Editorial
COVID-19
travel
restrictions
and
the
International
Health
Regulations
–
Call
for
an
open
debate
on
easing
of
travel
restrictions
The COVID-19 pandemic caused by the novel coronavirus (SARS-CoV-2) has caused national governments worldwide to mandate several generic infection control measures such as physicaldistancing,self-isolation, andclosureof non-essential shops,restaurantsschools,amongothers.Somemodelssuggest physical distancing would have to persist for 3 months to mitigatethepeakeffectsonhealthsystemsandcouldberequired onan intermittent basis for12 to18 months(Flaxman et al., 2020).
Apartfromthesecontrolmeasurestravelrestrictionsduringthe early phase of theChina outbreak wereuseful toconfineit to Wuhan,themajorsourceoftheoutbreak(Kraemeretal.,2020) althoughultimatelythesemeasuresdidnotpreventthespreadof COVID-19tootherregionsofChina.Theglobalspreadofthe SARS-CoV-2hasclearlybeenassociatedwithregionalandinternational travelwhich has contributed to the pandemic (Candido et al., 2020).Tolimitcross-borderspread,bothregionallyandglobally, manycountrieshaveswiftlyadoptedsweepingmeasures, includ-ingfulllockdownsofshops,companies,shuttingdownairports, imposingtravelrestrictionsandcompletelysealingtheirborders, tocontaintransmission(GostinandWiley,2020).Thegroundingof internationaltravelaspartoftheglobalresponsetopreventspread has caused profound disruption of travel and trade and has threatenedthesurvivalof manyairlines, travelcompanies,and associatedbusinesses.
Travelbanstoaffectedareasordenialofentrytopassengers comingfromaffectedareasareusuallynoteffectiveinpreventing theimportationofcasesbuthaveasignificanteconomicandsocial impact.SincetheWHOdeclarationofapublichealthemergencyof internationalconcernon30January2020,andasof8thApril,2020, 180countrieshavereportedtoWHOadditionalhealthmeasures thatsignificantlyinterferewithinternationaltrafficinrelationto traveltoandfromChinaorothercountries,rangingfromdenialof entryofpassengers,visarestrictionsorquarantineforreturning travellers(WHO,2020a).Tore-starttheworldeconomyagainit willbeimportanttoeasetravelrestrictionsassoonaspossible. Whilsttravelrestrictionmeasuresthatsignificantlyinterferewith international traffic may be justified at the beginning of an outbreak,sincetheyallowcountriestimetoimplementeffective preparedness measuresbased oncareful risk assessment, they shouldbebasedonareasonedscientificevaluationoftheavailable
evidenceontheirpossibleeffectiveness.Theyshouldalsobe time-limitedandreconsideredandrevisitedonaregularbasisasbetter information on both the effectiveness and the socio-economic impactof themeasuresemerges. Thus an opendebateis now requiredonwhenandhowtheyneedtobelifted.Thisdebatecould usefully be framed in the context of the International Health Regulations.
The purposeof theWHO InternationalHealth Regulations (WHO,2020b)isto‘prevent,protectagainst,controlandprovidea publichealthresponse totheinternational spreadofdiseasein waysthatarecommensuratewithandrestrictedtopublichealth risks,andwhichavoidunnecessaryinterferencewithinternational trafficand trade’.TheIHRarefocussedonpublichealthevents where4keyconsiderationsarepresent(WHO,2005):
1.Isthepublichealthimpactoftheeventserious? 2.Istheeventunusualorunexpected?
3.Isthereasignificantriskofinternationalspread?
4.Is there a significant risk of international travel or trade restrictions?
InthecaseofCOVID-19,theanswertoalltheabovequestionsis ‘YES’ and this is what led to the Emergency Committee recommendingtotheDirectorGeneralinJanuarythatCOVID-19 constitutedaPublicHealthEmergencyofInternationalConcern. WithintheIHRthedeclarationofaPHEICopensupthepossibility forWHOtomakeTemporaryRecommendationsonmeasuresthat shouldbeimplementedtohelpbringtheeventundercontrol.The COVID-19EmergencyCommitteemadea wide rangeof recom-mendationtotheDirectorGeneralbuttheCommitteespecifically stated“TheCommitteedoesnotrecommendany travelortrade restrictionbasedonthecurrentinformationavailable”.
