How are countries readjusting international travel in the context of COVID-19, and what criteria is being used to inform decision-making?

Cross-Country Analysis


How are countries readjusting international travel in the context of COVID-19, and what criteria is being used to inform decision-making?

As the pandemic has evolved, each country in the World Health Organization (WHO) European Region has applied entry requirements for some international travellers.

Due to the rapidly changing epidemiological situation, countries have implemented a multiplicity of restrictions and entry requirements that fluctuate on a weekly basis and differ based on the traveller’s country of origin/departure. In many cases, these requirements have been lifted and re-implemented. In December 2020, many governments are attempting to restore non-essential international traffic across borders while working to limit the risk of case importation.

This analysis examines the strategies implemented by countries across the European Region in approaches for readjusting international travel in the context of COVID-19. Information was collected from open-source government websites by the COVID-19 Incident Management Support Team of the WHO Regional Office for Europe and from the COVID-19 Health Systems Response Monitor (HSRM) (up to 27 November 2020). Selected country examples are provided for Andorra, Belarus, Belgium, Croatia, Czech Republic, Estonia, Georgia, Germany, Greece, Hungary, Iceland, Israel, Italy, Latvia, Lithuania, Malta, Montenegro, the Netherlands, Norway, Portugal, Romania, San Marino, Slovakia, Switzerland, the United Kingdom and Uzbekistan.

This analysis can help to inform the international travel restriction policies as Member States consider the modality for reopening their borders.

Background

On 30 January 2020, the Director-General of WHO declared the outbreak of SARS-CoV-2 a Public Health Emergency of International Concern (PHEIC). Throughout the pandemic, all 55 States Parties to the International Health Regulations (IHR) (2005) in the WHO European Region have implemented some type of additional health measure that significantly interferes with international traffic, as defined under article 43 of the IHR with the aim to control the spread of the virus.

The IHR is the main legally-binding instrument to prevent, protect against, control and provide a public health response to 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. International travel measures include entry and/or exit bans via air, land and/or sea, as well as suspension of the issuance of visas. Where and when travellers have been allowed entry, they have often been subject to entry requirements such as quarantining in state facilities or at home or providing a negative COVID-19 test.

Following the implementation of entry bans, most countries have gradually readjusted their international travel measures

Entry bans on travellers have been implemented in the context of COVID-19 in the WHO European Region since January 2020. While around 90% of States Parties had put in place entry bans via land, sea or air by March, the majority gradually transitioned from banning the entry of travellers from all countries to banning the entry of travellers from some selected countries.

The Netherlands implemented entry bans for travellers from outside the European Union (EU) in March but lifted this ban for some countries in July. Moreover, Belgium limited non-essential travel outside its internal borders in March, but partially lifted this travel restriction for the United Kingdom and four other countries in the Schengen area in June. As of 17 November, common entry restrictions implemented by States Parties for some groups of travellers, across the WHO European region are land border restrictions (42 States Parties), flight restrictions (45 States Parties) and sea restrictions (32 States Parties). Although the region has seen a recent resurgence of cases, most countries have not reimplemented entry bans on all travellers, but instead have taken a risk-based approach with additional requirements for entry.

Cumulative incidence threshold is the main epidemiological criterion being used by national authorities to classify countries based on the assessed level of risk

Many countries have based their travel regulations on the 14-day cumulative incidence of cases per 100,000 population in the country of departure. During the spring and summer, Estonia, Latvia and Lithuania restricted the entry of travellers coming from countries with a threshold above 25 cases per 100,000, while implementing a quarantine requirement for travellers from countries with an incidence above 15 or 16 per 100,000. In May, Germany classified countries (or subnational regions) in which the number of cases exceeded 50 per 100,000 population as risk areas and travellers from these areas were required to provide proof a COVID-19 test.

WHO recommends that the gradual lifting of travel measures (or temporary restrictions) should be based on a thorough risk assessment, taking into account:

  • country context
  • the local epidemiology and transmission patterns
  • the national health and social measures to control the outbreak, and
  • the capacities of health systems in both departure and destination countries, including at points of entry.

