 
ship operators. The letter stated that CDC was aware of allegations of 
cruise ship non-compliance with the April 15, 2020 Extension through 
social media and other sources. Alleged instances of non-compliance 
included not adhering to

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social distancing protocols; unauthorized crew transfers while outside 
of U.S. waters; not submitting weekly surveillance data (through the 
EDC form); not relocating all crew to single-occupancy cabins with 
private bathrooms; not cancelling all social gatherings; and not 
closing all crew bars, gyms, or other group settings. The letter 
requested that cruise ship operators investigate and report instances 
of non-compliance to CDC and explain in writing what corrective actions 
had been taken to ensure future compliance. Only two cruise ship 
operators, Virgin Voyages \17\ and Royal Caribbean Cruise Ltd (RCL), 
and CLIA \18\ responded in writing.
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    \17\ On May 13, 2020, Virgin Voyages submitted a report listing 
non-conformities with the NSO. As a corrective measure, it added its 
NSO response plan in its entirety to its company Safety Management 
System and further advised its ships that any proposed deviations 
required advance approval.
    \18\ On May 14, 2020, CLIA responded to the letter requesting a 
meeting with the CDC Director to further engage with CDC. 
Subsequently, on June 11, the CDC Director hosted a teleconference 
with CLIA and other members of the cruise line industry during which 
CDC responded to questions submitted by CLIA relating to procedures, 
clarifications, and crew transfers and repatriations under the NSO.
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    On May 13, 2020, RCL responded to the May 11 ``Dear Colleague'' 
letter stating that it had investigated the allegations in the six 
areas described in the letter and believed that it was in full 
compliance. On June 9, 2020, CDC sent a letter to RCL stating that on 
May 20, 2020, CDC had received attestations for 64 ship-to-ship 
transfers occurring from May 12 to May 20 for 21 ships in both the 
Royal Caribbean International and Celebrity Cruises, Inc. brands. While 
RCL had originally represented that these transfers were for crew who 
met CDC's criteria for ``recovered'' from COVID-19, RCL in later 
communications acknowledged that transferred crew had not met these 
criteria. Furthermore, while RCL officials did submit multiple 
attestations for these transfers, the attestations were submitted 
belatedly after the transfers were complete. The submitted attestations 
were also per ship, not per disembarkation, and lacked a required 
disembarkation date. For these reasons, the attestations were 
inconsistent with CDC's Interim Guidance. On June 15, 2020, RCL 
responded stating that these incidents were due to a misinterpretation 
of the Interim Guidance and that it would adjust its practices in the 
future.
    On May 22, 2020, CDC sent a Notice of Potential Non-Compliance with 
the No Sail Order to Norwegian Cruise Line Holdings Ltd (NCLH). The 
notice stated that CDC had become aware of reports of alleged non-
compliance on several NCLH cruise ships including the Norwegian Escape, 
Norwegian Epic, Norwegian Joy, Oceania Marina, and Seven Seas 
Navigator. These allegations included not adhering to social distancing 
protocols, not cancelling all social gatherings, not relocating all 
crew to single-occupancy cabins with private bathrooms, not suspending 
self-service buffets, and crew not wearing cloth face coverings when 
outside individual cabins. CDC further requested that NCLH address the 
veracity of these allegations and outline what corrective steps it 
would take to prevent reoccurrences.
    On May 29, 2020, NCLH sent a response to CDC's May 22 letter. It 
cited the difficulty in achieving and mandating social distancing among 
crew members at all times. NCLH had modified dining venues, seating, 
and meal service to facilitate social distancing, but allowed a 
``maximum of 4 persons at a table'' onboard all ships. It had also 
