[Federal Register Volume 85, Number 57 (Tuesday, March 24, 2020)]
[Notices]
[Pages 16628-16631]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2020-06166]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Disease Control and Prevention
No Sail Order and Suspension of Further Embarkation
AGENCY: Centers for Disease Control and Prevention (CDC), Department of
Health and Human Services (HHS).
ACTION: Notice.
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SUMMARY: The Centers for Disease Control and Prevention (CDC), a
component of the Department of Health and Human Services (HHS),
announces the issuance of a No Sail Order and Suspension of Further
Embarkation on March 14, 2020 for all cruise ships that are not
voluntarily suspending operation.
DATES: This action was effective March 14, 2020.
FOR FURTHER INFORMATION CONTACT: Jennifer Buigut, Division of Global
Migration and Quarantine, Centers for Disease Control and Prevention,
1600 Clifton Road NE, MS V18-2, Atlanta, GA 30329. Phone: 404-498-1600.
Email: [email protected].
SUPPLEMENTARY INFORMATION: On March 14, 2020, the Director of the
Centers for Disease Control and Prevention issued the following No Sail
Order and Other Measures Related to Operations. A copy of the order is
provided below and a copy of the signed order can be found at https://www.cdc.gov/quarantine/cruise/index.html.
U.S. Department of Health and Human Services Centers for Disease
Control and Prevention (CDC) Order Under Sections 361 & 365 of the
Public Health Service Act (42 U.S.C. 264, 268) and 42 Code of Federal
Regulations Part 70 (Interstate) and Part 71 (Foreign): No Sail Order
and Other Measures Related to Operations
Applicability
This Notice of No Sail Order and Other Measures Related to
Operations shall apply only to the subset of carriers \1\ described
below and hereinafter referred to as ``cruise ships,'' except this
Order shall not apply to any cruise ship that voluntarily suspends
operations for the period of this Order:
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\1\ Carrier is defined by 42 CFR 71.1 to mean ``a ship,
aircraft, train, road vehicle, or other means of transport,
including military.''
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All commercial, non-cargo,\2\ passenger-carrying vessels operating
in
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international, interstate, or intrastate waterways and subject to the
jurisdiction of the United States with the capacity to carry 250 \3\ or
more individuals (passengers and crew) with an itinerary anticipating
an overnight stay onboard or a twenty-four (24) hour stay onboard for
either passengers or crew.\4\
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\2\ Given the substantial risk of person-to-person transmission
of COVID-19, as opposed to transmission via indirect contact, this
Order is currently limited to passenger, non-cargo vessels.
\3\ Based on substantial epidemiological evidence related to
congregate settings and mass gatherings, this Order suspends
operation of vessels with the capacity to carry 250 individuals or
more. Evidence shows that settings as small as nursing homes or
movie theaters can proliferate the spread of a communicable disease.
As the numbers of passengers and crew onboard a ship increases,
certain recommended mitigation efforts such as social distancing
become more difficult to implement. In light of the demonstrated
rapid spread of this communicable disease in current cruise ship
settings, application of this Order to vessels carrying 250 or more
individuals is a prudent and warranted public health measure.
Moreover, the management of current coronavirus cases in addition to
existing seasonal care needs (e.g., influenza) has placed an extreme
burden on the public health and healthcare systems and this Order
will help avoid further stressing those systems.
\4\ This order shall not apply to vessels operated by a U.S.
Federal or State government agency. Nor shall it apply to vessels
being operated solely for purposes of the provision of essential
services, such as the provision of medical care, emergency response,
activities related to public health and welfare, or government
services, such as food, water, and electricity.
