Operational framework for international travel-related public health measures in the context of COVID-19
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Operational framework for international travel-related public health measures in the context of COVID-19
© WHO
Operational framework for international travel-related public health measures in the context of COVID-19
Abstract. Continued community transmission of coronavirus disease 2019 (COVID-19) in most Member States of the WHO European Region means that international travel will continue to pose a particular challenge in the coming year. Member States should take appropriate measures to reduce transmission of SARS-CoV-2, the virus that causes COVID-19, during international travel, recognizing that a comprehensive set of public health measures adapted to the local epidemiological context and capacities can mitigate the risk substantially but cannot achieve “zero risk”. Therefore, a risk-based approach to international travel is needed, which prioritizes essential travel. The aim of this operational framework is to support Member States of the WHO European Region in their decision-making options with regard to international travel measures in the context of the constantly changing epidemiological situation across the Region and limited scientific evidence on the effectiveness of measures. Taking into account the practices, trends and lessons learnt in implementing travel restrictions over the past year, the framework establishes a coordinated approach by outlining guiding principles and considerations, risk-assessment criteria and indicators in areas such as local epidemiology in departure and destination countries, public health and health service capacity and performance, contextual factors and point-of-entry capacity. This will guide decisions on introducing, reintroducing or easing international travel measures. Document number: WHO/EURO:2021-3246-43005-60136 © World Health Organization 2021 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for noncommercial purposes, provided the work is appropriately cited, as indicated below. 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Contents
Acknowledgements
Acronyms
1. Background 8
2. Aim and objectives of the operational framework 9
3. Current provisions under the IHR on international travel 10
4. Guiding principles on the implementation of international travel measures 11
4.1 Legal and political principles 11
4.2 Ethical principles 11
4.3 Scientific principles 12
4.4 Multisectoral coordination and planning for disease prevention and control, 12
surveillance and case management
5. Key considerations on common international travel measures from WHO 13
and partners
5.1 Prioritizing selected groups of travellers from international travel restrictions 13
5.2 Exit and entry screening for signs and symptoms of COVID-19 13
5.3 SARS-CoV-2 testing before departure, on arrival and as follow-up tests 13
5.4 International contact-tracing, including health declaration forms and PLFs 14
before departure
5.5 Quarantine of travellers 14
5.6 Management of suspected cases 14
5.7 Proof of COVID-19 vaccination in the context of international travel 15
(digital or paper-based)
6. Generating and systematically reviewing the evidence to inform implementation 16
of international travel measures
7. Overview of WHO technical and operational support relevant to international 19
travel in the context of COVID-19 available to Member States
7.1 Guidelines, briefs and operational tools 19
7.2 Webinars and direct country support 19
7.3 Training 19
7.4 Simulation exercises and intra-/after-action reviews 20
8. Proposed risk-assessment criteria to implement a harmonized and coordinated 21
approach to travel measures in the WHO European Region
9. Conclusions and the way forward 24
References 25
Contents
Annex 1. Current practices on international travel in the context of COVID-19 29
A1.1 Entry bans 30
A1.2 SARS-CoV-2 testing for travellers 30
A1.3 Quarantine of international travellers 34
A1.4 Health declaration/entry forms 35
A1.5 Exit and entry screening for signs and symptoms of COVID-19 35
A1.6 Immunity certificates 35
A1.7 Vaccination certificates 35
A1.8 Euopean Union Digital COVID Certificate Initiative 36
A1.9 Enforcement mechanisms and costs associated 36
with international travel
A1.10 Communication and advice for international travellers 36
References 37
Annex 2. WHO catalogue of technical assistance at points of entry 39
Annex 3. Additional considerations from partners 44
A3.1 European Commission, Council of the European Union and
the European Centre for Disease Prevention and Control 44
A3.2 EU Healthy Gateways 45
References 46
© WHO / Hery Razafindralambo
Acknowledgements This document was developed by the Country Capacity Monitoring and Evaluation (CME) unit of the Country Health Emergency Preparedness (CPI) Department, WHO Regional Office for Europe, in consultation with WHO headquarters. The team comprised Ihor Perehinets, Tanja Schmidt, Ute Enderlein and Jennifer Addo. During the development of this guidance, the team received valuable contributions from colleagues of the COVID-19 Incident Management Team of the WHO Regional Office for Europe. Overall guidance was provided by the Regional Emergency Director at the WHO Regional Office for Europe, Dorit Nitzan, and the Incident Manager of the COVID-19 Incident Management Support Team (IMST), Catherine Smallwood. Special thanks go to colleagues at WHO headquarters for their technical contributions: Ninglan Wang, Sara Barragan Montes, Mika Kawano and David Bennitz. Sincere appreciation also goes to colleagues at the European Centre for Disease Prevention and Control and European Commission, who provided valuable input to this document. Acronyms COVID-19 coronavirus disease 2019 ECDC European Centre for Disease Prevention and Control EU European Union EASA European Union Aviation Safety Agency IATA International Air Transport Association ICAO International Civil Aviation Organization IHR International Health Regulations IPC infection prevention and control ITH GDG (WHO) International Travel and Health Guideline Development Group LAMP loop-mediated amplification (test) PCR polymerase chain reaction (test) PHSM public health and social measures PLF passenger locator form PoE point of entry RT reverse transcriptase rRT-PCR real-time reverse transcriptase-polymerase chain reaction (test) Rt reproductive number SARS-CoV-2 severe acute respiratory syndrome coronavirus-2 SPAR State Party Self-Assessment Annual Reporting Tool TMA transcription-mediated amplification (test) UI uncertainty interval VOC variant of concern
8 Operational framework for international travel-related public health measures in the context of COVID-19
1. Background
From the beginning of the coronavirus disease epidemiological and transmission scenarios
2019 (COVID-19) pandemic, a package of public and socioeconomic situations.
