Technical note to WHO AFRO Member States on international travel

1 Technical note to WHO AFRO Member States on international Travel 2 WHO/AF/EPR/EMR/05, 2022 © World Health Organization Regional Office for Africa, 2022 Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence 3 Technical note to Member States of the WHO African Region on international travel Priority actions for Member States: Globally, the number of new COVID-19 cases and deaths has continued to decline since the end of March 2022, although the interpretation of the downward trend must take into account the changes in testing strategies initiated by several countries (1).The African Region has continued to report a decreasing trend in new cases since January 2022, while deaths have dropped since February 2022 (2). With the increased population immunity in many of the Member States via vaccination and/or prior infection in the Region1 and the improved ability to detect and control SARS-CoV-2, particularly through PCR testing and genomic sequencing and augmented intensive care unit (ICU) and non-ICU beds, Member States are encouraged, as long as they follow the risk-based approach principles (3), to: • lift or adjust international travel measures at points of entry (PoEs) including PCR tests on arrival and prior to departure; • lift international traffic bans; • apply individual protective measures (such as wearing masks covering the mouth and nose, hand hygiene, physical distancing, etc.) throughout the journey (3); • not require proof of vaccination against COVID-19 as the only pathway or condition permitting international travel (4); • implement at ground crossings, in addition to travel measures, interventions related to cross-border coordination and collaboration with neighbouring countries (5), the transnational ground transport industry (6) and cross-border communities. Background The coronavirus disease 2019 (COVID-19) pandemic continues to affect people's lives across the globe. The World Health Organization (WHO) at the global level developed and updated guidance to Member States on international travel, encouraging countries to take a multilayered risk management approach to reduce transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) associated with international travel (3)(7). WHO highlights the need to strengthen the monitoring of the occurrence of omicron variants and its lineages (8) and to adopt evidence- based measures (9). Some progress and achievements of the COVID-19 response have been observed in the WHO African Region, such as enhanced testing and tracing capacities, developed clinical case management capacities, improved genomic surveillance and vaccination.2 However, there have been four successive waves of the COVID-19 pandemic in the WHO African Region. Building on the successes mentioned above, the monitoring of the virus and the circulation of variants throughout the world (10) and Africa, this document adapts the global policy and technical guidance on international travel to the WHO African Region. The adaptation process considers the knowledge of WHO experts in the area in relation to the effectiveness, impact, relevance, feasibility, and utility of the interventions implemented to date in international traffic and points of entry 1 Rapid risk assessment, acute event of potential public health concern EMS Event ID 2020-E000001 2 WORLD HEALTH ORGANIZATION 2022. The Future of WHO COVID-19 Response Operation in Africa in 2022. Brazzaville, Congo: World Health Organization Regional Office for Africa. 4 (PoEs). This process also considers the need for the social and economic recovery of the countries in the Region, coupled with the continuous control of the SARS-CoV-2 virus in a way that it does not pose a threat to societies and livelihoods – particularly populations at highest risk – or overwhelm health systems and public health capacities. This document will enable African countries to better guide their interventions to avoid unnecessary interference with international traffic while remaining effective in responding to the pandemic and consequently fostering the social and economic recovery of the WHO African Region. Risk mitigation measures The measures should be commensurate with the risk, time-limited, evidence-based, and applied with respect for travellers’ dignity, human rights and fundamental freedoms. Two groups of measures are applied in a multilayered risk mitigation approach: the basic risk mitigation measures that should always be in place and the supplementary risk mitigation measures that should be