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General Background
COVID-19 is a communicable disease caused by a novel (new)
coronavirus, SARS-CoV-2, that was first identified as the cause of an
outbreak of respiratory illness that began in Wuhan, China. The virus
is thought to spread primarily by person-to-person contact through
respiratory droplets produced when an infected person coughs or
sneezes; it may also spread through contact with contaminated surfaces
or objects. Manifestations of severe disease have included severe
pneumonia, acute respiratory distress syndrome (ARDS), septic shock,
and multi-organ failure. According to the World Health Organization
(WHO), approximately 3.6% of reported COVID-19 cases have resulted in
death globally. This mortality rate is higher among the elderly or
those with compromised immune systems. Older adults and people who have
severe chronic medical conditions like heart, lung, or kidney disease
are also at higher risk for more serious COVID-19 illness. Early data
suggest older people are twice as likely to have serious COVID-19
illness.
On January 30, 2020, the Director General of the WHO declared that
the outbreak of COVID-19 constitutes a Public Health Emergency of
International Concern under the International Health Regulations. The
following day, the Secretary of the Department of Health and Human
Services (HHS) declared that COVID-19 constitutes a public health
emergency under the Public Health Service Act. To date, CDC has issued
Level 3 Travel Health Notices recommending that travelers avoid all
nonessential travel to China, Iran, South Korea, and most of Europe;
the U.S. Department of State has issued a global Level 3 Health
Advisory directing U.S. citizens to reconsider all travel abroad due to
the global impact of COVID-19 and Level 4 Travel Advisories (Do Not
Travel) for China, Iran, and certain parts of Italy. In addition, CDC
has recommended that travelers, particularly those with underlying
health conditions, avoid all cruise ship travel worldwide; the U.S.
Department of State has similarly issued guidance that U.S. citizens
should not travel by cruise ship at this time. As of March 11, 2020,
the President of the United States has suspended entry to the U.S. by
most foreign nationals who have recently visited China, Iran, and most
of Europe due to COVID-19. On March 11, 2020, the WHO declared the
COVID-19 outbreak a pandemic. As of March 13, 2020, there have been
over 132,000 cases of COVID-19 globally in over 122 locations resulting
in over 4,950 deaths; more than 1,620 cases have been identified in the
United States, with new cases being reported daily and over 41 deaths
due to the disease. A Presidential Declaration of National Emergency
concerning COVID-19 was issued on March 13, 2020.
Global efforts to slow transmission have included drastic control
measures with substantial societal and economic impact. Countries such
as Russia, Australia, the Philippines, Japan, Israel, and the United
States have imposed stringent restrictions on travelers who have
recently been in China. Similar travel restrictions have since been
imposed on individuals from countries experiencing substantial
outbreaks, including Iran, South Korea, and Europe. In many countries,
including the United States, citizens, permanent residents, and their
close relatives returning from areas known to have high rates of
infection are being requested to self-quarantine for 14 days (a period
estimated to encompass the incubation period for the virus) following
return from countries with sustained community transmission. Despite
these unprecedented global efforts at containment, cases of COVID-19
have been shown to rapidly propagate, crossing international borders
with ease. For example, the Islamic Republic of Iran has seeded at
least 97 COVID-19 cases in 11 other countries, as reported by the WHO,
and as of March 9, 2020, the Schengen Area of Europe has exported 201
COVID-19 cases to 53 countries.
In the United States, community transmission has occurred in
Washington State, California, and New York. CDC is closely monitoring
COVID-19 transmission and is supporting state and local health
departments in conducting contact tracing investigations of confirmed
COVID-19 cases identified in the United States. These investigations
are complex and resource intensive; persons identified as infected or
at-risk can require observation, movement restriction (such as
isolation or quarantine), clinical evaluation, and care. Public health
authorities in the United States are working concurrently to contain
the spread of the disease and mitigate its impact.
Risk of Transmission on Cruise Ships
Cruise ships often involve the movement of a number of people in
closed and semi-closed settings. Cruises vary in size, with larger
cruises involving populations of more than 4,000 passengers and crew.
Like other close-contact environments, cruise ships facilitate
transmission of COVID-19.
