No Sail Order and Suspension of Further Embarkation

Cited as:85 FR 16628
Court:Centers For Disease Control And Prevention, Health And Human Services Department
Publication Date:24 Mar 2020
Record Number:2020-06166
Federal Register, Volume 85 Issue 57 (Tuesday, March 24, 2020)
[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
                [[Page 16629]]
                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