guided by a risk assessment whose key guiding questions are included in the interim guidance: “Technical considerations for implementing a risk-based approach to international travel in the context of COVID-19” (3). Basic risk mitigation measures Travel advice All travellers should remain vigilant for signs and symptoms of COVID-19, get vaccinated when it is their turn and adhere to the public health and social measures (PHSM) that apply in each country at all times, including by using masks appropriately, respecting physical distancing, following good respiratory etiquette and avoiding crowded and poorly ventilated spaces (9). Persons who are unwell, or who have not been fully vaccinated or do not have recent (less than six months) SARS-CoV-2 infection and are at increased risk of developing severe disease and dying, including people aged 60 years or older or those with comorbidities that present increased risk of severe COVID-19 (for example, heart disease, cancer and diabetes), should be advised to postpone travel to areas with community transmission (9). All travellers must follow recommendations and continue to adhere to personal protective measures such as the use of masks and physical distancing both while on board conveyances and at PoEs (3). International travellers should understand that their countries of departure and arrival may have different epidemiological situations and therefore be on different levels of PHSM implementation as per WHO guidance on a risk-based approach. It is therefore important to source information from the country of intended arrival ahead of embarkation on international travels. Self-monitoring for international travellers WHO recommends that travellers should self-monitor for the potential onset of symptoms for 14 days on arrival and report symptoms and travel history to local health authorities, as per instructions received by authorities in the host country, prior to departure and/or on arrival. The relevant information and instructions should be provided on how and when to contact local health authorities and on the arrangements to be made by the health authority to supervise the self-monitoring for prompt action (3). 5 Environmental controls and public health and social measures at points of entry Crowd control by increasing the number of security and passport control booths to shorten queues, physical distancing, mask use and hand hygiene measures should be put in place to minimize the risk of transmission at PoEs during check-in, passport control, in rest rooms, security areas, areas for interviewing COVID-19 suspected cases, waiting areas, boarding, disembarking, customs, baggage pick-up and any other areas where travellers congregate. Appropriate cleaning and disinfection procedures should be followed as per WHO guidance, with particular emphasis on surfaces that are frequently touched (3). Engage in cross-border collaboration for managing crowding at ground crossings by organizing and synchronizing travellers’ movements across the ground crossing. Environmental controls and public health and social measures on conveyances Environmental control measures and PHSM should be promoted and complied with on board conveyances (3) in accordance with the ICAO Council Aviation Recovery Task Force (CART) Take-off: Guidance for Air Travel through the COVID-19 Public Health Crisis (11), and International Maritime Organization (IMO) COVID-19 guidance (12). International contact tracing International contact tracing should be rapidly conducted when a cluster or chain of SARS-CoV-2 transmission involves more than one country in a coordinated and collaborative manner through national IHR focal points (NFPs) in line with WHO guidance for contact tracing (13). Bilateral exchanges between countries may facilitate case investigation aimed at identifying the source of infection and requiring retrospective tracing of cases up to two weeks before an identified case developed symptoms or was tested positive. International contact tracing is particularly important for countries with no cases, imported/sporadic cases or a small number of cluster cases. International contact tracing may be challenging in countries where community transmission is ongoing and surveillance capacities are overwhelmed (3). With the WHO strategy on contact tracing and quarantine shifting its objective from interrupting all chains of transmission to reducing morbidity and mortality, especially among vulnerable groups, national authorities, when conducting international contract tracing, may choose to prioritize vulnerable