CDC response to 60d FRN public comments

Summary and Response to Public Comment

On April 30, 2021, CDC published a 60-day Federal Register Notice inviting the general public and other Federal agencies to comment a proposed information collection project titled Phased Approach to the Resumption of Passenger Operations. This collection accompanied a CDC Order entitled the Framework for Conditional Sailing Order (CSO). Note, CDC has extended the Framework for Conditional Sailing Order with minor modifications. The CDC Director signed the Temporary Extension & Modification of the CSO on October XX, 2021; it is effective upon expiration of the current CSO on November 1, 2021.

CDC received 20 comments from members of the general public. While a majority of respondents supported CSO and the proposed collection, many modified their support with critiques and caveats. There were also some commenters that opposed the CSO and the associated collection, and others that argued CDC’s Order and collection are not sufficient and need to be strengthened. CDC thanks all commenters for providing their input.

Outside scope topics: CDC received several comments that provide legal strategy related to Florida v. Becerra. CDC cannot respond to any comment related to ongoing litigation. Additionally, several comments reference ideas for future legislation. These comments fall beyond CDC’s scope as only Congress has the authority to modify or change statutory language.

The following is a discussion of public comments received which are applicable and within the scope of the Order and the information collection. Topics such as: COVID-19 testing requirements, COVID-19 vaccination requirements, Phase 1 response plans, Phase 2A agreements, Phase 2B simulated voyages, information reporting and sharing, and others are discussed below.

A summary of those comments and a response to those comments are found below.

1. Overall Comments, Concerns, and Critiques

Almost every commenter shared his or her overall opinion on the CSO and its associated information collection.

One quarter of respondents asserted that the CSO is a useful mechanism for mitigating the risks of COVID-19 during cruise ship travel, as well as a necessary data collection project for the proper performance of the functions of the CDC.

An additional quarter of respondents felt that, while burdensome on cruise ship operators, the CSO and information collection are medically and scientifically sound. Two of these commenters requested that CDC revisit its burden estimates to ensure that all costs have been accounted for. CDC has provided updated burden estimates to the Office of Management and Budget (OMB) as a part of this information collection. Upon information and belief, these estimates accurately reflect the annual total costs associated with the CSO Extension and its associated information collection.

One commenter offered support for the CSO but suggested that CDC consider narrowing the scope of the Order. CDC has taken this comment into consideration. When the CSO was extended, its scope was narrowed to any person operating or intending to operate a foreign-flagged cruise ship in U.S. waters and to any person operating a foreign-flagged cruise ship outside of U.S. waters if the cruise ship operator intends for the ship to return to operating in U.S. waters.

Another commenter shared support for the CSO, so long as CDC considered direct input from cruise ship operators on its requirements. Since November 2020, CDC has been engaging in biweekly phone calls with cruise lines to ensure questions concerning the terms of the CSO are answered in a timely fashion to facilitate compliance. Additionally, CDC has facilitated ad hoc meetings with cruise line representatives at their request.

Other commenters opposed the CSO and its information collection and called for their elimination. Two of these opponents felt that the CSO’s required COVID-19 mitigation measures and case reporting create too great a burden for cruise ship operators. Another voiced opposition because the methodology and assumptions relied upon in the CSO and the information collection are flawed and therefore cannot provide accurate data. CDC disagrees with these respondents. Since the issuance of the CSO, cruise lines, with CDC assistance, have resumed passenger operations and successfully developed and implemented health and safety protocols to manage COVID-19. These protocols have averted overwhelming onboard medical facilities and burdening shoreside hospital resources.

CDC also received several comments to the effect that the CSO and the associated collection is not sufficient to mitigate the risks of cruise travel during the COVID-19 pandemic. CDC appreciates the concerns expressed by these respondents. However, while cruising will never be a zero-risk activity for spread of COVID-19, the CSO’s requirements and recommendations—which are based on the best available science—are working to manage this risk and allow cruise ship operators to resume passenger operations in a way that mitigates the risk to crew members, passengers, port personnel, and communities.