There are several features of cruise ships that increase the risk
of COVID-19 transmission. A hallmark of cruise travel is the number and
variety of person-to-person contacts an individual passenger may have
daily. The dynamics of passenger-to-passenger, passenger-to-crew, crew-
to-passenger, and crew-to-crew intermingling in a semi-closed setting
are particularly conducive to SARS-CoV-2 spread, resulting in high
transmission rates. Cruises include frequent events that bring
passengers and crew close together, including group and buffet dining,
entertainment events, and excursions. Cruise ship cabins are small,
increasing the risk of transmission between cabinmates. Close
quartering is a particular concern for crew, who typically eat and
sleep in small, crowded spaces. Infection among crew members may lead
to transmission on sequential cruises on the same vessel because crew
members may continue working and living onboard the ship from one
cruise to the next. Crew from one ship may in turn serve onboard
multiple different ships for subsequent voyages, which also has the
potential to amplify transmission.
Transmission of COVID-19 on cruise ships may also be amplified by
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difficulty decontaminating numerous surfaces in common areas.
Contamination of frequently touched surfaces, such as door handles and
faucets in public toilet rooms, elevator buttons, handrails in stairs
and passageways, and utensils/dispensing mechanisms (for beverages) in
self-service buffets, etc., is also likely to be a significant factor
in transmission. Less obvious examples of frequently touched surfaces,
include playing cards, slot machine levers, and chips in the casino;
computer keyboards in the internet caf[eacute]; books, puzzles, and
games in the library; gym equipment; counters and surfaces in gift
shops; and the cruise card used by passengers to pay/register for
everything on board and exit/enter the ship in port. The high volume of
people on board a cruise ship and wealth of high-touch surfaces make
successful control of this method of transmission very difficult.
Moreover, the nature of cruise travel presents additional
opportunities for spread of the disease to ports of calls and
passengers' home communities. During a cruise, disembarkation of
passengers at sequential ports of call under uncontrolled conditions
may lead to disease transmission in those ports. Once a cruise
concludes, passengers residing in different countries or throughout the
United States may require air transportation or other types of common
carriers to return home. Return of disembarked infected passengers to
their communities could lead to widespread, interstate disease
transmission.
Quarantine and isolation measures are difficult to implement
effectively onboard a cruise ship and only occur after an infection has
already been identified onboard a cruise. If ships are at capacity, it
may not be feasible to fully separate ill and well persons onboard the
ship, particularly among the crew. Because crew are required to
continue working to keep a ship safely operating, effective quarantine
for crew is particularly challenging.
Already Observed Impact of Cruise Ship Travel in General and in the
U.S.
Cruise ship travel has already been associated with a number of
COVID-19 clusters and outbreaks, including on the Diamond Princess
(Asia) and the Grand Princess (California to Mexico, California to
Hawaii). The threat of spread is not limited to larger cruise ships. An
outbreak onboard a Nile River cruise with 171 passengers and crew (29
of which were American citizens) resulted in 45 confirmed COVID-19
cases (3 of which are American citizens). Many of these passengers
returned home before any notifications about COVID-19 were provided,
potentially spreading the disease to their home communities. Evidence
of COVID-19 transmission onboard six similar Nile River cruise ships,
each carrying approximately 100 passengers, illustrates that even ships
with moderate numbers of passengers and crew onboard carry a
substantial risk of disease transmission and outbreak.
The initial stages of the COVID-19 epidemic were marked by the
outsized role of a single cruise ship, the Diamond Princess in
Yokohama, Japan, which for a period of 18 days was the setting for the
largest number of cases outside the original epicenter in China. The
outbreak of COVID-19 onboard the Diamond Princess demonstrates the
speed and extent of disease transmission that can occur onboard cruise
ships. Despite quarantine and isolation efforts, more than 700 cases of
infection with the virus that causes COVID-19 were identified among
Diamond Princess passengers and crew during the three weeks following
the identification of one case of COVID-19 in a person who was
symptomatic before leaving the ship. There are several cases of severe
disease associated with the Diamond Princess, including at least six
deaths. Additionally, approximately half of the infected passengers did
not report symptoms at the time their infections were diagnosed.