The WHO's advice, based on many years of international outbreakresponse,wasconsideredbymanytobereasonableand evidence-basedbuttherecommendationontravelrestrictionshas not beenheededbygovernments andpoliticiansin thefaceof rapidspreadofCOVID-19betweencountries.Thishighlightsthe apparent dissonance between scientific advice and political realities[and indeedpublicperception]. Asmany countriesare now approachingthe peak orflattening phase ofthe epidemic curvethis dissonancewillagain becomeforefrontand anopen
https://doi.org/10.1016/j.ijid.2020.04.029
1201-9712/CrownCopyright©2020PublishedbyElsevierLtdonbehalfofInternationalSocietyforInfectiousDiseases.ThisisanopenaccessarticleundertheCCBY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).
InternationalJournalofInfectiousDiseases94(2020)88–90
ContentslistsavailableatScienceDirect
International
Journal
of
Infectious
Diseases
debateisrequiredonliftingoftravelrestrictions.Severalquestions needtobeconsidered:
1.Why have several countries systematically ignored WHO's adviceonnotrestrictingtravelduringtheCOVID-19outbreak? Isitthattheadvicewasconsideredwrongorthattheadvicewas inconsistentwiththepublicperceptionthatclosingborderswas a“sensible”thingtodo?
2.Giventhatcountrieshaveunilaterallymadedecisionstoclose downinternationaltravel,howcanwegetbetterscienceand evidenceintodecisionsaboutlifting theserestrictions asthe outbreak resolves sothat internationaltrade and theglobal economycanstarttorecover?Itseemsinevitablethatcountries willmoveatdifferentspeedstothesedecisions,reflectingthe differentevolutionoftheoutbreakineachcountry.Promotinga risk-basedapproachtoliftingthetravelrestrictionsthatmight varyfromcountrytocountrycouldprovideawayforwardbutit will need a degree of international coordination to avoid a random, possibly chaotic, certainly confusing, and probably ineffectiveprocess.ThiscoordinationshouldcomefromWHOin linewiththe mandategivento WHOby themember states through the IHR. Countries with still very few cases and potentialtoarrestandeliminatethefewcasesthattheyhave, shouldnot openuptravelwithoutverystrictquarantine for arrivals.Thiscouldreducetheconflictbetweenscience-based adviceandpoliticaldecisionmaking.
3.Whatmitigatingmeasureswillbeavailabletoreducetheriskof a resurgence of the outbreak as public health measures, includingtravelrestrictions,areeased?Inparticularwhatrole (if any) will PCR and immunity (serology) testing play in managingtheimpactofliftingrestrictions?Itwillbeimperative that countrieseasingrestrictions(whether social or physical distancing ortravel restrictions)haveinplace resourcesand capacityfordetecting,testingandquarantiningallnewcases arisingaswellastracingandtrackingallcontacts.
TherehasbeenevidenceofglobalcapacityissueswithPCRtests andpossiblyofmarketinfluencing tosecuretesting capacityin somecountries.Shouldtherebe,withinthespiritoftherecentG20 statement (G20, 2020), international cooperation facilitated by WHOtoensuretestingcapacityismadeavailableinamanaged waytocountriesasandwhentheyneeditmost?Indeed,theWHO the7thAprilcertifiedthefirsttwoPCRtests(WHO,2020c)and adviceontheuseofpoint-of-caretests(WHO,2020d).
ThemajorityofpersonswhohavebeeninfectedSARS-CoV-2 recoverand appeartobeimmuneand non-infectious(Toetal., 2020)althoughrecurrencehavebeenreportedbutneedfurther confirmation(Zhouetal.,2020).Wedonotknowforhowlongsuch immunitylastsbutneutralizingantibodieswasfoundmorethan two years after infection with SARS-CoV (Wu et al., 2007). A validated, specific and sensitive test to detect SARS-CoV-2-specific-IgGis urgentlyrequiredtosupportcountries’efforts to controltheoutbreak.Thereiscurrentlynoevidencetorecommend serologyasanimmunitypassportandwedonothaveany long-termdataabouthoweffectiveandlong-lastingimmunitymightbe but there will undoubtedly be pressure to implement such measures.It wouldbehelpfulifthiswas coordinatedtoensure a consistent approach globally, with consistent standards and requirements,andsuchanapproachisalsoclearlywithinWHO's IHRmandate.
AsSARS-CoV-2continuestospreadacrossdifferent geographi-calregions,withdifferentepidemiologicalpatternsbeingseen,we awaithowitwillevolveovertimeandacrossseasons[inboththe north and south hemisphere]. Meanwhile ongoing proactive surveillance shouldbe maintained and the searchfor effective serologicaltests,treatmentsandvaccinesbepursuedvigorously.