health and social measures (PHSM) has been
implemented by all countries to prevent and curb Central to WHO’s position is that all essential
the spread of the disease. The permeability of travel should be prioritized, while risks related to
points of entry (PoE) for passengers and cargo flow non-essential travel should be managed in line
varies greatly and countries have implemented with WHO’s risk-based recommendations. WHO
measures at different points in time according to recommends that national policies on international
their epidemiological situation and health system travel measures are based on a continuous risk
capacity, and economic and political situations. assessment of the country of departure with the
country of destination (3), and that these are in line
As the COVID-19 pandemic continues, Member with the legal obligation of all States Parties to the
States are implementing and adjusting international IHR. All measures for travel restrictions at borders
travel measures to reduce importation, exportation should be implemented in conjunction with risk-
and onward transmission of severe acute mitigation measures such as mask-wearing, hand
respiratory syndrome coronavirus-2 (SARS-CoV-2), hygiene, respiratory etiquette, physical distancing
often in line with their health system capacity. and good ventilation.
Not all measures, however, are coordinated with
neighbouring or other countries, and they do not
always correspond to the requirements of the
International Health Regulations (IHR) (2005) (1).
In line with the need for a harmonious and
coordinated approach to the implementation of
international travel measures, the sixth meeting
of the International Health Regulations (2005)
Emergency Committee regarding the COVID-19
pandemic advised WHO to lead the development
of risk-based international standards and guidance
for reducing SARS-CoV-2 transmission related
to international travel (by air, land and sea). The
standards and guidance would be based on current
science and good practices and should include
clear recommendations for testing approaches and
quarantine duration, as appropriate (2).
Despite the reporting and collecting of a wealth © WHO
of data on international travel measures during the
past year, analysis of their effectiveness and their
impact on reducing the transmission of COVID-19
remains sporadic and inconclusive. Further
research is needed to discern clearer answers on
the effectiveness of measures under different
Operational framework for international travel-related public health measures in the context of COVID-19 9
2. Aim and objectives of the operational
framework
The aim of the operational framework is to support The framework has three annexes:
Member States in their decision-making options
with regard to international travel measures in the
· Annex 1. Current practices on international travel
in the context of COVID-19;
context of the constantly changing epidemiological
situation across the Region and limited scientific · Annex 2. WHO catalogue of technical assistance
evidence on the effectiveness of measures. at PoE; and
Considering practices, trends and lessons learnt in
· Annex 3. Additional considerations from partners
(including the European Commission, Council
implementing travel restrictions over the past year,
of the EU and the European Centre for Disease
the framework establishes a coordinated approach
Prevention and Control).
by outlining guiding principles and considerations,
risk-assessment criteria and indicators in areas such
as local epidemiology in departure and destination
countries, public health and health service capacity
and performance, contextual factors and PoE
capacity. This will guide decisions on introducing,
reintroducing or easing international travel
measures.
The proposed criteria will be reassessed
continuously throughout the course of the
pandemic, taking into account the changing
epidemiological situation and health system
capacity in countries.
The full list of criteria and indicators is provided in
Chapter 8. Additional recent factors also need to be
considered, such as the introduction of vaccination
and the spread of new SARS-CoV-2 variants of
concern (VOCs) in the Region.
© WHO / Ajay Maharjan
10 Operational framework for international travel-related public health measures in the context of COVID-19
3. Current provisions under the IHR
on international travel
The IHR (1) is the main international legally binding
agreement that addresses the international spread
of disease in ways that are commensurate with,
and restricted to, public health risks, and which
avoid unnecessary interference with international
traffic and trade. The aim of the IHR is to prevent,
protect against, control and provide a public
health response to the international spread of
disease, particularly during public health events
of international concern. The IHR also includes
provisions aimed at reducing the risk of disease
spread at international airports, ports and ground © WHO / P. Phutpheng
crossings.
Articles 22–25, 27, 28 and 37–39 provide regulations
on management and conveyances in the context
The rights and responsibilities of PoE are clearly
of public health threats. Articles 35 and 36 and
stated in paragraphs V–VIII and Annex 1B of the
Annexes 6 and 7 include provisions for the use
IHR. These specifically outline PoE core capacities
of the International Certificate for Vaccination or
and their obligation to build up relevant public
Prophylaxis, according to the model presented in
health capacity, identify competent authorities
Annex 6. Article 40 deals with charges for health
and report to WHO relevant data concerning
measures regarding travellers, which in only a
sources of infection or contamination, particularly
few exceptional cases, should not be paid for by
at designated PoE.
travellers.