2. COVID-19 Testing Requirements

CDC received several comments on the CSO’s COVID-19 testing requirements, all of which suggested that CDC should strengthen these requirements. Six commenters recommended that CDC update its protocols to require COVID-19 testing for all individuals on board on a more frequent basis. Most of these commenters agreed that it is necessary to test all passengers and crew for COVID-19 daily. While we agree that daily testing of passengers and crew on cruise ships would enhance COVID-19 detection on board, CDC recognizes that daily COVID-19 testing is not operationally feasible for cruise ship operators. CDC’s COVID-19 testing protocols for cruise ships that are currently in place appropriately balances the best available science with what is operationally possible.

CDC received a comment that it should require disembarkation COVID-19 testing for all cruise ship passengers and require that this testing be done at a certified laboratory. The cruise ship operator must conduct laboratory testing of all passengers who are not fully vaccinated on the day of embarkation and the day of disembarkation as required by CDC’s COVID-19 Operations Manual for Simulated and Restricted Voyages. CDC also recommends that all cruise passengers get tested for COVID-19 3-5 days after their trip, regardless of vaccination status.

3. COVID-19 Vaccination Requirements

CDC received a number of comments concerning COVID-19 vaccination requirements, or lack thereof, in the CSO. Five commenters worried that the CSO and the related information collection do not adequately address the risk of sailing with passengers and crew who are not fully vaccinated against COVID-19. To address this risk, eight of the twenty commenters believed that CDC should require all crew and passengers to be vaccinated against COVID-19 prior to embarking a cruise ship. An additional four commenters would like CDC to strongly recommend that cruise ship operators require proof of having received a COVID-19 vaccine for all passengers and crew. It should be noted that one commenter felt COVID-19 requirements should not be implemented due to the burden these requirements may place on individuals.

COVID-19 vaccines are effective at helping protect against severe disease and death from variants of the virus that causes COVID-19 currently circulating, including the Delta variant. For this reason, CDC’s Operations Manual for Simulated and Restricted Voyages recommends that cruise ship operators incorporate COVID-19 vaccination strategies to maximally protect passengers and crew in the maritime environment, at seaports, and in land-based communities. CDC has offered incentives to cruise ship operators that sail with a high percentage of fully vaccinated crew and passengers, such as the option to bypass the Phase 2B simulated voyage. Additionally, CDC’s cruise ship travel health notice recommends that people are fully vaccinated against COVID-19 prior to traveling on a cruise ship and that people who are not fully vaccinated avoid travel on cruise ships, including river cruises, worldwide.

One commenter asked CDC to address in the CSO U.S. states that ban proof of COVID-19 vaccination requirements and information collection. While CDC strongly recommends that all individuals who are eligible and able to be vaccinated against COVID-19 receive a COVID-19 vaccine, CDC recognizes that state and local governments have the authority to enact public health regulations and requirements in their respective jurisdictions.

Two commenters insisted that CDC require cruise ship operators to sponsor and facilitate COVID-19 vaccinations for the individuals that live in the communities where cruise ships port, both in the U.S. and abroad. CDC strongly recommends that all who are eligible and able to be vaccinated against COVID-19 receive a COVID-19 vaccine. However, in the U.S., state and local governments are primarily responsible for allocating COVID-19 vaccines in their jurisdictions. Additionally, CDC cannot dictate how sovereign nations allocate their COVID-19 vaccine resources.

4. Other COVID-19 Mitigation Measures on Board

Several commenters would like CDC to implement additional COVID-19 mitigation measures for cruise ships to better protect passengers, crew, port personnel, and communities.

Two commenters believed CDC must be more specific when describing the onboard mitigation measures intended to protect passengers and crew from COVID-19. CDC agrees that detailed COVID-19 mitigation requirements and recommendations are necessary to facilitate the resumption and continuation of safer, healthier sailing. For this reason, CDC has enumerated its expectations for cruise ship operators in the text of its Order and on its Cruise Ship Guidance webpage.

Several comments were made regarding capacity limits and physical distancing. One commenter felt CDC should limit cruise ship capacity to ensure adequate space for physical distancing. Three other commenters relayed that, rather than reducing overall capacity, CDC should require cruise lines to consider prevention through design. These commenters recommend, for example, utilizing larger dining spaces at reduced occupancy, banning the operation of cruise ship night clubs and self-service buffets, and redesigning shared spaces to accommodate fewer people to allow for improved physical distancing. CDC welcomes these comments and agrees physical distancing is necessary to reduce the possibility of COVID-19 transmission if a case occurs on board a ship. CDC’s physical distancing requirements and recommendations can be found in the COVID-19 Operations Manual for Simulated and Restricted Voyages.