Measures should be:

  • proportionate to public health risks
  • adjusted based on risk-assessments
  • conducted regularly and systematically as the COVID-19 situation evolves, and
  • communicated regularly to the public.

On 13 October, the Council of the EU recommended that Member States adopt a common set of criteria for assessing EU countries and implementing travel restrictions, thus allowing a coordinated approach to travel throughout the EU. The criteria included the 14-day notification per 100,000, the test positivity rate per 100,000 and the testing rate. As of 17 November, some countries such as the Czech Republic, Ireland, Lithuania and Norway have applied this Council of the EU criteria in implementing travel measures. For third countries, the Council of the EU recommended lifting entry restrictions based on the epidemiological situation and containment measures, including physical distancing, as well as economic and social considerations and reciprocity. Reciprocity, a political criterion by which countries lift travel measures for other countries provided they are granted the same treatment, has been used by some countries such as Germany, Georgia, and Greece. Georgia lifted border restrictions and allowed travel for any purpose for travellers from five EU countries that allowed entry for travellers from Georgia, namely Estonia, Germany, France, Latvia and Lithuania. Germany lifted entry restrictions for travellers from China, South Korea and Japan on the condition that the same measure was extended to German citizens. Furthermore, Greece lifted entry restrictions for travellers from China on the basis of reciprocity.

Entry requirements, such as mandatory quarantine and COVID-19 testing of incoming travellers from specific countries, are being increasingly implemented to counter blanket entry bans amid the resurgence of cases

Countries began implementing quarantine requirements for travellers from countries, or sub-national locations within countries, since the beginning of the outbreak. In January, Iceland required travellers from Wuhan, China to quarantine at home for 14  days. In February, Malta required travellers from Italy, China (including Hong Kong), Singapore, Japan, Iran and South Korea to spend 14 days in mandatory quarantine. In March, Slovakia ordered travellers returning from China, South Korea, Iran and Italy to undergo self-isolation for 14 days. By the end of March, the requirement to quarantine for some or all incoming travellers upon entry had been a nearly ubiquitous measure in the WHO European Region, with more than 76% of States Parties implementing it at that point in time.

Following a similar pattern as entry bans, the WHO European Region has seen a shift from countries requiring the quarantining of all travellers to requiring quarantining of travellers from only certain locations, often labelled as ‘high risk’. In the beginning of July, the United Kingdom imposed a 14-day self-isolation requirement for all countries, except the 59 countries on its travel corridor list. In August, Romania required travellers coming from 25 countries classified as areas with ‘high epidemiological risk’ (yellow area) to quarantine for 14 days. In October, Uzbekistan required all countries from yellow and red zones to provide a negative PCR test and quarantine for 14 days upon arrival.  While the most common length of required quarantine among countries is 14 days, the quarantine length differs among countries. Increasingly, countries like the Netherlands, Belarus and Hungary  have reduced their quarantine period from 14 to 10 days, while Israel reduced it from 14 to 12 days in November. As a result of the increase in number of cases in most EU countries since September 2020, many countries have expanded the number of countries on these quarantine lists, while countries like Hungary and the Czech Republic reintroduced entry bans with few exceptions for entry.

Figure 1. Number of States Parties implementing quarantine requirements in the WHO European Region (as of 17-Nov-2020)

Furthermore, a growing number of countries have also used a COVID-19 testing requirement to supplement or replace quarantine measures.  In Croatia the 14-day quarantine can be reduced with a PCR test performed on day 7. In Estonia, the 10-day quarantine can be reduced with two PCR tests performed on arrival and on day 7. In Iceland, international travellers may select between a 14-day quarantine requirement or double testing and a 5-day quarantine between the two tests (on arrival and day 6).