contacts, including people older than 60 years, immunocompromised patients, or people with multiple comorbidities. Supplementary risk mitigation measures Exit and entry screening for signs and symptoms of COVID-19 Temperature screening: Temperature screening using infra-red hand-held thermometers or scanners at PoEs should be reviewed. Historically, temperature screening at PoEs has been implemented for a variety of diseases. However, there is currently no high-quality evidence available to support entry screening based on temperature measurement as an effective COVID-19 control measure. WHO encourages countries that are implementing temperature measurement at exit and/or entry to share their evaluations of the use of this measure, since they are critical to building an evidence base and increasing the 6 understanding of its effectiveness and impact in the context of COVID-19 (3). Visual screening and interviewing passengers: WHO recommends visual screening of departing and arriving travellers for signs and symptoms (for example, coughing and difficulty breathing) and interviewing passengers (when necessary) about signs and symptoms and any exposure to confirmed or probable cases during the 14 days prior to travelling (3). SARS-CoV-2 testing for international travellers Testing travellers before departure and on arrival does not mean that they cannot spread the virus during and after travel as they could have been recently infected with SARS-CoV-2 and could be incubating the disease. Furthermore, verifying the authenticity of test results across different countries remains a challenge. Using an rRT-PCR test on patients who have clinically recovered and have built an antibody response to the virus, could be positive while they are not considered infectious (14). Nucleic acid amplification testing (NAAT), such as real-time reverse- transcription polymerase chain reaction (rRT-PCR) could be limited at PoEs. The infrastructure and biosafety requirements for molecular testing in a laboratory are stringent and the PoE should meet this standard. The slow turnaround time will either increase crowding at the point of entry and disrupt physical distancing or require the traveller’s release with the test result subsequently sent to the traveller. Therefore, strict measures such as digital tracing tools or apps for easy tracking of travellers should be in place to easily trace positive cases and follow up contacts if necessary. A country that has the capacity to conduct testing for incoming travellers, may adopt a risk-based approach by using antigen-detecting rapid diagnostic tests (Ag-RDTs) where access to rRT-PCR is limited. They are easy to use, offer rapid turnaround of results (15) and have a lower sensitivity compared to nucleic acid amplification testing (NAAT) (16). “WHO Emergency Use Listing”(17) sets Ag-RDTs that are highly reliable. However, the use of Ag- RTDs must take into account the fact that travellers are considered to be a low-prevalence population, and that the risk of false positive results is high (low predictive value). Confirmatory testing with NAAT following positive Ag-RDT is strongly advised (16). Countries should share their rationales. Quarantine for international travellers In line with the individualized approach to public health measures, countries may consider fully vaccinated (two weeks at least prior to travelling) or recovered individuals (within six months prior to travelling and no longer infectious as per WHO criteria for releasing COVID-19 patients from isolation) (18) as lower-risk travellers and may consider waiving testing and/or quarantine for arriving international travellers. Such decisions should be based on a detailed risk assessment that considers the COVID-19 control objectives of the destination country and the transmission and impact of the new variants of concern (VOC) on the national system’s capacities in the departure country (19). 