As we start toemerge from the initial phase of the outbreak, internationalcooperation,collaboration,leadershipandauthority willbecritical–wherewillitcomefrom?
Authordeclarations
All authors have a specialist interest in emerging and re-emergingpathogensandreportnopotentialconflicts.
Acknowledgments
FrancineNtoumi,NathanKapata,RichardKockandAlimuddin ZumlaaremembersinvestigatorsofthePan-AfricanNetworkon EmergingandRe-EmergingInfections[PANDORA-ID-NET;https:// www.pandora-id.net/] funded bythe Europeanand Developing Countries Clinical Trials Partnership, the EU Horizon 2020 Framework Program for Research and Innovation. A. Z. is in receiptofanNIHResearchSeniorInvestigatoraward.
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EskildPetersen* InstituteforClinicalMedicine,FacultyofHealthSciences,University ofAarhus,Denmark,andDirectorateGeneralforDiseaseSurveillance andControl,MinistryofHealyh,Muscat,Oman,andEuropeanSociety forClinicalMicrobiologyandInfectiousDiseases[ESCMID]TaskForce forEmergingInfections,Basel,Switzerland BrianMcCloskey CentreonGlobalHealthSecurity,ChathamHouse,RoyalInstituteof InternationalAffairs,London,UnitedKingdom
DavidS.Hui DepartmentofMedicine&Therapeutics,ChineseUniversityofHong Kong,PrinceofWalesHospital,Shatin,NewTerritories,HongKong, China RichardKock TheRoyalVeterinaryCollege,UniversityofLondon,Hatfield, Hertfordshire,UnitedKingdom FrancineNtoumia,b
aUniversitéMarienGouabi,FondationCongolaisepourlaRecherche
Médicale,Brazzaville,Congo
b
UniversityofTübingen,Germany ZiadA.Memisha,b
aResearchCentre,KingSaudMedicalCity,MinistryofHealth,Riyadh,
SaudiArabia
bCollegeofMedicine,AlfaisalUniversity,Riyadh,SaudiArabia
NathanKapata NationalPublichealthInstitute,MinistryofHealth,Lusaka,Zambia EsamI.Azhar KingFahdMedicalResearchCenter[KFMRC],FacultyofApplied MedicalSciences,KingAbdulazizUniversity,Jeddah,SaudiArabia MarjoriePollack InternationalSocietyforInfectiousDiseases,Boston,MA,USA LarryC.Madoffa,b
aInternationalSocietyforInfectiousDiseases,Boston,MA,USA bUniversityofMassachusetts,DivisionofInfectiousDiseases,
Worcester,MA,USA DavidsonH.Hamera,b
aDepartmentofGlobalHealth,BostonUniversitySchoolofPublic
Health,Boston,MA,USA
bSectionofInfectiousDisease,DepartmentofMedicine,Boston
UniversitySchoolofMedicine,Boston,MA,USA JeanB.Nachegaa,b,c
a
DepartmentofMedicineandCenterforInfectiousDiseases, StellenboschUniversity,CapeTown,SouthAfrica
bUniversityofPittsburghGraduateSchoolofPublicHealth,Pittsburgh,
PA,USA
cDepartmentsofEpidemiologyandInternationalHealth,Johns
HopkinsBloombergSchoolofPublicHealth,Baltimore,MD,USA N.Pshenichnayaa,b
aNationalMedicalResearchCenterofPhthisiopulmonologyand
InfectiousDiseases,Moscow,Russia
b
RostovStateMedicalUniversity,Rostov-on-Don,Russia AlimuddinZumla CenterforClinicalMicrobiology,DivisionofInfectionandImmunity, UniversityCollegeLondon,andNIHRBiomedicalResearchCentre, UCLHospitalsNHSFoundationTrust,London,UnitedKingdom * Correspondingauthor. E-mailaddresses:eskild.petersen@gmail.com(E.Petersen), BMcCloskey@chathamhouse.org(B.McCloskey), dschui@cuhk.edu.hk(D.Hui), rkock@rvc.ac.uk(R.Kock), fntoumi@fcrm-congo.com(F.Ntoumi), zmemish@yahoo.com(Z.Memish), nkapata@gmail.com(N.Kapata), eazhar@kau.edu.sa(E.Azhar), pollackmp@mindspring.com(M.Pollack), dhamer@bu.edu(D.Hamer), jnacheg1@jhu.edu(J.Nachega), a.i.zumla@gmail.com(A.Zumla). Received12April2020