Articles 30–32 are relevant for travellers under
Articles 42 and 43 outline reporting requirements
public health observation, who should be allowed
for implementation of health measures. These
to continue travelling if they do not pose an
should be applied in a transparent and non-
imminent public health risk and are reported to
discriminatory manner and in accordance with
health authorities at their final destination for
relevant national law and obligations under
follow up. Health measures relating to entry
international law.
of travellers should exclude invasive medical
examination, vaccination or other prophylaxis as
an entry condition. The IHR also mandates the
treatment of travellers with respect for dignity,
human rights and fundamental freedoms.Operational framework for international travel-related public health measures in the context of COVID-19 11
4. Guiding principles on the implementation
of international travel measures
International travel restrictions applied to prevent 4.2 Ethical principles
the importation or spread of COVID-19 must be International travel during the COVID-19 pandemic
based on appropriate legal, political, ethical and should always prioritize emergencies and
scientific principles, and on a strong mechanism humanitarian actions, travel of essential personnel
for multisectoral coordination. such as daily commuters and international workers,
repatriations, cargo transport for essential supplies
4.1 Legal and political principles such as food, medicines and fuel, crew changes
National authorities may implement risk-mitigation and urgent family reasons.
measures that restrict international traffic if such
measures are: Decisions on risk mitigation must be weighed
against the impacts the measures have on
· in accordance with their national legislation societies, including effects on mental health
and relevant provisions of the IHR;
and psychosocial well-being, human rights,
· risk-based; food security, the economy and socioeconomic
· evidence-based; disparities, the continuity of health and public
health programmes, and public sentiment and
· coherent; adherence.
· proportionate to the public health risk; Article 40 of the IHR states that no charge shall
· not constituting unnecessary interference be levied by a State Party for measures intended
with international traffic and trade. to ascertain the health status of a traveller who
is examined for the protection of public health.
Restrictions to free movement should be applied
National authorities therefore would need to
in a non-discriminatory manner with respect for
identify resources and mechanisms to cover the
the principle of proportionality and should not
cost of tests performed on travellers.
be unilaterally imposed, in case they have a
significant impact on other Member States. Prior No discrimination should be applied by Member
consultations are therefore essential. States through, for instance, applying more
generous rules to travellers from a neighbouring
Introduction, adjustment and discontinuation of
country and less generous ones to those from
risk-mitigation measures should be based on a
other countries experiencing the same
thorough risk assessment conducted systematically
epidemiological situation. Relevant exceptions
and regularly (ideally every two weeks) (4).
to border communities nevertheless may apply.
At the European Union (EU) level, countries
Clear and comprehensive information about
are called to implement the Council of the EU
restrictions and applicable requirements should
recommendations for a coordinated approach
always be made widely available to the public and
to free movement (4) and its updates, based on
in as many languages as is reasonable or necessary.
specified epidemiological criteria mapped by
the European Centre for Disease Prevention and When feasible, measures should be adopted
Control (ECDC) (5). (or lifted) in a controlled, step-wise manner, and
should be well communicated to citizens, residents
and neighbouring countries to allow better
understanding of the effects of each measure on
transmission dynamics and coordination between
countries.12 Operational framework for international travel-related public health measures in the context of COVID-19
4.3 Scientific principles 4.4 Multisectoral coordination and planning for
The gradual lifting of travel restrictions should disease prevention and control, surveillance
be based on a thorough risk assessment that and case management
considers country context, local epidemiology National and, where needed and applicable,
and transmission patterns, including circulation subnational authorities involved in the risk
of VOCs, national health and social measures to assessment process should (3):
control the outbreak, and the capacity of health
systems in both departure and destination
· inform all public and private entities responsible
for implementation of international travel
countries, including at PoE. Any subsequent
measures about the requirements in place so
measure must be proportionate to public
that they can bring their operations into
health risks and should be adjusted based on
compliance;
a risk assessment conducted regularly and
systematically as the COVID-19 situation evolves · make operational arrangements to facilitate
and communicated regularly to the public (3). compliance with such requirements, including
the timely exchange of information with health
authorities through, for example, passenger
manifests for contact-tracing purposes and
completion and collection of passenger locator
forms (PLFs); and
· coordinate with conveyance operators to comply
with countries’ requirements for the submission
of the Maritime Declaration of Health, Annex 8 of
the IHR and the Health Part of the Aircraft General
Declaration, Annex 9 of the IHR.
© WHO / P. PhutphengOperational framework for international travel-related public health measures in the context of COVID-19 13
5. Key considerations on common international
travel measures from WHO and partners
Decisions on risk mitigation must be weighed Member States allow air cargo operations
against the impacts these measures have including, but not limited to granting extra-
on societies, including on mental health and bilateral rights, in particular for all-cargo services,
psychosocial well-being, human rights, food to foreign airlines to facilitate the transportation of
security, the economy and socioeconomic essential goods, supplies and COVID-19 vaccines.
