No Sail Order and Suspension of Further Embarkation; Second Modification and Extension of No Sail Order and Other Measures Related to Operations, 44085-44094 [2020-15810]
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Federal Register / Vol. 85, No. 140 / Tuesday, July 21, 2020 / Notices
quarantined for the remainder of their
voyage, how should cruise ship
operators encourage passengers to notify
the medical center when they
experience COVID–19 symptoms?
26. How should cruise ship operators
decrease or eliminate the risk for
COVID–19 transmission for both
passengers and crew in the following
group settings?
a. Embarkation and disembarkation?
b. Safety drills and trainings?
c. Dining?
d. Onboard entertainment events?
e. Shore excursions?
Summary Questions
27. What benefits can be expected in
terms of averted deaths and illnesses
and how does this compare to the
expected financial costs of the above
measures?
28. Should cruise ship operators be
required to designate a responsible
company official who will accept legal
responsibility for failure to implement
measures to protect public health?
Please note that comments received,
including attachments and other
supporting materials, are part of the
public record and are subject to public
disclosure. Comments will be posted on
https://www.regulations.gov. Therefore,
do not include any information in your
comment or supporting materials that
you consider confidential or
inappropriate for public disclosure. If
you include your name, contact
information, or other information that
identifies you in the body of your
comments, that information will be on
public display. CDC will review all
submissions and may choose to redact,
or withhold, submissions containing
private or proprietary information such
as Social Security numbers, medical
information, inappropriate language, or
duplicate/near duplicate examples of a
mass-mail campaign. CDC will carefully
consider all comments submitted to this
docket. CDC does not accept public
comment by email.
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Dated: July 16, 2020.
Sandra Cashman,
Executive Secretary, Centers for Disease
Control and Prevention.
[FR Doc. 2020–15812 Filed 7–17–20; 11:15 am]
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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
Centers for Disease Control and
Prevention (CDC), Department of Health
and Human Services (HHS).
ACTION: Notice.
AGENCY:
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, passengercarrying 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: dgmqpolicyoffice@cdc.gov.
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
SUMMARY:
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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/.
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
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Federal Register / Vol. 85, No. 140 / Tuesday, July 21, 2020 / Notices
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.
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.
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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
1 No Sail Order and Suspension of Further
Embarkation. www.federalregister.gov/documents/
2020/03/24/2020-06166/no-sail-order-andsuspension-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-offurther-embarkation-notice-of-modification-andextension-and-other. Last accessed June 24, 2020.
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• 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’’:
All commercial, non-cargo,4 passengercarrying 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
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
3 Carrier is defined by 42 CFR 71.1 to mean, ‘‘a
ship, aircraft, train, road vehicle, or other means of
transport, including military.’’
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.
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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.
‘‘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 § 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
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
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.
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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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.
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.
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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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
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/
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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.
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.
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 shipspecific 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
quarantine/cruise/management/interim-guidanceno-sail-order.html
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 °F [38 °C]) plus either cough or sore throat
in the absence of another diagnosis.
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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 COVIDlike 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.
• ‘‘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 nonworking 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 colorcoding status for individual ships are
updated weekly at https://www.cdc.gov/
coronavirus/2019-ncov/travelers/crew14 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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disembarkations-commercialtravel.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.
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 cruiserelated 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 workintensive 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
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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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 NonCompliance 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 noncompliance 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.
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
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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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
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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 selfservice 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
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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
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.
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to cruise ships with overnight
accommodations carrying more than
100 people operating in Canadian
waters until October 31, 2020.
On March 18, 2020, the GovernorGeneral 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.
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
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-shipprohibition-extended. Last accessed June 24, 2020.
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.
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case of COVID–19 or COVID-like illness
in the past 28 days).
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–19like 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 COVIDlike illness cases among crew.
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
Rocklo¨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
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.
25 Rocklo
¨ v J, Sjo¨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.
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(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.
Rocklo¨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
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: https://
dx.doi.org/10.15585/mmwr.mm6923e4.
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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 highdensity 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.
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
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-safetysupport/hd-testing.html. Last accessed June 18,
2020.
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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 noncompliance 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
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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
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.
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
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/novelcoronavirus-2019/situation-reports.
31 See 5 U.S.C. 553(b)(B), (d)(3).
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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
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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.
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, influenzalike 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;
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.
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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 shoreside 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 onshore 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;
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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
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44093
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.
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
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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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.
for Motor Vehicle Safety Strategic Plan,
2020–2029. NIOSH received comments
from 11 respondents including
professional organizations and the
public. All comments received were
carefully reviewed and addressed,
where appropriate. In general, revisions
in response to comments focused on
clarifying the worker groups and
research topics that are a priority in the
strategic plan. NIOSH Responses to
Public Comments documents can be
found in the Supporting Documents
section on www.regulations.gov for this
docket.
Dated: July 16, 2020.
Robert K. McGowan,
Chief of Staff, Centers for Disease Control
and Prevention.
John J. Howard,
Director, National Institute for Occupational
Safety and Health, Centers for Disease Control
and Prevention.