Two respondents requested that CDC require improved ventilation onboard to reduce the risk of COVID-19 transmission. CDC appreciates this comment and agrees that when indoors, ventilation mitigation strategies can help reduce viral particle concentration. The lower the concentration, the less likely viral particles can be inhaled into the lungs (potentially lowering the inhaled dose); contact eyes, nose, and mouth; or fall out of the air to accumulate on surfaces. Protective ventilation practices and interventions can reduce the airborne concentrations and reduce the overall viral dose to occupants. Accordingly, CDC’s COVID-19 Operations Manual for Simulated and Restricted Voyages includes requirements and recommendations for Heating, Ventilation, and Air Conditioning(HVAC) systems to minimize the possibility of dispersing the virus particles through the air.

One member of the general public stressed that CDC must compel cruise ship operators to have sufficient medical resources onboard. CDC concurs. Our requirements for cruise ship medical centers can be found in the COVID-19 Operations Manual for Simulated and Restricted Voyages and Technical Instructions for Mitigation of COVID-19 Among Cruise Ship Crew.

Another comment implored CDC to require stringent contact tracing before, during, and after cruise ship voyages. Contact tracing slows the spread of COVID-19. In its COVID-19 Operations Manual for Simulated and Restricted Voyages, CDC provides cruise ship operators with its recommendations for efficient and effective contact tracing. However, it is the responsibility of the cruise ship operator to determine when contact tracing is necessary.

One commenter sought to simplify CDC’s COVID-19 mitigation measures for cruise ship operators by suggesting the mitigation measures be uniform for all individuals, regardless of COVID-19 vaccination status. While we acknowledge such a suggestion may alleviate some of the burden associated with enforcing COVID-19 mitigation measures, CDC rejects this comment as it is not supported by the best available science.

One comment encouraged CDC to reevaluate its stance on medical evacuations at sea. In this commenter’s opinion, by reserving medical evacuations at sea for the most dire circumstances, CDC is not doing enough to protect the other passengers and crew onboard from possible COVID-19 infection. The individual proposed medically evacuating all travelers infected with COVID-19 from the ship. CDC rejects this comment for a number of reasons. First, cruise ship operators must have protocols in place for onboard medical staffing—including number and type of staff—and equipment in sufficient quantity to provide a hospital level of care (e.g., ventilators, face masks, personal protective equipment) for patients without the immediate need to rely on shoreside hospitalization. Second, cruise ship operators have the option of disembarking COVID-19 positive travelers at one of their port stops. Third, and most importantly, the U.S. Coast Guard—who is responsible for medical evacuations at sea—does not have the resources necessary to evacuate every COVID-19 patient on cruise ships. Thus, medical evacuations at sea must be reserved for life and death situations.

5. Specific Protections for Crew, Passengers, Port Personnel, and Communities

Quite a few respondents worried that the CSO and the associated information collect did not contemplate great enough protections for individual crew members, passengers, and port communities.

Several commenters concluded that cruise ship crew are uniquely vulnerable to COVID-19 and therefore crew member protections must clear and uniform across the cruise industry. Two of the CSO’s paramount objectives are preserving human life and preserving the health and safety of cruise ship passengers, crew members, port personnel, and communities. To that end, CDC has provided instructions to cruise ship operators to ensure health and safety protections for travelers (crew and passengers) in a way that mitigates the risk of spreading COVID-19. These instructions can be found in CDC’s Technical Instructions for Mitigation of COVID-19 Among Cruise Ship Crew.

Other commenters were concerned that the cruising public is not fully aware of the risks associated with cruise travel during the COVID-19 pandemic. The commenters suggested that CDC educate the public about these risks, and also require cruise ship passengers and crew to provide their informed consent before embarkation. One commenter believed that cruise ship passengers should have to sign waivers of liability as well.

CDC has published several webpages that provide public health recommendations and transparency to cruise ship travelers. CDC’s Travel Health Notice for Cruise Ship Travel recommends that people who are not fully vaccinated avoid travel on cruise ships, including river cruises, worldwide. In addition, it recommends that individuals with an increased risk of severe illness also avoid travel on cruise ships, including river cruises, regardless of vaccination status. This webpage also includes recommended COVID-19 measures for passengers before they board, while on board, and after they disembark. Additionally, CDC’s Cruise Ship Color Status webpage uses surveillance data from the previous 7 days—regardless of voyage dates— and CDC investigation findings to indicate the COVID-19 situation onboard all cruise ships operating or planning to operate in U.S. waters. This page is intended to provide transparency to the public so that passengers can make informed decisions based on their preexisting medical conditions and risk of severe illness. Additional public resources regarding cruise ship travel during the COVID-19 pandemic can be found on the Cruise Ship Travel During COVID-19 webpage.