disparities, the continuity of health and public
health programmes, and public sentiment and 5.2 Exit and entry screening for signs and
adherence. Special attention must be paid to symptoms of COVID-19
groups in situations of vulnerability, such as There is currently no high-quality evidence to
refugees and migrants, including temporary support entry screening based on temperature
and seasonal workers. These population groups measurement as an effective way of diagnosing
have existing vulnerabilities worsened by the COVID-19. People may be travelling during
COVID-19 pandemic, which may increase their risk the incubation period (between exposure and
of contracting the disease, including challenges symptom onset), may not exhibit fever early in the
related to limited access to health care; deprived course of the disease or may reduce fever through
living conditions; inability to adequately apply the use of antipyretic medications (3). The European
physical distancing and other PHSM; poor access Union Aviation Safety Agency (EASA) states that
to COVID-19 information in the relevant languages; if national policy recommends implementing
reduction of income; increased discrimination thermal screening (temperature checks) due to
and stigmatization; and increased exposure to national response-plan regulations, a protocol for
psychological harms, among others. screening and identifying the required staff and
resources to operate it should be developed in
5.1 Prioritizing selected groups of travellers coordination with PoE authorities (9).
from international travel restrictions
WHO encourages countries that are implementing
In accordance with their national legislation, and
temperature measurement at exit and/or entry to
as per relevant provisions of the IHR, national
share their evaluations of the use of this measure,
authorities may implement risk-mitigation
since they are critical to fostering understanding
measures that restrict international traffic if
of its effectiveness and impact in the context of
such measures are risk-based, evidence-based,
COVID-19.
coherent, proportionate to the public health risk
and, consequently, do not constitute unnecessary 5.3 SARS-CoV-2 testing before departure,
interference with international traffic and trade. The on arrival and as follow-up tests
further transmission of new VOCs to a geographical Testing at borders is not a substitute for other
area may be delayed to some extent by reducing public health measures. International travellers
the movement of people through minimizing should not be categorized as suspected COVID-19
non-essential travel, particularly in countries and/or cases unless they meet the case definition.
areas where the local levels of transmission are low Individuals who meet the COVID-19 case definitions,
(6, 7). WHO recommends that international travel or who are contacts of confirmed cases, should not
should always be prioritized for emergencies and be allowed to travel.
humanitarian actions, travel of essential personnel,
repatriations and cargo transport for essential To avoid diverting resources from settings and
supplies such as food, medicines and fuel (3). The patients where testing can have a higher public
International Civil Aviation Organization (ICAO) (8) health impact and drive positive action, WHO
recommends that: does not recommend that healthy travellers be14 Operational framework for international travel-related public health measures in the context of COVID-19
designated as a priority group for SARS-CoV-2 PLFs to facilitate international contact-tracing if
testing, especially if testing resources are limited. a positive case is detected. PLFs collect data on
In principle, high-risk settings and high-risk passengers and are sometimes combined with
groups, including people at risk of developing health declaration forms. PLFs have been published
severe disease, vulnerable populations and health by WHO, the EU, the International Air Transport
workers, including health workers in training and Association (IATA) and ICAO. The EU implementing
support services (such as laboratory and cleaning decision 2021/858 adopted on 27 May 2021 supports
services), should be prioritized for testing, in line data collection and exchange of national PLFs in
with WHO guidance (10). For further information on the EU/European Economic Area (EEA) for the
recommendations on the type of test, please refer purpose of cross-border contact-tracing. PLF
to the WHO scientific brief COVID-19 diagnostic use remains a national competency and EU PLF
testing in the context of international travel (11). participation remains voluntary. Work is also under
ICAO states that while testing is not universally way to digitalize PLFs, enabling compatibility with
recommended by public health authorities as a national passenger registration forms (15, 16).
routine health screening method, Member States
contemplating testing as part of their COVID-19 5.5 Quarantine of travellers
risk-management strategy should apply the International travellers are not considered to be
approach outlined in the ICAO manual on testing contacts of COVID-19 cases unless a traveller
and cross-border risk management measures, meets the definition of a contact. Countries with
which advocates predeparture and post-arrival no (active) cases, imported/sporadic cases, a
testing with reduced quarantine duration (12). ECDC small number of clusters of cases or those having
recommends that when travel measures are being controlled transmission are striving to maintain
considered, current evidence supports a combined this status. Those lacking adequate capacity to
approach to quarantine and testing of travellers cope with an increased burden may decide to
– a predeparture test (or test directly upon arrival) implement quarantine measures for travellers
combined with quarantine and a further test 5–7 arriving from countries with a significantly higher
days after arrival to confirm the possibility of being incidence. In these circumstances, they should
released from quarantine if the test is negative (6). require quarantine only following a thorough risk
assessment (3) that respects travellers’ dignity,
5.4 International contact-tracing, including human rights and fundamental freedoms. The
health declaration forms and PLFs before aim should be to minimize any discomfort or
departure distress associated with the health measures
International contact-tracing should be conducted applied to them, as outlined in the IHR (1). Article
through harmonized PLFs in a coordinated and 40 1.c of the IHR (1) states that no charges shall
collaborative manner through rapid information- be levied on a traveller for appropriate isolation or
sharing via national IHR focal points. Contacts of quarantine. ICAO recommends that governments
the identified case from two days before to may determine that quarantine measures can be
14 days after symptom onset should be identified combined with other measures, including testing
in line with WHO guidance for contact-tracing on day five or later, to reduce the duration of
(13). Bilateral exchanges between countries may quarantine (12).