``designated large open-air area spaces to be utilized by crew at their 
leisure, limiting the amount of people and encouraging social 
distancing.'' NCLH stated that ships operating with reduced manning 
limited its ability to operate without self-service buffets. Lastly, 
NCLH stated that it believed it had exceeded CDC's guidance ``by not 
just asking but encouraging our crew to wear face coverings.'' NCLH's 
response did not specifically address what corrective actions it would 
take to align its practices with CDC's Interim Guidance and did not 
address the issue of not relocating crew to single-occupancy cabins 
with private bathrooms.
    On July 2, 2020, CDC sent NCLH an additional notice requesting that 
it take immediate corrective action to align its practices with the 
April 15, 2020 Extension and CDC's Interim Guidance. CDC asked NCLH to 
explain with greater specificity what steps it had taken to instruct 
crew across its fleet to wear cloth face coverings when outside of 
individual cabins (e.g., through posted signage or verbal reminders). 
CDC further noted that depending on table size, allowing a maximum of 4 
persons at a table did not ensure maintaining a minimum distance of 2 
meters (6 feet) from one another during meal service. Furthermore, to 
the extent that NCLH had allowed crew to gather in any group setting, 
it was advised to discontinue this practice until ``Green'' status 
onboard the ship had been achieved. Moreover, CDC advised NCLH that 
operating a self-service meal operation was considered a high-risk 
practice because of the role of fomites in transmission of COVID-19 and 
advised it to discontinue this practice on all ships across its fleet. 
Lastly, CDC requested NCLH explain whether it had at any time not 
relocated all crew to single-occupancy cabins with private bathrooms.
    On July 9, 2020, CDC received NCLH's response to its July 2 letter. 
NCLH stated that it had implemented new procedures to mandate the 
wearing of face coverings by crew members when outside of individual 
cabins. To reinforce this mandate, it had instituted ``mask patrols'' 
comprised of security team members who were authorized to order crew 
members back to their cabins if seen not properly masked in public 
areas. NCLH also confirmed that it had discontinued its previous 
practice of allowing up to four crewmembers to dine together at the 
same table. It further confirmed that it understood CDC's color-coding 
system and noted that all gyms, bars, and lounges fleetwide were closed 
and remained closed since the inception of the NSO. NCLH had also 
disseminated CDC materials in written form fleetwide to all crew 
members, instead of conducting in person meetings or trainings on 
COVID-19. NCLH further confirmed that it had discontinued self-service 
meal operations and in lieu of such self-service operations had 
designated crew members to assist other crew members during meal 
service. Lastly, while it had initially found housing of all crew 
members in single-occupancy cabins to be infeasible based on the number 
of crew members on board, it confirmed that all remaining crew members 
who had not repatriated were currently housed in single occupancy 
cabins with private bathrooms.
    On June 10, 2020, CDC sent a Notice of Potential Non-Compliance 
with the No Sail Order to Disney Cruise Lines (DCL) relating to 
inadequate spacing and mixing of staterooms intended for ``well'' and 
``sick'' crew and potential failure to discontinue buffet meal service 
during an ongoing COVID-19 outbreak. These concerns were based on 
records and photographs received by CDC from the Disney Wonder to 
document compliance with elements outlined in the April 15, 2020 
Extension. CDC also sent DCL a separate letter documenting its concerns 
regarding a sustained outbreak of COVID-19 or COVID-like illness among 
crew onboard the Disney Wonder during the period of the April 15, 2020 
Extension. Since April 15, 2020, CDC had received reports of 181 cases 
of confirmed COVID-19 and 19 case of COVID-like illness associated with 
this