Because simulated voyages are intended to test a cruise ship operator’s COVID-19 mitigation protocols, CDC requires passengers on these voyages to provide their informed consent and submit a medical certification to the cruise ship operator prior to embarkation. If any minors are to participate in the simulation then the informed consent of a parent or guardian, and the written assent of the minor must also be documented. (Note: all persons younger than eighteen years old must be fully vaccinated against COVID-19 as a condition of participation on a simulated voyage.) It is CDC’s belief that cruise ship crew, by virtue of signing an employment contract, and restricted voyage passengers, by virtue of purchasing a ticket, have provided their informed consent about working or sailing on a cruise ship during a pandemic. While it is not required by CDC, cruise ship operators, at their discretion, may ask passengers to sign waivers of liability as a condition of embarkation.

Three commenters believed that CDC should limit cruise ship operator’s ability to make port outside U.S. waters, though for different reasons. Two commenters made the point that restricting interactions in foreign ports of call would reduce the likelihood that COVID-19 is introduced on board ship, while three commenters sought to protect the local community from COVID-19 transmission via cruise ship travelers. CDC appreciates the commenters’ concerns; however, CDC does not have authority to dictate where cruise ship operators make port outside of U.S. waters. In fact, per 46 U.S.C. 55103, foreign-flagged vessels may not travel between U.S. ports without including a stop at a foreign port in their itinerary.

One commenter asserted that a cruise ship operator should be obligated to cover any medical costs that can be attributed to cruising during the COVID-19 pandemic. CDC acknowledges this comment; however, CDC does not have the authority to enact such a requirement.

6. Phase 1 Response Plans

One commenter noticed that the CSO requires cruise ship operators to submit and abide by a No Sail Order (NSO) response plan as part of the CSO’s requirements. This commenter asked CDC to create an NSO response plan equivalent for cruise ships that did not operate in U.S. waters under the NSO. Another commenter complained that the CDC does not specify what information must be included in the NSO response plan. While elements of the NSO response plans are referenced in the CSO and available at No Sail Order and Suspension of Further Embarkation, CDC has taken these comments into consideration and has added the elements of a COVID-19 response plan to the CSO Extension. The COVID-19 response plan, which can be submitted by a cruise ship holding company and apply to all cruise ships operated by the holding company’s brands, must include: (1) terminology and use of definitions that align with how CDC uses and defines the following terms: “confirmed COVID-19,” “COVID-19-like illness,” “close contact,” “fully vaccinated for COVID-19,” and “isolation” and “quarantine” (including timeframes for isolation and quarantine); (2) protocols for on board surveillance of passengers and crew with COVID-19 and COVID-19-like-illness; (3) protocols for training all crew on COVID-19 prevention, mitigation, and response activities; (4) protocols for on board isolation and quarantine, including how to increase capacity in case of an outbreak; (5) protocols for COVID-19 testing that aligns with CDC technical instructions; (6) protocols for onboard medical staffing—including number and type of staff—and equipment in sufficient quantity to provide a hospital level of care (e.g., ventilators, face masks, personal protective equipment) for the infected without the immediate need to rely on shoreside hospitalization; and (7) procedures for disembarkation of passengers who test positive for COVID-19.

7. Phase 2A Agreements

Only two comments were made regarding the Phase 2A’s agreements with ports of entry, healthcare organizations, and housing facilities. One commenter felt that, though burdensome, these agreements are necessary aspects of the CSO and should be continued. Another commenter concurred the agreements were necessary, but believed they need to be better explained.

CDC agrees that the Phase 2A agreements are a necessary component of the CSO. CDC’s expectations for these agreements are spelled out in the Order and in CDC’s Technical Instructions for a Cruise Ship Operator’s Agreement with Port and Local Health Authorities. It should be noted that during discussions with cruise ship operators, port authorities, and state and local health authorities, all parties requested additional CDC assistance with the required agreements. In response to these requests, CDC has provided a checklist for additional reference.