also serve the purpose of case investigation by
requiring retrospective tracing of people who were 5.6 Management of suspected cases
contacts of COVID-19 cases two weeks before they The management of cases at PoE entails detection
experienced symptom onset, in line with WHO of ill travellers, interview of ill travellers, reporting
guidance for case investigation (14). of alerts of ill travellers with suspected COVID-19
to local or national health authorities, isolation,
Data protection must be considered throughout and initial case management and referral of ill
the contact-tracing process. Health information travellers with suspected COVID-19 (17). These
and/or personal details of an identifiable individual components of management of cases must be
exchanged between countries should be kept encompassed in the public health emergency plan
confidential in line with Article 45 of the IHR and for the PoE (18). ICAO iterates that all positive tests
national legislation. The use of encrypted and should be referred for clinical diagnosis (12). The
password-protected communication is encouraged EU health gateways provide a flow diagram for the
in these circumstances (14). Most countries require management of a possible case and contacts onOperational framework for international travel-related public health measures in the context of COVID-19 15
board ships and the procedures of free pratique
from the time of identification of a possible case
until the ship is allowed to depart (19).
5.7 Proof of COVID-19 vaccination in the
context of international travel (digital
or paper-based)
5.7.1 Proof of COVID-19 vaccination as a
requirement for exit or entry
WHO’s current position is that national authorities
and conveyance operators should not introduce
requirements of proof of COVID-19 vaccination for
international travel (in any form – digital or paper-
based) as a condition of entry or exit, given the
limited (although growing) evidence about the
performance of vaccines in reducing transmission © WHO / Blink Media - Chiara
and the persistent inequity in global vaccination Luxardo
distribution (20). At the time of writing, this
measures. These would be based on whether
temporary recommendation has been issued by
incoming travellers:
the WHO Director-General to all States Parties to
the IHR (2005) on two occasions, after the 6th, · are fully vaccinated, meaning they have received
7th and 8th meetings of the IHR Emergency the last recommended dose of a vaccine against
Committee on COVID-19 (2, 21, 22). COVID-19 listed by WHO for emergency use or
approved by a stringent regulatory authority two
ICAO also recommends that vaccination should weeks or more prior to travelling; or
not be a prerequisite for international travel: if, and
at such time as, evidence shows that vaccinated
· have proof of SARS-CoV-2 infection confirmed
by a real-time reverse transcriptase-polymerase
persons would not transmit SARS-CoV-2 or would
chain reaction (rRT-PCR) test received within the
present a reduced risk of transmitting the virus,
past six months and are no longer infectious as
Member States could consider exempting such
per WHO’s criteria for releasing COVID-19 patients
persons from testing and/or quarantine measures
from isolation.
(23). The European Commission has adopted
a legislative proposal establishing a common Data from vaccination studies show nevertheless
framework for a digital green certificate to facilitate that some vaccinated persons may still become
safe free movement inside the EU from June 2021, infected. International travellers who are vaccinated
underpinning that proof of vaccination cannot be a are unlikely to develop severe COVID-19 disease
prerequisite for free travel (24). and thereby contribute to an increased strain on
health systems in the countries of destination. The
5.7.2 Proof of COVID-19 vaccination, recovery risk they pose for further transmission, however,
status or negative test result to exempt remains largely unknown, although results
individuals from testing or quarantine from ongoing trials and observational studies of
requirements for travelling internationally vaccine effectiveness against symptomatic and
As COVID-19 vaccination roll-out progresses asymptomatic infection, viral load and duration
in most countries, evidence grows about the of viral shedding are suggestive of relevant effect,
performance of vaccines against development including against transmission (25). Ability to infect
of severe COVID-19 disease and death. To a lesser others remains an important knowledge gap and
extent, as evidence of protection against infection this guidance will be updated as more evidence
and reduction of transmission increases, and emerges. Adherence to other public health and
knowledge about performance against VOCs preventive measures – such as appropriate mask
increases, national authorities implementing use, physical distancing or respiratory etiquette
testing or quarantine as a condition for entry of – must continue for all international travellers,
international travellers may consider individualized irrespective of their vaccination status.
approaches to exempting them from these16 Operational framework for international travel-related public health measures in the context of COVID-19
6. Generating and systematically reviewing
the evidence to inform implementation of
international travel measures
WHO remains committed to providing updated A WHO-commissioned rapid review of evidence
guidance on international travel based on the conducted using a systematic approach of studies
latest scientific evidence. WHO, with support available up to 13 November 2020 on the public
from the Cochrane Collaboration, commissioned health effectiveness and impact of screening at
a systematic review on the evidence available till borders, quarantine of travellers, testing of travellers
June 2020 on the effectiveness of travel measures and border closures has recently been published
on reducing international transmission of COVID-19. (29). This review was performed before the
Since October 2020, WHO has been convening emergence of VOCs and vaccine roll-outs.