[[Page 44090]]

ship. Of particular concern was the fact that this outbreak had 
continued over a ten-week time frame, including before the April 15, 
2020 Extension, with the last date of COVID-like illness reported to 
CDC on May 25, 2020.
    On June 24, 2020, DCL responded that inadequate spacing and mixing 
of staterooms intended for ``well'' and ``sick'' crew occurred because 
of the challenges of transferring asymptomatic, symptomatic, and COVID-
19-positive crew members between rooms and limited availability of 
vacant staterooms with balconies. DCL also denied that an ``active'' 
buffet meal service was in place and affirmed that crew members would 
point out desired meal items and then have other crew members serve 
those items to them on a plate. In regard to the outbreak onboard the 
Disney Wonder, DCL asserted that any discrepancies in reporting 
positive test results to the CDC were due to inadvertent error. As a 
corrective action, DCL stated that it had reviewed and reinforced the 
proper procedures for reporting of illness to the CDC. In describing 
what factors may have led to the magnitude and duration of this 
outbreak, DCL noted that numerous crew members who subsequently tested 
positive for COVID-19 were asymptomatic and that some of these crew 
members served as essential crew and were not quarantined in their 
rooms until the results of ship-wide testing were received.

Actions Taken by Other Countries in Regard to Cruise Ship Travel

    A number of countries have taken aggressive steps to mitigate the 
risks of COVID-19 exacerbated by cruise ship travel. On March 9, 2020, 
Canada's Chief Public Health Officer issued a formal health advisory 
asking all Canadians to avoid travelling on cruise ships because the 
ships represent a high-risk environment for viral transmission of 
COVID-19. On March 19, 2020, the Canadian Government issued Ship Safety 
Bulletin No. 05/2020: Deferral of the Canadian Cruise Ship Season for 
Vessels Capable of Carrying 500 Persons or More until July 1, 2020.\19\ 
These regulations restricted cruise ships capable of carrying 500 or 
more persons, including both passengers and crew members from accessing 
ports managed by port authorities, public ports, public port 
facilities, and the St. Lawrence Seaway until July 1, 2020. On May 29, 
2020, these restrictions were extended to cruise ships with overnight 
accommodations carrying more than 100 people operating in Canadian 
waters until October 31, 2020.
---------------------------------------------------------------------------

    \19\ Deferral of the Canadian Cruise Ship Season for Vessels 
Capable of Carrying 500 Persons or More until July 1, 2020--SSB No.: 
05/2020. www.tc.gc.ca/eng/marinesafety/bulletins-2020-05-eng.htm. 
Last accessed June 24, 2020.
---------------------------------------------------------------------------

    On March 18, 2020, the Governor-General of the Commonwealth of 
Australia declared a human biosecurity emergency that included a ban on 
international cruise ships entering Australian ports.\20\ On May 15, 
2020, the Governor-General extended the human biosecurity emergency 
period for an additional three months, from June 17 to September 17, 
2020.\21\ This enabled the Minister for Health on May 20, 2020, to 
extend a prohibition on the arrival at any Australian port of any 
international cruise ship that had left a foreign port. These 
restrictions include direct arrivals and round-trip cruises. On May 22, 
2020, the restriction on cruise ships entering Australian waters was 
extended for a further three months until September 17, 2020. Under 
this restriction, any cruise ship capable of carrying more than 100 
passengers is prohibited from operating cruises in Australia. When this 
restriction went into effect on March 27, 2020, there were 28 
international cruise ships in Australian waters. Under the direction of 
the Australian Border Force, these ships and their crew safely 
departed.
---------------------------------------------------------------------------

    \20\ COVID-19 Legislative response--Human Biosecurity Emergency 
Declaration Explainer. www.aph.gov.au/About_Parliament/
Parliamentary_Departments/Parliamentary_Library/FlagPost/2020/March/
COVID-19_Biosecurity_Emergency_Declaration. Last accessed June 24, 
2020.
    \21\ Cruise Ship Prohibition Extended. www.newsroom.abf.gov.au/
releases/cruise-ship-prohibition-extended. Last accessed June 24, 
2020.
---------------------------------------------------------------------------

    In addition, as of July 10, 2020, numerous countries have 
restricted passenger cruise ship travel to some degree. These include 
Aruba, Barbados, Bermuda, British Virgin Islands, Cayman Islands, 
Dominican Republic, Greece, Grenada, Honduras, Norway, Panama, 
Seychelles, and Spain.

Supplemental Information Relating to COVID-19 Transmission Onboard 
Cruise Ships

    As of July 10, 2020, CDC has recorded approximately 99 outbreaks of 
COVID-19 onboard 123 ships within U.S. jurisdiction \22\ including 958 
confirmed cases, 2,015 suspect/probable cases and 34 deaths. Of the 49 
ships currently operating or planning to operate in U.S. waters during 
the period of the April 15, 2020 Extension, COVID-19 activity onboard 
continues and there still remain 10 ``Provisionally Red'' ships (i.e., 
reporting at least one confirmed case of COVID-19 or COVID-like illness 
in the past 28 days).
---------------------------------------------------------------------------

    \22\ The U.S. Coast Guard considers certain ships operating 
outside of U.S. waters subject to their jurisdiction for emergency 
response purposes. These ships are not included in CDC's 
calculations.
---------------------------------------------------------------------------

    Since the issuance of the April 15, 2020 Extension, cruise ships 
with significant outbreaks involving passengers and crew, such as the 
Celebrity Eclipse (92 confirmed COVID-19 cases, 8 suspect/probable 
COVID-19-like illness cases) and the Coral Princess (29 confirmed, 107 
suspect/probable, and 5 deaths), arrived on U.S. shores as other 
countries around the world closed their ports to cruise ships.\23\ 
These outbreaks not only endangered those onboard and at seaports, but 
also exposed travelers and communities throughout the world as sick and 
exposed passengers from ships like the Zandaam \24\ (10 confirmed, 233 
suspect/probable, 7 deaths), Ruby Princess, and Costa Luminosa 
traversed international airports, boarded planes, and returned to their 
homes. The CDC does not have official case counts for the Costa 
Luminosa and Ruby Princess, which docked in foreign seaports; however, 
the media have reported that these two ships are responsible for a 
significant number of cases and deaths.\14\ These outbreaks have 
continued in crew members on ships like the Disney Wonder, on which a 
COVID-19 outbreak spanned 10 weeks and included 229 confirmed and 43 
COVID-like illness cases among crew.
---------------------------------------------------------------------------