On March 4, 2020, Placer County, California officials reported the
death of a passenger who had been onboard the Grand Princess cruise
ship during a voyage from February 11-21, 2020 (Sailing A) and was a
confirmed COVID-19 case. As of March 7, 2020, there were 22 presumptive
positive cases of COVID-19 among persons who were onboard Sailing A.
The Grand Princess left San Francisco for a second sailing on February
21 (Sailing B). Sixty-eight passengers and most of the crew from
Sailing A were also on Sailing B. While testing of those who were
onboard Sailing B continues, to date, 22 crew and 8 passengers have
tested positive for COVID-19. As a result of the outbreak onboard the
Grand Princess, the Federal government engaged in a massive effort to
disembark and quarantine American passengers from the ship on four
military bases to help prevent further transmission to the passengers'
home communities. Passengers from Sailing A were from more than 30 U.S.
states and 25 countries; Sailing B included passengers from over 50
countries. More than 70 persons from this voyage have reported symptoms
and require assessment and evaluation and additional confirmed cases in
multiple states/countries are anticipated.
The Director Has Reason To Believe That Cruise Ship Travel May Continue
To Introduce, Transmit, or Spread COVID-19
Cruise ship travel markedly increases the risk and impact of the
COVID-19 disease outbreak within the United States. Disembarkation of
passengers at sequential ports may lead to disease transmission in
those ports. Return of disembarked infected passengers to their
communities could lead to widespread disease transmission. Cases that
have been confirmed to date may have led to secondary transmission,
including in a healthcare worker.
Furthermore, the passenger population of cruises often includes a
substantial number of older adults, meaning there is higher risk for
COVID-19 morbidity and mortality. Industry trade publications report
that 51% of cruise ship passengers are over the age of 50. The median
age of passengers onboard the Grand Princess Sailing B, for example,
was 66 and 1,200 passengers on the ship were over age 70. Given these
demographics, many cruise passengers are at high risk for severe
disease if they become infected.
Beyond the risk to these individuals, the intensive care
requirements for cruise ship passengers with severe disease stresses a
healthcare system already overburdened and facing a shortage of beds
needed for influenza and other seasonal and critical healthcare
conditions. The addition of further cruise ship cases place healthcare
workers at substantial increased risk. Specifically, these cases divert
medical resources away from persons with other medical problems and
other COVID-19 cases, consuming precious diagnostics, therapeutics, and
protective equipment. Ongoing concerns with cruise ship transmission
also draw valuable resources away from the immense Federal, state, and
local effort to contain and mitigate the spread of COVID-19. Safely
evacuating, triaging, quarantining, and repatriating cruise ship
passengers involves complex logistics, incurs financial costs at all
levels of government, and diverts resources away from larger efforts to
suppress or mitigate the virus.
Coordination Efforts With the Cruise Ship Industry
To address the continued and significant risks and burdens posed by
ongoing cruise ship operations, CDC and other Federal agencies have
engaged with representatives from
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Cruise Lines International Association (``CLIA''), the leading industry
trade group. To that end, CLIA members and certain individual cruise
lines have voluntarily taken steps to try to mitigate the impact of the
spread of COVID-19. On March 13, 2020, CLIA and their associated
members announced that all member cruise lines would voluntarily
suspend cruise ship operations from U.S. ports of call for 30 days as
public health officials and the Federal government continue to address
COVID-19. The Federal government recognizes the enormity and importance
of this action taken by CLIA and the commitment it demonstrates to
protecting the health of both cruise ship passengers and the public at
large. Following the example set by CLIA members, additional cruise
lines have also voluntarily suspended operations from U.S. ports of
call. Although the CLIA members and the additional cruise lines
implementing a voluntary suspension of operations represent a large
majority of the cruise industry, not all cruise lines or ships have
announced a voluntary suspension of operations or that they will follow
the important example set by CLIA members. This Order is intended to
cover and specifically apply to those cruise lines or ships that do not
undertake a voluntary suspension of operations. As a result, this Order
specifically excludes from applicability any cruise line or ship that
voluntarily suspends operations for the period of this Order, as CLIA
members have done.