the International Travel and Health Guideline
Development Group (ITH GDG) (26) to develop A review of the impact of symptom/exposure-
guidance documents based on systematic reviews based screening of international travellers found
of the evidence on the efficacy, safety and harms the following: one modelling study reported that
of specific public health interventions for the global implementation of screening measures
mitigation of SARS-CoV-2 transmission before, would reduce the number of cases exported per
during and after travel. The ITH GDG currently is day by 82%; four modelling studies predicted
focusing on air travel, which will be followed by delays in epidemic development, although there
maritime travel and travel via land. was wide variation in the results obtained between
the studies; and four additional modelling studies
The first ITH GDG publication, Evidence to predicted that the proportion of cases detected
recommendations: COVID-19 mitigation in the would range from 1% to 53%. In addition, nine
aviation sector (27), describes the methodological observational studies noted the observed detected
approaches underpinning its work and presents proportion ranged from 0% to 100%, although all
an analytical framework that will inform interim but one study observed this proportion to be less
guidance and recommendations. The document than 54%.
presents the nine questions to be addressed, which
relate to infection prevention and control (IPC), With regard to quarantine of international travellers,
health screening, quarantine and isolation, testing, a consistent, largely positive estimated effect was
contact-tracing, risk communication and restriction observed, suggesting that quarantine of travellers
of air travel, among others. may reduce the incidence of, and mortality from,
COVID-19 in the arrival country. The results ranged
The second publication, Evidence to from limited to substantial effects, depending on
recommendations: methods used for assessing the duration of (and compliance with) quarantine,
health equity and human rights considerations in levels of community transmission, travel volumes,
COVID-19 and aviation (28), describes the process and other PHSM in place. One modelling study
WHO is undertaking to assess the reporting of estimated that quarantine of all incoming travellers
key factors related to health equity and human reduced the proportion of imported cases by 55%
rights in the primary literature of specific public for a seven-day quarantine period and by 91% for
health interventions as they relate to COVID-19 and a 14-day quarantine period. One observational
aviation. Guidance documents to address the nine study reported that, out of all positive cases
questions are currently being developed using among incoming air travellers, almost 50% tested
methodologies described in the documents and positive on arrival, and around 13% remained
will be published in the coming weeks. asymptomatic but tested positive on day 14
of quarantine, concluding that asymptomatic
patients with COVID-19 represented a potentialOperational framework for international travel-related public health measures in the context of COVID-19 17
reservoir of infection. Two modelling studies and level of transmission in the country of departure,
one observational study have also indicated the co-interventions, the destination country and its
importance of early quarantine in the management mitigation strategies, the porosity of borders and
of outbreaks on board cruise ships, although the the timing of implementation of border closures.
ability to prevent the spread of the virus becomes Restriction of international air travel was associated
less effective as the ratio of asymptomatic cases with a substantial decrease in the growth
increases. The studies conclude that while onboard acceleration of epidemic progression across 62
quarantine may offer financial and operational countries (−6.05%) (29).
advantages in outbreak response and provide
reassurance to the shore-based wider community, With much of the evidence derived from modelling
its effectiveness is likely to be dependent on studies, notably for travel restrictions that reduce or
multiple operational factors, including cabin stop cross‐border travel and quarantine of travellers,
numbers, availability of RT-PCR tests, and strict there is a lack of real‐world evidence. The certainty
adherence to IPC measures and mechanisms to of the evidence for most travel‐related control
enforce compliance. In addition, it may have a measures and outcomes is very low and the true
detrimental physical and mental health impact (29). effects are likely to be substantially different from
those reported here. Broadly, travel restrictions may
Several observational studies found that the limit the spread of disease across national borders.
proportion of positive cases detected through Many studies suggest that the effects depend on
testing among arriving international travellers additional factors, such as levels of community
ranged between 58.3% and 90.24%, depending transmission, travel volumes and duration, other
on the timing of the tests (on arrival or two or public health measures in place, and the exact
more days afterwards), with PCR tests conducted specification and timing of the measure (29).
two days after arrival being more effective in
detecting cases. Modelling studies suggested that The ITH GDG evaluated the results of this
PCR testing of all incoming travellers on arrival systematic review, taking into consideration
followed by the isolation of those testing positive contextual factors such as the protection of
and requiring a negative test at the end of isolation individual civil liberties, individuals or groups
reduced the proportion of imported cases by who have limited social and/or economic capital,
90% for a seven-day and 92% for a 14-day isolation children, racial and ethnic minorities, people with
period. Other studies have shown that a single RT- disabilities and people with underlying medical
PCR test on arrival captured two thirds of positive conditions, including mental health issues. The ITH
cases among arriving international travellers, with GDG considered that public health interventions
most of the rest detected through a second test such as quarantine for travellers might have the
on day 7 (29). greatest impact in countries with low COVID-19
incidence and many international arrivals, and
Most studies assessing the impact of border in countries at the tipping point of exponential
closures showed reductions in imported or growth (29). The undesirable effects may exceed
exported cases and transmission in the community, the benefits in countries that already have a high
varying from no significant reduction to a large incidence and/or exponential growth. Quarantine
number of cases avoided. Two studies showed of travellers must also be feasible from the
reductions in the number of deaths, ranging perspective of border management and cost,
from a small effect to a large reduction, three and be accompanied by clear communications to
modelling studies suggested reductions in the travellers, transport operators, the public and other
effective reproductive number (Rt) and six studies stakeholders. The positive benefits of quarantine
showed that travel restrictions may delay the time in reducing SARS-CoV-2 transmission must be
to an outbreak, ranging from less than one day balanced against the related risks of infringement
to 85 days, and decrease the risk of an outbreak of human rights, psychosocial and economic harm,
from a slight reduction of 1% to a large effect of disruption to travel and trade, and reductions in
37%. The variation in results may be explained by the movement of essential goods and workforce
differences in study methodologies, including mobility (30).