    \23\ The Pandemic at Sea. www.washingtonpost.com/graphics/2020/politics/cruise-ships-coronavirus/. Last accessed June 18, 2020.
    \24\ The Pariah Ship. www.bloomberg.com/features/2020-zaandam-pariah-ship/. Last accessed June 18, 2020.
---------------------------------------------------------------------------

    The current scientific evidence suggests that cruise ships pose a 
greater risk of COVID-19 transmission than other settings. A recent 
article published in the Journal of Travel Medicine by Rockl[ouml]v et 
al. demonstrated that the Diamond Princess cruise ship experienced an 
onboard R0 (basic reproduction rate) for COVID-19 of 14.8 
before ship-wide quarantine was enacted.\25\ This means that each case 
onboard the Diamond Princess transmitted COVID-19 to approximately 15 
other people. This reproduction rate is approximately four times higher 
than the R0 of the original epicenter of the outbreak in 
Wuhan, China, which was 3.7, meaning that each person with COVID-19 in 
the early days of the outbreak in Wuhan transmitted the disease to 
approximately four other people. In late February/early March, 149 
cases of PCR-confirmed COVID-19

[[Page 44091]]

(of 589 tour participants) were found among U.S. residents linked to 
Egyptian Nile Cruises. This heightened rate of transmission onboard 
cruise ships has been documented in other academic 
publications.9 \26\ Cruise ship conditions amplified an 
already highly transmissible disease.
---------------------------------------------------------------------------

    \25\ Rockl[ouml]v J, Sj[ouml]din H, Wilder-Smith A. COVID-19 
Outbreak on the Diamond Princess Cruise Ship: Estimating the 
Epidemic Potential and Effectiveness of Public Health 
Countermeasures. J. Travel Med. 2020; 18;27(3):taaa030. doi: 
10.1093/jtm/taaa030.
    \26\ Payne DC, Smith-Jeffcoat SE, Nowak G, et al. SARS-CoV-2 
Infections and Serologic Responses from a Sample of U.S. Navy 
Service Members -- USS Theodore Roosevelt, April 2020. MMWR Morb 
Mortal Wkly Rep 2020;69:714-721. DOI: http://dx.doi.org/10.15585/mmwr.mm6923e4.
---------------------------------------------------------------------------

    Rockl[ouml]v et al. surmised that this heightened rate of 
transmission is due to the high population density onboard on ships, 
which are typically more densely populated than cities or most other 
living situations. While this is one contributing factor, CDC's 
surveillance data acquired during the period of the NSO show that 
drastically decreasing population onboard does not extinguish 
transmission. Other factors likely contributing to onboard transmission 
are crew living and working in close quarters in a partially enclosed 
environment where social distancing may prove challenging even with a 
limited number of people onboard.
    In addition, the recent investigation by Payne et al. of 
transmission onboard a U.S. Navy ship demonstrated high transmission 
rates and high rates of mild disease and asymptomatic infection among 
crew.\25\ These mild presentations and asymptomatic cases make case 
detection and isolation and quarantine practices based on clinical 
presentation alone challenging. Thus, covert spread of infection among 
crew may keep the virus circulating from one voyage to the next. The 
Navy ship investigation also demonstrates the importance of avoiding 
onboard congregate settings. However, with limited dining options and 
work areas on board cruise ships, avoiding congregate settings is 
challenging for crew.
    Numerous challenges have arisen in detecting COVID-19 transmission 
onboard ships. Although examples can be given from most cruise lines, 
the experiences of four Royal Caribbean ships, the Vision of the Seas, 
Liberty of the Seas, Enchantment of the Seas, and Adventure of the 
Seas, particularly illustrate how an undetected COVID-19 outbreak may 
occur. These four ships reported no confirmed COVID-19 cases or COVID-
like illness in crew for 28 days or longer. However, when crew 
subsequently disembarked in countries that required shoreside testing, 
confirmed cases of COVID-19 were detected in 55 crew members. While CDC 
has recommended periodic random testing of symptomatic and asymptomatic 
crew, to our knowledge, only 20 of 49 ships currently operating or 
planning to operate in U.S. waters during the period of the April 15, 
2020 Extension have performed testing.
    While regular testing is not a panacea and a negative test result 
cannot be used to rule out infection conclusively,\27\ the addition of 
viral testing can help detect infected crew members earlier and isolate 
them from others. Viral testing should be used along with other 
measures to decrease transmission,\28\ such as symptom screening, 
isolation and quarantine, routine social distancing, and frequent 
handwashing. Unfortunately, testing requires a rapid turnaround of 
results to be useful, and this has proven particularly challenging for 
ships, even when in port. Difficulties may include lack of point-of-
care testing onboard and inadequate staffing to collect, track and 
transport samples. When rapid testing is more available, regular, 
repeated testing of those on board, as recommended in other high-
density workplace settings, may help to detect COVID-19 outbreaks. 
Absent wider availability and implementation of testing, undetected 
outbreaks of COVID-19 among crew are likely to reoccur.
---------------------------------------------------------------------------

