2020-06166. 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.

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: [phone]. Email: [e-mail].

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:

All commercial, non-cargo,^[2] passenger-carrying vessels operating in 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]

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 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 café; 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 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.

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.

Footnotes

1.  Carrier is defined by 42 CFR 71.1 to mean “a ship, aircraft, train, road vehicle, or other means of transport, including military.”

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.

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.