COVID-19 test requirements differ across the region on the type of test required or accepted. In addition to this, testing requirements differ with regards to the point in time they are requested. State Parties may require proof of COVID-19 tests before arrival, test travellers upon arrival (e.g. at airports or train stations), or require follow-up tests several days after arrival. When considering the type and timing of tests, as of 17 November, 34 countries required a test before arrival, with 31 explicitly mentioning negative PCR tests, Montenegro accepts a serological test and Italy and Norway require an antigen test. Andorra also accepted a TMA test. For the 21 countries obligating a COVID-19 test performed on arrival, 18 explicitly mentioned requiring a negative PCR test, Italy and San Marino mentioned an antigen test and San Marino mentioned a serological test. Fifteen countries have implemented a follow-up PCR test after arrival.

Figure 2. Number of States Parties implementing COVID-19 testing requirements in the WHO European Region (as of 17-Nov-2020)

International travel restrictions have caused substantial disruptions to essential travel and trade, despite countries across the European Region putting in place varying exceptions for the maintenance of essential services.

Although restrictions on international travel and trade have been implemented by all 55 States Parties in the WHO European Region, most countries have put in place exceptions to allow entry for essential goods and services. For example, countries such as Croatia, Slovakia, Switzerland and Portugal have granted entry to foreigners who perform essential tasks relating to study or work. However, many countries have also imposed export bans on essential medical goods such as personal protective equipment, medical equipment and essential pharmaceutical products such insulin and morphine, and non-medical goods such as food and animal products, with the aim of ensuring public safety, security and limiting the strain on country capacity. At supranational level, in March, intergovernmental agencies like the European Commission enforced similar export bans on behalf of all 27 Member States, while the Eurasian Economic Commission enforced trade bans for its members, namely Armenia, Belarus, Kazakhstan, Kyrgyzstan and the Russian Federation.

In a joint statement with the World Trade Organization, WHO has called on countries to ensure that measures adopted to prevent the spread of the COVID-19 pandemic do not adversely impact the food supply chain, global trade and transport of medical and other essential supplies, as well as essential workers for the pandemic response. Furthermore, the fourth meeting of the IHR (2005) Emergency Committee, which is comprised of a panel of experts who convene every 90 days during a pandemic to advise the WHO Director-General, emphasized this by stating that essential services should be maintained with sufficient funding, supplies and human resources.

In line with the nature of the outbreak, the international travel measures implemented by countries to suppress the transmission of the virus are rapidly changing and vary extensively across the WHO European Region. As the situation evolves and more is understood about the virus, countries have increasingly implemented risk-based approaches and have remained adaptable by using tools such as COVID-19 testing to ease or supplement other travel measures. With recent strides in vaccine development, it is foreseeable that countries may include vaccination into their strategies for readjusting international travel measures.

Jennifer Addo, Sara Barragan Montes, Tanja Schmidt, W. Leif William Van Grinsven 

References

COVID-19: Council adopts a recommendation to coordinate measures affecting free movement. 13 October 2020. (https://www.consilium.europa.eu/en/press/press-releases/2020/10/13/covid-19-council-adopts-a-recommendation-to-coordinate-measures-affecting-free-movement/#)

Joint statement by WTO Director-General Roberto Azevêdo and WHO Director-General Tedros Adhanom Ghebreyesus. 20 April 2020. (https://www.who.int/news/item/20-04-2020-joint-statement-by-wto-director-general-roberto-azev%C3%AAdo-and-who-director-general-tedros-adhanom-ghebreyesus)

Statement on the fourth meeting of the International Health Regulations (2005) Emergency Committee regarding the outbreak of coronavirus disease (COVID-19). 01 August 2020. (https://www.who.int/news/item/01-08-2020-statement-on-the-fourth-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-outbreak-of-coronavirus-disease-(covid-19))

WHO (2008) International Health regulations (2005). Second Edition. World Health Organization. (https://www.who.int/ihr/9789241596664/en/)

WHO (2020) IHR portal. (https://www.who.int/ihr/access/en/)

WHO (2020) Public health considerations while resuming international travel. COVID-19 Travel advice. 30 July 2020. Geneva: World Health Organization (https://www.who.int/news-room/articles-detail/public-health-considerations-while-resuming-international-travel) All URLs accessed on 26 November 2020.