    \27\ Watson J, Whiting PF, Brush JE. Interpreting a covid-19 
test result. BMJ 2020; 369: m1808. doi: https://doi.org/10.1136/bmj.m1808.
    \28\ Testing Strategy for Coronavirus (COVID-19) in High-Density 
Critical Infrastructure Workplaces after a COVID-19 Case Is 
Identified. www.cdc.gov/coronavirus/2019-ncov/community/worker-safety-support/hd-testing.html. Last accessed June 18, 2020.
---------------------------------------------------------------------------

Lack of Consensus Among Cruise Ship Operators and Need for Additional 
Industry-Led Efforts Regarding Safely Resuming Passenger Operations

    Cruise ship operators have taken tentative steps to advance their 
public health response to COVID-19, improve safety, and achieve 
readiness to safely resume passenger operations. Under the co-
chairmanship of former Health and Human Services Secretary Michael O. 
Leavitt, two cruise lines, RCL and NCLH, have assembled a team of 
subject-matter experts from a variety of disciplines under the moniker 
of the ``Healthy to Sail Alliance.'' The group intends ``over the next 
few months . . . to conduct a robust, scientifically grounded 
exploration on issues of cruise line health and safety'' (emphasis 
added). Furthermore, this group states that it will ``deliver to the 
cruise lines a set of public health recommendations that will provide 
participating cruise lines with a guide or pathway as they pursue their 
individual company efforts to achieve the confidence of regulators and 
passengers.''
    Additionally, a variety of cruise lines have promoted interventions 
to manage COVID-19 onboard ships in both online and in print marketing 
materials. These interventions include enhanced stateroom cleaning, 
installation of new air filters, preboarding health screenings, 
increased social distancing, increased availability of hand sanitizer, 
and more self-service meal options. It would thus be of benefit to have 
further industry-led engagement as to which strategies, best practices, 
and procedures, either singularly or in combination, would be most 
effective in protecting the health of passengers, crew, and global 
communities.
    CDC will continue to update its guidance and recommendations to 
specify basic safety standards and public health interventions based on 
the best scientific evidence available. CDC will also continue to 
consult with international maritime public health partners on ways to 
reduce COVID-19 transmission on ships and will continue to monitor the 
global COVID-19 situation.

Findings and Immediate Action

    The difficulty to date of cruise ship operators to submit and 
adhere to appropriate NSO response plans during a time of limited 
operations, as well as ongoing concerns relating to non-compliance with 
disease prevention protocols and continued outbreaks of COVID-19 
onboard cruise ships, highlight the need for further action prior to 
resuming passenger operations.
    Accordingly, and consistent with 42 CFR 70.2, 71.31(b), and 
71.32(b), the Director of CDC (``Director'') finds that cruise ship 
travel exacerbates the global spread of COVID-19, that the scope of 
this pandemic is inherently and necessarily a problem that is 
international and interstate in nature, and such transmission has not 
been controlled sufficiently by the cruise ship industry or individual 
State or local health authorities. As described in the March 14, 2020 
Order, cruise ship travel markedly increases the risk and impact of the 
COVID-19 disease epidemic within the United States. If unrestricted 
cruise ship passenger operations were permitted to resume, infected and 
exposed persons disembarking cruise ships would place federal partners 
(e.g., Customs and Border Protection and the U.S. Coast Guard), 
healthcare workers, port personnel, and communities at substantial 
unnecessary risk.
    The Director also finds evidence to support a reasonable belief 
that cruise ships are or may be infected or