8. Phase 2B Simulated Voyages:

Several of the comments submitted to CDC reference the CSO’s Phase 2B simulated voyages. Three commenters found that simulated voyages are beneficial elements of the CSO’s phased-in approach, and one of these commenters believed that all ships should conduct a simulated voyage. Conversely, three commenters believed that the public health value of simulated voyages does not outweigh the costs. Finally, an additional commenter recommended that CDC delay the implementation of simulated voyages until specific health and legal concerns were addressed.

CDC had found that simulated voyages are a critical aspect of the CSO. Simulated voyagers are intended to demonstrate the cruise ship operator’s ability to mitigate the risks of COVID-19 onboard its cruise ship. Before a cruise ship operator can increase the number of passengers onboard its ships, which increases the risk of COVID-19 transmission onboard, it must be able to show that its COVID-19 mitigation protocols are sufficiently robust, and its crew are adequately prepared to handle the associated increased risk. We reject the notion that the public health benefits of simulated voyages are outweighed by the costs.

One commenter was extremely concerned that passengers and crew participating in simulated voyages are being placed in conditions which may expose them to disease or chronic harm. Two of the CSO’s paramount objectives are preserving human life and preserving the health and safety of cruise ship passengers, crew members, port personnel, and communities. For this reason, cruise ship operators must adhere to a number of health and safety protocols when conducting a simulated voyage. These requirements are explained in detail in CDC’s Order, Technical Instructions for Simulated Voyages by Cruise Ship Operators, and information collection. Additionally, volunteer passengers must be at least 12 years of age. The cruise ship operator must obtain from all volunteer passengers a written certification from a healthcare provider that the volunteer passenger has no pre-existing medical conditions that would place that individual at high risk for COVID-19 as determined through CDC guidance. Furthermore, the cruise ship operator must document the informed consent of all adult participants in writing. If any minors are to participate in the simulation then the informed consent of a parent or guardian, and the written assent of the minor, must also be documented. All persons younger than eighteen years old must be fully vaccinated against COVID-19 as a condition of participation in a simulated voyage.

Two commenters insisted that CDC conduct inspections on some or all of the simulated voyages to ensure compliance with the CSO’s requirements. During simulated voyages, cruise ships are subject to virtual and in-person inspections by CDC. The cruise ship operator’s properties and records must be made available for inspection to allow CDC to ascertain compliance with its requirements. Such properties and records include but are not limited to vessels, facilities, vehicles, equipment, communications, manifests, list of passengers, laboratory test results, and employee and passenger health records. CDC has issued additional technical guidance outlining the specific areas that may be inspected and corresponding recommendations. As of October 8, 2021, CDC has conducted 4 inspections during simulated voyages.

Several commenters requested that CDC provide additional, detailed information regarding simulated voyage requirements. These commenters specifically requested that CDC 1) include in Phase 2B the option to opt-out of simulated voyages in both the Order and the information collection, 2) describe what makes a simulated voyage successful. The options to opt-out of simulated voyages are explained in detail in CDC’s Order, Technical Instructions for Simulated Voyages by Cruise Ship Operators, and information collection. A simulated voyage is deemed successful when the cruise ship operator illustrates to CDC that it is ready and able to mitigate the risks of COVID-19 onboard its cruise ship, or when a cruise ship operator demonstrates to CDC that it has addressed any identified deficiencies with its COVID-19 mitigation protocols.

9. Information Reporting and Sharing

Several comments were made regarding CDC’s information collection, the way in which that information is collected, and who the collected information should be shared with.

One commenter noticed that CDC’s information collection only applies to cruise ship operators and not cruise ship passengers. This individual argued that collecting passenger information is critical because passengers outnumber crew on cruise ships. CDC appreciates this comment, however, the CSO Extension applies to any person operating or intending to operate a foreign-flagged cruise ship in U.S. waters and to any person operating a foreign-flagged cruise ship outside of U.S. waters if the cruise ship operator intends for the ship to return to operating in U.S. waters while this Order remains in effect. As the CSO’s requirements do not apply to passengers, CDC does not collect information directly from passengers.