7 Border closure or suspension of travel International traffic bans, including border closures and suspension of flights, do not prevent the international spread of the new variant, and they place a heavy burden on lives and livelihoods. In addition, they can adversely impact global health efforts during a pandemic by disincentivizing countries to report and share epidemiological and sequencing data (9). WHO recalls that in the context of the COVID-19 pandemic, international travel should always be prioritized for emergencies and humanitarian actions; travel by essential personnel; repatriations; and cargo transport of essential supplies such as food, medicines and fuel (9). Other keys considerations applied to risk mitigation measures Proof of COVID-19 vaccination in the context of international travel Countries do not require proof of vaccination against COVID-19 for international travel as the only pathway or condition permitting international travel. States Parties should consider a risk- based approach to the facilitation of international travel (4). Ground crossings Ground crossings are often characterized by complex and varied environments with porous borders and larger cross-border communities, usually with strong social and economic connections. Various means of transport ranging from trains, trucks (lorries), buses, automobiles, motorcycles or bicycles and animals are used to cross the border. Some people even pass through on foot. In such settings, in addition to a risk-based approach implementing the PHSM measures (masking, physical distancing, hand hygiene, respiratory hygiene) at all PoEs, ground crossings should consider the below interventions: - Cross-border coordination and collaboration could include harmonization of surveillance at PoEs, international contact tracing, joint vaccination campaigns and information-sharing with neighbouring countries (5). - The transnational ground transport industry should be sensitized on risk communication, PHSM, vaccination, coordination between the PoE and the country, public health surveillance system for contact tracing (6). Countries should raise awareness among cross-border communities on implementing surveillance, risk communication and community engagement (RCCE), PHSM, vaccination and case management activities leading to reduced prevalence and incidence of COVID-19 in those communities that move easily across borders. Risk communication It is essential to proactively communicate information that is clear, consistent, in appropriate language and supported by easy-to-understand images, agreed on by all entities needing to convey messages to the travelling public and those managing the travel process. Messages should be conveyed to travellers in advance of their trip to help them with personal planning. To combat misinformation and disinformation, messages should also be shared with the general public and operators through traditional media, social media, COVID-19 helplines and travel websites (such as airline, airport and hotel booking sites) (3). 8 Costs associated with public health measures for international travel In the context of the COVID-19 pandemic, and given the high costs associated with measures required in many countries for international travellers as a condition of entry or exit, countries are advised to reduce the current financial burden on international travellers for the measures applied to them for the protection of public health (for example, testing, isolation/quarantine, and vaccination) (4)(3)(20). 9 References 1. Weekly epidemiological update on COVID-19 - 20 April 2022 [Internet]. (https://www.who.int/publications/m/item/weekly-epidemiological-update-on-covid-19--- 20-april-2022, accessed 21 April 2022) 2. OEW16-1111720422022.pdf [Internet]. (https://apps.who.int/iris/bitstream/handle/10665/353351/OEW16-1111720422022.pdf, accessed 21 April 2022) 3. WHO-019-nCoV-Risk-based-international-travel-2021.1-eng.pdf [Internet]. (https://apps.who.int/iris/bitstream/handle/10665/342212/WHO-019-nCoV-Risk-based- international-travel-2021.1-eng.pdf?sequence=1&isAllowed=y, accessed 8 November 2021) 4. Statement on the eleventh meeting of the International Health Regulations (2005) Emergency Committee regarding the coronavirus disease (COVID-19) pandemic [Internet]. (https://www.who.int/news/item/13-04-2022-statement-on-the-eleventh-meeting-of-the- international-health-regulations-(2005)-emergency-committee-regarding-the-coronavirus- disease-(covid-19)-pandemic, accessed 18 April 2022) 5. World Health Organization. Handbook for public health capacity-building at ground crossings and cross-border collaboration [Internet]. Geneva: World Health Organization; 2020 (https://apps.who.int/iris/handle/10665/331534, accessed 18 March 2022) 6. CROSS-BORDER MANAGEMENT OF COVID-19 OUTBREAK IN EAST & SOUTHERN AFRICA_0.pdf [Internet]. (https://www.afro.who.int/sites/default/files/Covid- 19/Techinical%20documents/CROSS-BORDER%20MANAGEMENT%20OF%20COVID- 19%20OUTBREAK%20IN%20EAST%20%26%20SOUTHERN%20AFRICA_0.pdf, accessed 18 March 2022) 7. WHO-2019-nCoV-Policy-Brief-Risk-based-international-travel-2021.1-eng.pdf [Internet]. (https://apps.who.int/iris/bitstream/handle/10665/342235/WHO-2019-nCoV-Policy-Brief- Risk-based-international-travel-2021.1-eng.pdf?sequence=1&isAllowed=y, accessed 