[[Page 44092]]

contaminated with a quarantinable communicable disease.\29\ This 
reasonable belief is based on information from epidemiologic and other 
data included in this document and the information described in the 
March 14, 2020 Order and the April 15, 2020 Extension. As a result, 
persons on board or seeking to board cruise ships may likely be or 
would likely become infected with or exposed to COVID-19 by virtue of 
being on board at a time when cases of COVID-19 are being reported in 
increasingly significant numbers globally.\30\
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    \29\ 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.
    \30\ Since the March 14, 2020 Order, the number of global cases 
of COVID-19 reported by the World Health Organization (WHO) has 
risen from 142,534 to 12,102,328 as of July 10, 2020, with 551,046 
deaths. See Situation Reports, WHO, https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports.
---------------------------------------------------------------------------

    Accordingly, under 42 CFR 70.2, the Director determines that 
measures taken by State and local health authorities regarding COVID-19 
onboard cruise ships are inadequate to prevent the further interstate 
spread of the disease.
    This Order is not a rule within the meaning of the Administrative 
Procedure Act (``APA''), but rather an emergency action taken under the 
existing authority of 42 CFR 70.2, 71.31(b), and 71.32(b). In the event 
that this Order qualifies as a rule under the APA, notice and comment 
and a delay in effective date are not required because there is good 
cause to dispense with prior public notice and the opportunity to 
comment on this Order.\31\ Considering the public health emergency 
caused by COVID-19 based, among other things, on its potential for 
spread on board cruise ships, it would be impracticable and contrary to 
the public health, and by extension the public interest, to delay the 
issuance and effective date of this Order. Similarly, if this Order 
qualifies as a rule per the definition in the APA, the Office of 
Information and Regulatory Affairs has determined that it would be a 
major rule, but there would not be a delay in its effective date as the 
agency has invoked the good cause provision of the APA.
---------------------------------------------------------------------------

    \31\ See 5 U.S.C. 553(b)(B), (d)(3).
---------------------------------------------------------------------------

    If any provision in this Order, or the application of any provision 
to any carriers, persons, or circumstances, shall be held invalid, the 
remainder of the provisions, or the application of such provisions to 
any carriers, persons, or circumstances other than those to which it is 
held invalid, shall remain valid and in effect.
    In accordance with 42 U.S.C. 264(e), this Order shall supersede any 
provision under State law (including regulations and provisions 
established by political subdivisions of States), that conflict with an 
exercise of Federal authority, including instructions by U.S. Coast 
Guard or HHS/CDC personnel permitting ships to make port or disembark 
persons under stipulated conditions, under this Order.
    This Order shall be enforceable through the provisions of 18 U.S.C. 
3559, 3571; 42 U.S.C. 243, 268, 271; and 42 CFR 70.18, 71.2.
    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, 71.31(b), 
71.32(b), for all cruise ships described above for the period described 
below, it is ordered:

Measures Related To Protecting Public Health of Communities Signed on 
March 14, 2020

    These measures were implemented to provide public health 
authorities, in concert with the cruise ship industry, the necessary 
pause in operations to develop and implement an appropriate and robust 
plan (1) to prevent and mitigate the further spread of COVID-19 in 
communities, and (2) to prevent the spread of the disease onboard and 
ensure the health of cruise ship passenger and crew.
    Accordingly, the following terms and conditions of the No Sail 
Order and Other Measures Related to Operations signed on March 14, 
2020, as modified and extended by this order, shall remain in effect. 
Consequently, it remains ordered:
    1. Cruise ship operators shall not disembark or reembark crew 
members except as directed by the USCG, in consultation with HHS/CDC 
personnel and, as appropriate, as coordinated with Federal, State, and 
local authorities.
    2. 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.
    3. While in port, the cruise ship operator shall observe health 
precautions as directed by HHS/CDC personnel.
    4. 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 ships' manifests and logs available and collecting any 
specimens for COVID-19 testing.