[FR Doc. 2020–15810 Filed 7–17–20; 11:15 am]
[FR Doc. 2020–15672 Filed 7–20–20; 8:45 am]
public health or other considerations; or
(3) September 30, 2020.
BILLING CODE 4163–18–P
BILLING CODE 4163–18–P
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Centers for Disease Control and
Prevention
Centers for Medicare & Medicaid
Services
[CDC–2019–0107, Docket Number NIOSH–
331]
[Document Identifier: CMS–P–0015A]
NIOSH Center for Motor Vehicle Safety
Strategic Plan, 2020–2029
National Institute for
Occupational Safety and Health
(NIOSH) of the Centers for Disease
Control and Prevention (CDC),
Department of Health and Human
Services (HHS).
ACTION: Notice of availability.
AGENCY:
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Centers for Medicare &
Medicaid Services, HHS.
ACTION: Notice.
AGENCY:
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The Centers for Medicare and
Medicaid Services (CMS) is requesting
that a new information collection
request (ICR) related to the Medicare
Current Beneficiary Survey (MCBS)
(OMB clearance 0938–0568) be
processed under the emergency
clearance process. Due to CMS’
determination that this collection of
information is needed prior to the
expiration of time periods established
under its regulations, an emergency
clearance is requested. Once the
emergency information collection
request is approved, CMS plans to seek
public comments during the required
60-day and 30-day notice and comment
periods associated with obtaining a
standard (non-emergency) OMB
approval for extending the information
collection request as part of the MCBS
(collected under 0938–0568). The
approval of this information collection
package is necessary because of the
urgent need to obtain timely data to
assess the impact of the coronavirus
pandemic on the Medicare population.
Adding a COVID–19 Supplement to the
MCBS data collection in October 2020
SUMMARY:
NIOSH announces the
availability of NIOSH Center for Motor
Vehicle Safety Strategic Plan, 2020–
2029.
DATES: The final document was
published on July 15, 2020 on the CDC
website.
ADDRESSES: The document may be
obtained at the following link: https://
www.cdc.gov/niosh/docs/2020-126/
default.html.
FOR FURTHER INFORMATION CONTACT: Kyla
Retzer, Western States Division, P.O.
Box 25226, Denver, Colorado 80225–
0226, (303) 236–5934 (not a toll-free
number), kretzer@cdc.gov OR Dr. Rosa
Rodriguez-Acosta, Division of Safety
Research, 1095 Willowdale Road, MS
1808, Morgantown, West Virginia
26505–2888, (304) 285–6299 (not a tollfree number), rer3@cdc.gov.
SUPPLEMENTARY INFORMATION: On
December 16, 2019, NIOSH published a
request for comment in the Federal
Register [84 FR 68458] on the draft
version of the document NIOSH Center
SUMMARY:
Emergency Clearance: Public
Information Collection Requirements
Submitted to the Office of Management
and Budget (OMB)
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will provide critical information to CMS
and the public.
Comments must be received by
July 27, 2020.
DATES:
When commenting, please
reference the document identifier or
OMB control number. To be assured
consideration, comments and
recommendations must be submitted
within 10 days in any one of the
following ways:
1. Electronically. You may send your
comments electronically to https://
www.regulations.gov. Follow the
instructions for ‘‘Comment or
Submission’’ or ‘‘More Search Options’’
to find the information collection
document(s) that are accepting
comments.
2. By regular mail. You may mail
written comments to the following
address: CMS, Office of Strategic
Operations and Regulatory Affairs,
Division of Regulations Development,
Attention: Document Identifier/OMB
Control Number lll, Room C4–26–
05, 7500 Security Boulevard, Baltimore,
Maryland 21244–1850.
To obtain copies of a supporting
statement and any related forms for the
proposed collection(s) summarized in
this notice, you may make your request
using one of following:
1. Access CMS’ website address at
https://www.cms.gov/Regulations-andGuidance/Legislation/
PaperworkReductionActof1995/PRAListing.
ADDRESSES:
FOR FURTHER INFORMATION CONTACT:
William Parham at (410) 786–4669.
Under the
PRA, Federal agencies are required to
publish notice in the Federal Register
concerning each proposed ICR.
Interested persons are invited to send
comments regarding our burden
estimates or any other aspect of this ICR
including the necessity and utility of the
proposed ICR for the proper
performance of the agency’s functions,
the accuracy of the estimated burden,
ways to enhance the quality, utility, and
clarity of the information to be collected
and the use of automated collection
techniques or other forms of information
technology to minimize the information
collection burden.
SUPPLEMENTARY INFORMATION:
Contents
This notice sets out a summary of the
use and burden associated with the
following ICR. More detailed
information can be found in the
collection’s supporting statement and
associated materials (see ADDRESSES).
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]]>Agencies
[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/.
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
[[Page 44089]]
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.
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\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.
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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.
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\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.
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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.
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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.
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\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.
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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.
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\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: https://dx.doi.org/10.15585/mmwr.mm6923e4.
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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.
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\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.
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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.
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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.
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\31\ See 5 U.S.C. 553(b)(B), (d)(3).
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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.
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\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.
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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