One fifth of the commenters asked CDC to include vaccination rates of passengers and crew onboard in the information collection. CDC requires cruise ship operators to submit the Enhanced Data Collection during COVID-19 Pandemic (EDC) form on a daily basis. Data points for this form include number of travelers (passengers and crew) currently onboard; case counts and diagnostic testing data for COVID-19 and COVID-like Illness (CLI); screening testing of asymptomatic travelers; isolation practices; and the percentage of travelers who are fully vaccinated.

One respondent would like CDC to compile and analyze all of the data received from cruise ship operators through its information collection to create a public report that assesses the safety of cruise ship travel during the COVID-19 pandemic. On a related note, one commenter believed that CDC should create a data base for public health statistics. CDC continually updates guidance, resources, and tools to inform decision-making as we learn more about COVID-19, please visit CDC’s Coronavirus Disease 2019 (COVID-19) for the most up-to-date information. With regards to cruise ship travel, CDC’s Cruise Ship Color Status and Cruise Ship Travel Health Notice webpages are regularly updated to keep the public informed of the COVID-19 situation on cruise ships.

One respondent would like CDC to make cruise ship operators’ Phase 2A agreements with ports of entry, healthcare organizations, and shoreside housing facilities available to the public. Similarly, one commenter feels that simulated voyage After Action Reports should be shared publicly. While CDC appreciates these commenters’ desire for increased transparency, information that concerns business trade secrets or other confidential commercial or financial information cannot be made public.

One commenter advised that cruise ship operators should be required to share a ship’s daily testing data with all passengers onboard. CDC has taken this comment into consideration, however, it must be noted that COVID-19 testing is not required to occur on a daily basis under the CSO.

Two commenters expressed concerns about how cruise ship operators submit the required information to CDC. In order to reduce the burden imposed on operators, they asked CDC to ensure that all information can be submitted electronically. Cruise ship operators may submit all required information to CDC’s Maritime Unit via email, except for the EDC form. The daily EDC form must be submitted electronically to Maritime Unit via REDCap(https://www.project-redcap.org/).

One comment to CDC recommended that the information collected from cruise ship operators be shared with all destination ports. Currently, CDC shares twice weekly data reports with state, territorial, and local health departments in jurisdictions where cruise ships port or travel on international itineraries, the Public Health Agency of Canada (PHAC), Transport Canada, the Caribbean Public Health Agency (CARPHA), the World Health Organization, and European Union Healthy Gateways. These reports include information provided to CDC via daily EDC reporting.

10. Encouraging Compliance

Two respondents suggested that CDC provide financial incentives, such as tax breaks, to cruise ship operators that comply with requirements under the CSO. With the exception of cruise ships operating out of Florida ports, cruise ship operators are obligated to follow the CSO’s requirements. Furthermore, CDC does not have the authority to provide such incentives.

In light of the Preliminary Injunction Order, entered by the U.S. District Court for the Middle District of Florida on June 18, 2021, another commenter would like for CDC to encourage safe cruise travel in Florida in creative ways. As of July 23, 2021, the CSO and accompanying measures, such as technical instructions, are nonbinding recommendations for cruise ships arriving in, located within, or departing from a port in Florida. CDC is continuing to operate the CSO as a voluntary program in Florida for such ships that choose to follow the CSO’s measures voluntarily. As of October 7, 2021, all cruise ships arriving in, located within, or departing from a port in Florida have opted-in to the CSO.

11. Timing of the Resumption of Cruise Ship Passenger Operations

One quarter of respondents agreed that it is not yet an appropriate time to resume cruise ship operations during the COVID-19 Pandemic. While CDC recognizes cruising will never be a zero-risk activity for spread of COVID-19, we have successfully worked with cruise ship operators to manage this risk and allow cruise ship operators to resume passenger operations in a way that mitigates the risk to crew members, passengers, port personnel, and communities.

Another respondent thought, following the expiration of the CSO, CDC should not impose any health and safety requirements on cruise ships. This respondent wished for the return of the pre-pandemic status quo on November 1, 2021. Since the issuance of the CSO, cruise lines, with CDC assistance, have resumed passenger operations and successfully developed and implemented health and safety protocols to manage COVID-19 that have averted overwhelming onboard medical facilities and burdening shoreside hospital resources. However, considering the continued spread of the Delta variant, emergence of other COVID-19 variants of concern, breakthrough cases among the fully vaccinated, and expected additional surges of cases and deaths, CDC has determined a temporary extension of the CSO is necessary for foreign-flagged cruise ships operating on international itineraries.