Measures Related To Protecting Public Health and Crew Safety Signed on 
April 9, 2020 and Made Effective on April 15, 2020

    These measures were implemented to, among other things, ensure a 
safe environment for crew members to work and disembark by requiring 
the submission of appropriate NSO response plans by cruise ship 
operators as a condition of obtaining controlled free pratique \32\ to 
continue to engage in any cruise ship operations in any international, 
interstate, or intrastate waterways subject to the jurisdiction of the 
United States.
---------------------------------------------------------------------------

    \32\ Under 42 CFR 71.1, controlled free pratique means 
permission for a carrier to enter a U.S. port, disembark, and begin 
operation under certain stipulated conditions.
---------------------------------------------------------------------------

    Accordingly, the terms and conditions of the Modification and 
Extension of No Sail Order and Other Measures Related to Operations, 
intended to protect public health and crew safety, signed on April 9, 
2020, and made effective on April 15, 2020, as modified and extended by 
this order, shall remain in effect. Consequently, it remains ordered:
    1. As a condition of obtaining controlled free pratique to continue 
to engage in any cruise ship operations in any international, 
interstate, or intrastate waterways subject to the jurisdiction of the 
United States, cruise ship operators shall develop, implement, and 
operationalize, an appropriate, actionable, and robust plan to prevent, 
mitigate, and respond to the spread of COVID-19 among crew onboard 
cruise ships.
    2. As a condition of obtaining controlled free pratique to continue 
to engage in any cruise ship operations in any international, 
interstate, or intrastate waterways subject to the jurisdiction of the 
United States, the cruise ship operator shall make the plan described 
in paragraph 1, above, available to HHS/CDC and USCG personnel.
    3. An appropriate plan is one that adequately prevents, mitigates, 
and responds to the spread of COVID-19 among crew onboard cruise ships 
and that, at a minimum, addresses the following elements:
    a. Onboard surveillance of crew with acute respiratory illnesses, 
influenza-like illnesses, pneumonia, and COVID-19, including reporting 
to HHS/CDC on a weekly basis on overall case counts, methods of 
testing, and number of crew requiring hospitalization or medical 
evacuation;

[[Page 44093]]

    b. Reports on the number of crew onboard the cruise ship and any 
increase in the numbers of crew with COVID-19 made to HHS/CDC and USCG 
on a daily basis for as long as the cruise ship is within waters 
subject to the jurisdiction of the United States;
    c. Onboard monitoring of crew through temperature checks and 
medical screening, including addressing frequency of monitoring and 
screening;
    d. Training of all crew on COVID-19 prevention, mitigation, and 
response activities;
    e. Protocols for any COVID-19 testing, including details relating 
to the shore-side transport, administration, and operationalization of 
laboratory work if onboard laboratory work is not feasible;
    f. Onboard isolation, quarantine, and social distancing protocols 
to minimize the risk of transmission and spread of COVID-19;
    g. Onboard medical staffing, including number and type of staff, 
and equipment in sufficient quantity to provide a hospital level of 
care (e.g., ventilators, facemasks, personal protective equipment) for 
the infected so as to minimize the need for hospitalization onshore;
    h. An outbreak management and response plan to provision and assist 
an affected cruise ship that relies on industry resources, e.g., 
mobilization of additional cruise ships or other vessels to act as 
``hospital'' ship for the infected, ``quarantine'' ship for the 
exposed, and ``residential'' ship for those providing care and 
treatment, including the ability to transport individuals between ships 
as needed;
    i. Categorization of affected crew into risk categories with clear 
stepwise approaches for care and management of each category;
    j. A medical care plan addressing onboard care versus evacuation to 
on-shore hospitals for critically ill crew, specifying how availability 
of beds for critically ill at local hospitals will be determined in 
advance and how the cruise ship operator will ensure acceptance at 
local medical facilities to treat the critically ill in a manner that 
limits the burden on Federal, State, and local resources and avoids, to 
the greatest extent possible, medivac situations. If medical evacuation 
is necessary arrangements for evacuation must be made with commercial 
resources (e.g., ship tender, chartered standby vessel, chartered 
airlift) and arrangements made with a designated medical facility that 
has agreed to accept such evacuees. All medical evacuation plans must 
be coordinated with the U.S. Coast Guard;
    k. Detailed logistical planning for evacuating and repatriating 
both U.S. citizens and foreign nationals to their respective 
communities and home countries via foreign government or industry-
chartered private transport and flights, including the steps the cruise 
ship operator will take to ensure those involved in the transport are 
not exposed (i.e., without the use of commercial flights to evacuate or 
repatriate individuals, whether within or from the United States);
    l. The projected logistical and resource impact on State and local 
government and public health authorities and steps taken to minimize 
the impact and engage with these authorities; all plans must provide 
for industry/cruise line management of suspected or confirmed cases of 
COVID-19 without resource burden on Federal, State, or local 
governments;
    m. Plan execution in all U.S. geographical areas--all plans must be 
capable of being executed anywhere in international, interstate, or 
intrastate waterways subject to the jurisdiction of the United States; 
and
    n. Cleaning and disinfection protocols for affected cruise ships.
    4. An appropriate plan shall be designed to minimize, to the 
greatest extent possible, any impact on U.S. government operations or 
the operations of any State or local government, or the U.S. healthcare 
system.
    5. The cruise ship operator shall further ensure that the plan is 
consistent with the most current CDC recommendations and guidance for 
any public health actions related to COVID-19. Where appropriate, a 
cruise ship operator may coordinate the development, implementation, 
and operationalization of a plan with other cruise ship operators, 
including an industry trade group.