8 November 2022) 8. Statement on Omicron sublineage BA.2 [Internet]. (https://www.who.int/news/item/22-02- 2022-statement-on-omicron-sublineage-ba.2, accessed 8 March 2022) 9. WHO advice for international traffic in relation to the SARS-CoV-2 Omicron variant (B.1.1.529) [Internet]. (https://www.who.int/news-room/articles-detail/who-advice-for- international-traffic-in-relation-to-the-sars-cov-2-omicron-variant, accessed 8 March 2022) 10. Update on SARS-CoV-2 variants of interest and variants of concern | EIS [Internet]. (https://extranet.who.int/ihr/eventinformation/announcement/41102-update-sars-cov-2- variants-interest-and-variants-concern, accessed 15 March 2022) 11. CART III_Take-off Guidance for Air Travel through the COVID-19 Public Health Crisis.en.pdf [Internet]. (https://www.icao.int/covid/cart/Documents/CART%20III_Take- off%20Guidance%20for%20Air%20Travel%20through%20the%20COVID- 19%20Public%20Health%20Crisis.en.pdf, accessed 10 March 2022) 12. Circular Letter No.4204-Add.4-Rev.3 - Coronavirus (Covid-19) - Ics Guidance For Ship Operators.pdf [Internet]. (https://wwwcdn.imo.org/localresources/en/MediaCentre/HotTopics/Documents/COVID%2 10 0CL%204204%20adds/Circular%20Letter%20No.4204-Add.4-Rev.3%20- %20Coronavirus%20%28Covid-19%29%20- %20Ics%20Guidance%20For%20Ship%20Operators.pdf, accessed 10 March 2022) 13. Contact tracing and quarantine in the context of the Omicron SARS-CoV-2 variant: interim guidance [Internet]. (https://www.who.int/publications-detail-redirect/WHO-2019-nCoV- Contact-tracing-and-quarantine-Omicron-variant-2022.1, accessed 8 March 2022) 14. WHO-2019-nCoV-Sci_Brief-international_travel_testing-2020.1-eng.pdf [Internet]. (https://apps.who.int/iris/bitstream/handle/10665/337832/WHO-2019-nCoV-Sci_Brief- international_travel_testing-2020.1-eng.pdf?sequence=1&isAllowed=y, accessed 8 November 2021) 15. Recommendations for national SARS-CoV-2 testing strategies and diagnostic capacities [Internet]. (https://www.who.int/publications-detail-redirect/WHO-2019-nCoV-lab-testing- 2021.1-eng, accessed 17 March 2022) 16. Antigen-detection in the diagnosis of SARS-CoV-2 infection [Internet]. (https://www.who.int/publications-detail-redirect/antigen-detection-in-the-diagnosis-of-sars- cov-2infection-using-rapid-immunoassays, accessed 17 March 2022) 17. 201202_eul_sars_cov2_product_list_.pdf [Internet]. (https://extranet.who.int/pqweb/sites/default/files/documents/201202_eul_sars_cov2_produc t_list_.pdf, accessed 17 March 2022) 18. Criteria for releasing COVID-19 patients from isolation [Internet]. (https://www.who.int/publications-detail-redirect/criteria-for-releasing-covid-19-patients- from-isolation, accessed 28 March 2022) 19. Considerations for implementing and adjusting public health and social measures in the context of COVID-19 [Internet]. (https://www.who.int/publications-detail- redirect/considerations-in-adjusting-public-health-and-social-measures-in-the-context-of- covid-19-interim-guidance, accessed 8 March 2022) 20. Statement on the tenth meeting of the International Health Regulations (2005) Emergency Committee regarding the coronavirus disease (COVID-19) pandemic [Internet]. (https://www.who.int/news/item/19-01-2022-statement-on-the-tenth-meeting-of-the- international-health-regulations-(2005)-emergency-committee-regarding-the-coronavirus- disease-(covid-19)-pandemic, accessed 8 March 2022) 11 For further information, please contact Dr Aurelien Pekezou Tchoffo – WHO AFRO Regional COVID-19 IMS Point of Entry Lead, WHO Regional Office for Africa Contact: pekezoua@who.int Dr Thierno Balde – WHO AFRO Regional COVID-19 IMS Incident Manager, WHO Regional Office for Africa Contact: baldet@who.int Dr Abdou Salam Gueye – Regional Emergency Director, Emergency Preparedness, and Response, WHO Regional Office for Africa Contact: gueyea@who.int List of contributors Dr Aurelien Pekezou Tchoffo - WHO Regional Office for Africa, Republic of Congo, Brazzaville Dr Boniface Otieno Oyugi - WHO Regional Office for Africa, Republic of Congo, Brazzaville Dr Nonso Ejiofor Ephraim - WHO Regional Office for Africa, Republic of Congo, Brazzaville Dr Mary Stephen - WHO Regional Office for Africa, Republic of Congo, Brazzaville Dr Ninglan Wang - WHO Headquarters, Geneva, Switzerland Dr Primous Togbemabou Godjedo - WHO AFRO Emergencies Hub, Senegal Dr Sara Barragan Montes - WHO Headquarters, Geneva, Switzerland Dr Solomon Woldetsadik Fisseha - WHO AFRO Emergencies Hub, Kenya Dr Thierno Balde - WHO Regional Office for Africa, Republic of Congo