Findings and Immediate Action
Accordingly, and consistent with 42 CFR 71.32(b), the Director of
CDC (``Director'') finds evidence to support a reasonable belief that
cruise ships are or may become infected or contaminated with a
quarantinable communicable disease.\5\ This reasonable belief is based
on information from epidemiologic and other data regarding the nature
and transmission of COVID-19 on cruise ships from the recent outbreaks
onboard the Diamond Princess, Grand Princess, and other cruise ships.
As a result, cruise ship passengers may be infected with or exposed to
COVID-19 by virtue of having been onboard a cruise ship at a time when
cases of COVID-19 are being reported in significant numbers globally
and specifically on cruise ships, when testing is available. The
Director also finds that cruise ship travel may exacerbate the global
spread of COVID-19. The scope of this pandemic is inherently and
necessarily a problem that is international and interstate in nature,
and cannot be controlled sufficiently by the cruise ship industry or
individual state or local health authorities. Accordingly, under 42 CFR
70.2, the Director determines that measures taken or likely to be taken
by state and local health authorities regarding COVID-19 onboard cruise
ships are inadequate to prevent the further interstate spread of the
disease.
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\5\ COVID-19 is a communicable disease for which quarantine is
authorized under Section 361 of the Public Health Service Act (42
U.S.C. 264) and 42 CFR 70.1, 71.1, as listed in Executive Order
13295, as amended by Executive Orders 13375 and 13674.
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The Director further determines that this Order provides public
health authorities, in concert with the cruise ship industry, the
necessary pause in operations to develop and implement an appropriate
and robust plan to prevent and mitigate the spread of COVID-19, and
acts to prevent the spread of the disease and ensure cruise ship
passenger and crew health.
Therefore, in accordance with Sections 361 and 365 of the Public
Health Service Act (42 U.S.C. 264, 268) and 42 CFR 70.2, 71.32(b), for
all cruise ships not voluntarily suspending operations for the period
described below, it is ordered:
1. Cruise ship operators shall be allowed to disembark passengers
and crew members at ports or stations only as directed by the United
States Coast Guard (USCG), in consultation with HHS/CDC personnel and,
as appropriate, as coordinated with Federal, state, and local
authorities.
2. Cruise ship operators shall not reembark any crew member, except
as approved by USCG, in consultation with HHS/CDC personnel, until
further notice.
3. Cruise ship operators shall not embark any new passengers or
crew, except as approved by USCG, or other Federal authorities as
appropriate, in consultation with HHS/CDC personnel.
4. Cruise ship operators shall not commence or continue operations
(e.g., shifting berths, moving to anchor, or discharging waste), except
as approved by USCG, in consultation with HHS/CDC personnel, until
further notice.
5. While in port, the cruise ship operator shall observe health
precautions as directed by HHS/CDC personnel.
6. The cruise ship operator shall comply with all HHS/CDC, USCG,
and other Federal agency instructions to follow CDC recommendations and
guidance for any public health actions relating to passengers, crew,
ship, or any article or thing on board the ship, as needed, including
by making ship's manifests and logs available and collecting any
specimens for COVID-19 testing.
7. This order does not prevent the periodic reboarding of the ship
by HHS/CDC personnel and/or USCG and/or other Federal, state, or local
agencies or the taking on of ships' stores and provisions under the
supervision of HHS/CDC personnel and/or USCG.
8. This order does not prevent the ship from taking actions
necessary to maintain the seaworthiness or safety of the ship, or the
safety of harbor conditions, such as movement to establish safe
anchorage, or as otherwise directed by USCG personnel.
CDC may modify this order by an updated publication in the Federal
Register or by posting an advisory to follow at www.cdc.gov.
Authority
The authority for these orders is Sections 361 and 365 of the
Public Health Service Act (42 U.S.C. 264, 268) and 42 CFR 70.2,
71.32(b).
Dated: March 19, 2020.
Robert R. Redfield,
Director, Centers for Disease Control and Prevention.
[FR Doc. 2020-06166 Filed 3-23-20; 8:45 am]
BILLING CODE 4163-18-P