By Michael Daignault, MD, Chief Medical Advisor, Reliant Health Services, Emergency Physician, Los Angeles
International travel during the age of the covid-19 pandemic is difficult. It involves navigating a country-by-country myriad of rules, regulations, apps, and QR codes for both incoming visitors and returning citizens alike. Despite the World Health Organization’s recommendation that countries apply an “evidence-informed and risk-based approach when implementing travel measures,” the role of testing for SARS-COV-2 in particular has been bogged down instead by reactionary politics, nationalism, and fear.
I recently experienced this patchwork of international regulations firsthand. Airlines such as Lufthansa do help facilitate this process – requiring uploaded documentation of vaccination or negative test results – prior to issuing a boarding pass. Spain requires an additional “FCS Health Control Form” before arrival and the QR code is scanned by public health authorities at the airport. France, Italy, Malta, and Slovenia require a European Digital Passenger Locator form to be completed prior to arrival. The United States has the stringiest requirements for citizens returning home – a negative test taken no later than one day before travel even if fully vaccinated.
Reducing testing requirements as BA.2 heats up
Unfortunately, it’s about to get even more complicated. More and more countries are reducing, and in some cases eliminating, covid-19 related requirements for travelers on the tail end of a global Omicron (BA.1) surge and a belief that the resulting wall of immunity signifies transition from a pandemic to an endemic stage. However, multiple European countries are now seeing their daily case numbers make a sharp U-turn and start to increase again, driven primarily by the more transmissible BA.2 Omicron subvariant. Asia-Pacific countries that vigorously pursued a “Zero Covid” policy for two years like South Korea, are now setting daily records for new cases. And in the U.S., more than 30% of wastewater monitoring sites are showing week-to-week increases in covid-19 levels as BA.2 steadily replaced BA.1 as the dominant variant in this country.
Starting on March 18, the United Kingdom (U.K.) will lift all requirements for incoming travelers. The Caribean country Aruba will follow suit on March 19. These countries will not require visitors to show proof of vaccination or a negative test, nor will they have to fill out a locator form or quarantine. On the other end of the spectrum, New Zealand, which was one of the countries who closed its borders throughout the pandemic as part of its “Zero Covid” policy announced it will move up its reopening for vaccinated U.S. travelers to May to accelerate the country’s economic recovery. But it will also maintain a rigorous testing policy including proof of a negative pre-departure test and additional required free at-home rapid antigen tests on the day of arrival and on day 5 or 6. Italy, which had one of the more stricter regulations for incoming travelers, recently dropped its additional testing requirement for fully vaccinated travelers. Canada will also drop pre-arrival testing for vaccinated returning citizens and travelers starting April 1.
Follow the evidence
Given the dichotomy of countries relaxing travel requirements with the looming threat of the highly-transmissible BA.2 subvariant, what is the role for testing in international travel?
First and foremost, it’s critical to reiterate that rapid antigen tests, or lateral flow, are the preferred diagnostic for public health-focused testing for travel. Multiple studies have demonstrated that rapid antigen tests are as accurate as the more expensive and time-delated molecular PCR tests in identifying infectious/contagious virus. PCR tests are a medical test that should only be used by physicians or in the hospital setting to confirm a suspected SARS-COV-2 diagnosis or to support a country’s genetic surveillance and sequencing efforts.
By dropping the testing requirement for fully-vaccinated and boosted travelers, most countries are now following the evidence-based approach advocated by the WHO. Studies from multiple countries done during the Delta variant wave showed that vaccinated individuals were less likely to spread the virus if they became infected. And when infected, were contagious for less time than those unvaccinated. Of particular application to airplane travel, a well-done Danish study showed that within households, fully vaccinated and boosted individuals were less susceptible to infection from even the more transmissible Omicron variant infection compared to unvaccinated individuals.
Canada recognized that pre-departure testing for those vaccinated presented an unnecessary logistical and financial burden in addition to not being aligned with the current science. I believe that most countries will fall somewhere between the two extremes of the U.K. and New Zealand regarding pre-departure testing for incoming travelers. And they’ll likely proceed in a careful step-wise fashion, having learned from the unpredictable nature of SARS-COV-2.
The U.S. should immediately follow suit, and only require pre-departure testing for unvaccinated travelers. With the recent appointment of Dr. Ashish Jha as White House Covid-19 Response coordinator, we in the scientific and public health community are optimistic that under his pragmatic and evidenced-based leadership, the U.S. will soon join Canada and Europe in following this approach.
Those unvaccinated who recently contracted an infection – likely Omicron – should also be allowed to present proof of recovery in place of pre-departure testing. And although evidence has emerged that reinfection with BA.2 can occur after BA.1 infection, this is a rare occurrence. While Omicron or its subvariant remain the dominant global strain, countries should be assured that travelers recently infected will likely not become reinfected nor contribute to further spread while visiting.
And finally, all countries should continue or start doing random PCR testing of incoming travelers – citizens and visitors alike – for the purpose of conducting genetic surveillance and enhancing early detection of potential new variants of concern (VOC) in coordination with the WHO. Despite the wide difference of opinion on testing for international travel, we can all agree that genetic surveillance for the purpose of quickly identifying new VOC is the linchpin of our testing strategy for this and future pandemics.
Reliant Health Services is a turn-key workplace and community COVID-19 testing solution. Our experience working with large scale testing initiatives has given us a perspective on testing that we are able to pass on to our clients and communities. Conducting consistent testing requires a nuanced approach to supply-chain logistics, management of human resources, and a compassionate approach to interfacing with the lives of employees and community members.
By reducing the friction in test coordination, we deliver a world class experience. By utilizing highly precise testing protocols, with minimally invasive specimen collection methods, we create the most comfortable experience possible for persons undergoing testing. To learn more, visit: https://relianthealthservices.com.