the assumptions upon which the models were
predicated, as well as differences in travel volumes,
the severity of restrictions/border closures, the18 Operational framework for international travel-related public health measures in the context of COVID-19 Evidence suggests that some newly identified VOCs may have increased transmissibility compared to previously circulating variants. It is likely that elevated risks of the exportation and importation of cases between countries via international travel, including cases of new VOCs, will continue (31). More systematic reviews of evidence therefore are required to inform the updating of WHO’s travel guidance, particularly in the context of VOCs and increasing vaccine coverage. © WHO / Light in Captivity
Operational framework for international travel-related public health measures in the context of COVID-19 19
7. Overview of WHO technical and operational
support relevant to international travel in the
context of COVID-19 available to Member States
WHO is providing and continuously updating Based on requests from Member States, WHO
COVID-19 recommendations and guidance developed checklists with key questions for
regarding international travel based on the IHR airports, seaports and ground crossings to assist in
and the latest scientific evidence. A summary is mitigating infection transmission among travellers,
provided below, and further details can be found crews, seafarers and ground staff, and to determine
in Annex 1. their level of readiness in the context of the
COVID-19 pandemic (33). The aims of the checklists
7.1 Guidelines, briefs and operational tools are to recognize weaknesses in the preparedness
WHO has developed interim guidance for a and response to COVID-19 at PoE and develop an
systematic assessment of the risk of importation, action plan on how to overcome the shortcomings.
exportation and onward transmission of SARS-
CoV-2. The guidance provides national authorities 7.2 Webinars and direct country support
with a step-by-step approach to decision-making The Regional Office is continuously receiving
for calibrating risk-mitigation measures and requests for information and/or assistance from
establishing policies for international travel (3). Member States or WHO country offices to inform,
A step-by-step risk assessment tool on how to train or provide guidance on matters related to
implement risk-mitigation measures for the international travel in the context of COVID-19.
gradual resumption of international travel in the Several webinars have been undertaken over
context of COVID-19 was developed in conjunction the past few months following specific requests
with the guidance. This methodology is most useful by countries. Advice and support on planning
for destination countries experiencing community and performing PoE assessments are provided
transmission, for which the primary concern is not continuously. Regular webinars are planned with
to overwhelm health system capacity (32). European priority countries to update them on
new guidelines, scientific briefs and WHO
Testing requirements for SARS-CoV-2 in monitoring data.
international travellers across the European Region
differ sharply and change over time. The WHO 7.3 Training
brief on diagnostic testing provides an overview The Regional Office has developed tailored
of SARS-CoV-2 diagnostic assays and their face-to-face or webinar training for staff at airports,
performance and suitability for potential use in seaports and ground crossings. In addition to
SARS-CoV-2 testing prior to departure, at PoE and providing guidance on general public health
on arrival (11). The statement of the seventh meeting measures, the training also illustrates how to detect,
of the IHR Emergency Committee regarding the assess and manage suspected cases of COVID-19
COVID-19 pandemic advises WHO to update the and their contacts in airports, port terminals or
risk-based guidance for reducing SARS-CoV-2 airplanes, on ships or at ground crossings. The
transmission related to international travel (by air, training includes advice on the development of PoE
land and sea) based on current science and best contingency plans and a half-day tabletop exercise
practices, which includes clear recommendations in which participants (health and non-health staff)
for testing approaches and traveller quarantine are challenged to detect and manage a suspected
duration, as appropriate, and to incorporate an case in their respective work environment.
ethical framework within the updated guidance
to guide national decision-making (21).20 Operational framework for international travel-related public health measures in the context of COVID-19
Currently, five online training courses are available 7.4 Simulation exercises and intra-/after-action
on the WHO website (on operational considerations reviews
for managing COVID-19 cases and outbreaks in To support and enhance countries’ preparedness
aviation, on board ships, at ground crossings, on efforts in relation to the COVID-19 pandemic,
cargo ships and fishing vessels, and management WHO has developed a series of COVID-19 tabletop
of ill travellers at PoE). These resources educate exercise packages, including one on examining
health and non-health personnel on PHSM, and strengthening existing plans, procedures
detection and management of suspected COVID-19 and capability for managing COVID-19 cases
cases, and coordination, communication and in international PoEs, in aviation and at ground
collaboration inside PoE, at conveyances and with crossings (35). Comprehensive guidance on
stakeholders (34). a COVID-19 intra-action review and a toolkit
have been published, including specific trigger
questions on PHSM and PoEs.
© WHO / / Tina Charlotte KiaerOperational framework for international travel-related public health measures in the context of COVID-19 21
8. Proposed risk-assessment criteria to implement
a harmonized and coordinated approach to travel
measures in the WHO European Region
Introduction, adjustment and discontinuation of risk-mitigation measures should be based on a thorough
risk assessment that is conducted systematically and regularly (ideally every two weeks) and continuously
adapted to emerging information. Detailed information may not always be available on departure countries’
local transmission indicators, health service capacity and PHSM.