Measures Related to Continued Protection of Public Health and Crew 
Safety

    These measures are intended to continue to protect U.S. 
communities, ensure a safe environment for crew to work and disembark, 
and defer the embarkation of passengers until there is a clear pathway 
for a safe return to passenger operations.
    Accordingly, it is ordered:
    1. Cruise ship operators shall continue to suspend passenger 
operations and not embark passengers, except as approved by HHS/CDC 
personnel and USCG, in consultation with other federal authorities as 
appropriate.
    2. As a condition of obtaining or retaining controlled free 
pratique to operate in any international, interstate, or intrastate 
waterways subject to the jurisdiction of the United States, cruise ship 
operators shall continue to follow CDC's Interim Guidance for 
Mitigation of COVID-19 Among Cruise Ship Crew During the Period of the 
No Sail Order, including reporting to HHS/CDC through weekly submission 
of the Enhanced Data Collection (EDC) form, as may be updated.\33\ 
Additionally, cruise ship operators shall report to USCG via Advance 
Notice of Vessel Arrival (ANOA), whenever in U.S. waters.
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    \33\ For cruise ship operators with ships that have not been in 
U.S. waters during the period of the No Sail Order or voluntarily 
withdrew their ships, the following conditions must be met prior to 
a ship returning to U.S. waters: (1) Submission of the EDC form for 
28-days preceding expected arrival in U.S. waters, and (2) a 
complete and accurate NSO response plan, including a signed 
Acknowledgment of No Sail Order Response Plan Completeness and 
Accuracy.
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    3. As a condition of obtaining or retaining controlled free 
pratique to operate in any international, interstate, or intrastate 
waterways subject to the jurisdiction of the United States, cruise ship 
operators with appropriate NSO response plans shall continue to follow 
the COVID-19 Color Coding System requiring preventive measures for crew 
onboard based on the ship's status, as determined by HHS/CDC.
    4. As a condition of obtaining or retaining controlled free 
pratique to operate in any international, interstate, or intrastate 
waterways subject to the jurisdiction of the United States, cruise ship 
operators with appropriate NSO response plans shall conduct viral 
testing for COVID-19 for crew in such a manner as described in the 
relevant CDC guidance with reporting of results on the EDC form.
    5. As a condition of obtaining or retaining controlled free 
pratique to operate in any international, interstate, or intrastate 
waterways subject to the jurisdiction of the United States, cruise ship 
operators must observe the requirements of this Order, the previous 
Orders, and the most current CDC recommendations and guidance for any 
public health actions related to COVID-19, even when outside of U.S. 
waters for any ships that intend to return to U.S. waters during the 
period that this Order remains in effect.
    This Order is effective upon signature and shall remain in effect 
until the earliest of (1) the expiration of the Secretary of Health and 
Human Services' declaration that COVID-19 constitutes a public health 
emergency; (2) the CDC Director rescinds or modifies the order based on 
specific

[[Page 44094]]

public health or other considerations; or (3) September 30, 2020.

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, 
71.31(b), 71.32(b).
    Note: Elsewhere in this issue of the Federal Register, CDC is 
publishing a companion notice that requests information from the public 
regarding cruise ship planning and infrastructure, safe resumption of 
passenger operations, and summary questions.

    Dated: July 16, 2020.
Robert K. McGowan,
Chief of Staff, Centers for Disease Control and Prevention.
[FR Doc. 2020-15810 Filed 7-17-20; 11:15 am]
BILLING CODE 4163-18-P