The factors summarized in Table 1 should be considered for all countries.
CRITERIA INDICATOR
Local epidemiology in • New confirmed cases per 100 000 population per week averaged over
departure and destination a two-week period in departure country
countries • Testing and test positivity rate of tests for COVID-19 infection
• Detection, prevalence and profile of VOC
Public health and health • Proportion of occupied hospital beds
service capacity and • Case fatality rate of resolved (outcome known) hospitalized cases
performance to detect • Number of persons tested per 1000 population per week, averaged over
and care for cases and
a two-week period
their contacts, including
among travellers, in the • Proportion of cases for which an investigation has been conducted within
destination country 24 hours of identification
PoE capacity • PoE requesting proof of test
• Number of PoE surveillance officers per 100 000 daily travellers
• Percentage of cases identified in the international context (international flights,
others) that have their contacts traced and measures taken within 48 hours of
case detection
PHSM implemented to • PHSM severity index
control the spread of • Support for/adherence to PHSM by the population
COVID-19 in departure
and destination countries
and available evidence on
adherence
Travel volumes between • International tourism
countries • International travel for work reasons
• Existing bilateral and multilateral agreements between countries to facilitate
free movement
Contextual factors,
including economic and
mental health impact,
human rights and
feasibility of applying
measures
Source: Technical considerations for implementing a risk-based approach to international travel in the context of COVID-19: interim
guidance: annex to: Policy considerations for implementing a risk-based approach to international travel in the context of COVID-19, 2 July
2021. World Health Organization (https://apps.who.int/iris/handle/10665/342212, accessed 19 August 2021). License: CC BY-NC-SA 3.0 IGO.22 Operational framework for international travel-related public health measures in the context of COVID-19
Recommended epidemiological criteria are trends or signals that may indicate the appearance
aligned with the criteria used by ECDC in mapping of new variants of interest or VOCs to allow national
countries in support of the Council of the EU and subnational authorities and travellers to make
recommendation on a coordinated approach to informed decisions and adjust their PHSM as
travel measures in the EU. necessary, including in relation to international
travel.
WHO encourages national authorities to
proactively and transparently share up-to-date Figure 1 shows an algorithm for implementing a
data on COVID-19 incidence, public health and risk-based approach to the gradual resumption
health service capacity and PHSM implemented or readjustment of international in-bound travel
at national and subnational levels. This includes measures in the context of COVID-19.
epidemiological information on unexpected
© WHO / Uka BorregaardOperational framework for international travel-related public health measures in the context of COVID-19 23
Figure 1. Algorithm for implementing a risk-based approach to the gradual resumption or readjustment
of international in-bound travel measures in the context of COVID-19
Is the projected 14-day (corrected) incidence rate in the COUNTRY OF DEPARTURE higher than the
projected 14-day (corrected) incidence rate in YOUR COUNTRY? Assess it alongside other key indicators
when they are available (such as mortality, testing positivity ratio, testing rates and testing strategy). Is
the COUNTRY OF DEPARTURE experiencing unexpected epidemiological trends or signals that may
indicate the presence of new variants of interest or VOCs that are not yet present in YOUR COUNTRY?
NO YES
See
Estimate travel volume across all routes
scenario 1
(air, land, sea)
Estimate potential increased burden of
COVID-19 by multiplying relative incidence
by total travel volume
Does YOUR COUNTRY have adequate
capacities to detect and cope with the
potential additional burden of COVID-19
cases while maintaining other essential
health services?
Repeat for
additional countries YES NO
of interest
Note: for further details on the different scenarios See See
in the mixed-methods risk-assessment tool, scenario 2 scenario 2
please refer to the Risk assessment tool to inform below below
mitigation measures for international travel in the
context of COVID-19 (32).24 Operational framework for international travel-related public health measures in the context of COVID-19
9. Conclusions and the way forward
© WHO / Light in Captivity
The persistence of community transmission in Under the IHR, Member States are required to
most Member States of the European Region and have or develop minimum public health capacities
the recent emergence of new VOCs means that to implement the IHR effectively. One of the 13
international travel will continue to pose a particular capacities in the compulsory IHR State Party
challenge in the coming months. Self-Assessment Annual Reporting Tool (SPAR) is
capacities at PoE. The European average scores
A coordinated approach to international travel from SPAR 2019 and 2020 suggest that further
measures aims to minimize the reintroduction and sustained preparedness and readiness efforts
of reactive entry bans, facilitate international travel are needed, particularly in this area, as it scored
and align risk-mitigation measures by introducing the lowest of the 13 capacities (61%) (36).
a set of criteria and a decision-making algorithm.
Restrictions on international travel, if necessary,
must be applied in accordance with the general
principles, in particular, proportional to the risk
assessment and non-discrimination (including
on the basis of nationality), and be based on
evidence, if available. Member States should
invest in research and generate evidence to
support their decisions to mitigate the risks
associated with international travel.Operational framework for international travel-related public health measures in the context of COVID-19 25
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