By Professor Ron Behrens, Professor Emeritus in Travel Medicine, London School of Hygiene and Tropical Medicine
We are all now living in and adjusting to life as dictated by the COVID-19 pandemic. The pandemic has brought about major changes to our work and home life which has left us all with great uncertainty to the future. I will explore what I see the challenges might be, and how the travel medicine fraternity might contribute to the response and adapt travel medicine practice to the changed future.
It is worth understanding what has happened in terms of tourism and air travel since the start of the pandemic in January 2020. The World Tourism Organisation (WTO) has estimated that in the 1st quarter of 2020 there has been a 22% decline in tourist arrivals from the same period 2019, which translates into a $80 billion loss of tourism receipts (1/3 of global receipts). The regional decrease in tourist arrivals over the first 5 months from the WTO data in Figure 1 and the global change in travel, fall in number passenger arrivals and weekly flights over the first 5-7 months of 2020 (1) (2) is shown in Figures 2 and 3.
Regionally across Europe, the percentage decline over the same time period was between 50-85% (Eurostat) and in the UK in March 2020, 50% fewer trips were made by travellers abroad (ONS). Comparing this decline to previous disruptions to global travel and tourism during the SARS epidemic of 2003, global travel declined by 0.4% and following the banking crisis of 2008, tourist arrival fell by 5.4%. Recovery to pre-crisis activity occurred within 11 months, to an average increase in arrivals of 4% per year. However, after the September 11 2001 attacks (0.1% global decline), it took 42 months for arrivals to return to 2000 levels.
Figures 2 and 3
Tourism income to small islands and regions of the world who have limited resources, have fragile environments, and are dependent on international tourism, and are countries to which Travel Medicine services are most relevant will be most impacted. These regions have had arrivals decline of 47% to April 2020, and lost income from tourism of the order of >20% of their annual GDP(3).
WTO forecasts an annual fall in tourist arrival by 60-80% (850m-1.1b tourist arrivals) and lost revenues of US$ $910b-$1.2tr for the year.
Trying to predict the recovery and return of tourism is difficult, and Figure 4 shows an estimate of return of passenger demand for flights by IATA, expressed as revenue passenger-kilometres (RPK) (4).
With active transmission ongoing in the majority of European and North American countries, together with cessation of international flights, most travel medicine services have been closed, or severely restricted. Some service may be providing occupational support but the public health threat in the first 2 quarters of 2020 has meant that almost no foreign leisure travel is taking place, and where it is starting up, to European destinations, does not require travel medicine input.
I will explore 3 scenarios which may in part, or in differing combination, describe the future of the pandemic and explore Travel Medicine roles within these 3 scenarios.
This would rely on an effective vaccine being discovered and administered on a global basis. This scenario has many unknowns and dependencies, and the timescale to its achievement is totally unpredictable. However, in my mind the vaccine programme would need to be implemented in both in the source populations and the host nation populations to ensure compete safety and protection. Were this achieved, COVID-19 impact on tourism and travel might be negated. However, I do foresee a remaining anxiety and insecurity in a proportion of travellers, which would reduce the numbers of travellers willing to undertake visits to exotic and remote regions, therefore impacting on Travel Medicine services.
I see in this scenario, scientists have produced a vaccine and treatments for COVID-19, but the vaccine does not provided complete protection in all ages and high risk travellers (for example older and pre-existing morbidity still at risk). The vaccine programme leaves some minimal background transmission in source and host countries and occasional outbreaks in areas, particularly of host countries. Treatment is available which reduces mortality, but availability is limited, again in predominantly host countries as are medical services.
In this scenario, Travel Medicine service will play a critical role in re-establishing travel and tourism and benefiting the global economy. Tourists will need expertise in assessing and defining risk of COVID-19 and other hazards, as undertaken in past practice, for each journey. Travel Medicine practitioners will need to use their skills in undertaking a personalised risk assessment on each traveller, identifying; potential for a COVID-19 infection, local and regional epidemiology of COVID-19, risk threshold of the traveller, immunity of host populations and the individual’s health insurance cover and access to medical services in-country. Accessing and understanding COVID-19 epidemiology will be fundamental to this risk assessment, and practitioners’ skills in accessing, interpreting and utilising data will be critical.
This assessment will be in conjunction with the standard travel medicine assessment of the many environmental, vector and water borne infections and behaviour related hazards.
Disease management and infection control will be a new role in dealing with COVID-19. We may have rapid diagnostic COVID-19 personalised kits, (and possibly even early rapid therapy) as part of the traveller’s medical bag, so training and educating travellers to their use will be part of the preparation.
This could be a situation where we have ongoing global transmission with widespread asymptomatic and clinical cases, and significant morbidity and mortality particularly in host countries. We have limited mitigating interventions and rely on infection control and physical distancing for infection mitigation. There will be limited global travel, and individuals seeking advice will probably be for emergency or occupational needs.
The Travel Clinic consultation in such an extreme context, will focus on personal and community risk. Balancing the individual’s vulnerability to COVID infection, the individual’s social context (people they live with and/or will be visiting) and the importance of their travel will need to be discussed. Insurance cover, access to diagnosis, repatriation and quarantine will all need to be explored. Quarantine regulations must also be planned into the consult. Consultation in this scenario will be extremely challenging and need current knowledge of all the information noted above.
In this scenario, specialist expertise will be required, and only small numbers of travellers will be accessing services. With global travel at the level down between 60-80%, the number of travel medicine providers will be limited, and they will be specialised in dealing with COVID-19 risk.
In the possibility that a useful vaccine(s) is available in the near term, the global population will need to be to achieve herd immunity and possible elimination. Since the smallpox campaign, no similar global public health campaign has been attempted. The world community will need comprehensive vaccine coverage and the manpower needed to meet this could be supported by personnel from many specialities including Travel Medicine. As the intervention will be around vaccine administration, I would see Travel Medicine providers having an important role in education, training and administering COVID-19 vaccines.
Dealing with vaccine resistance and hesitancy will be one of the challenges to be meet. (5) Vaccine coverage in excess of 90% would be the aspiration for COVID-19 suppression/control/elimination. In this global programme there will be a role for the Travel Medicine providers in supporting the safe dissemination of COVID-19 vaccines. The same technical issues of standard vaccination (cold chain, safe administration, informed consent) in the clinic will be required for COVID-19 vaccines.
Vaccination and certification
If, and when, a vaccination is available and introduced, travellers immunisation status against COVID-19 is likely to be a mandatory requirement for travelling between countries.
A framework for this has already established through the WHO’s International Health Regulations (IHR) 2005. In a similar way that yellow fever International Certificate of Vaccination or Prophylaxis (ICVP), is required for travellers arriving in specified yellow fever endemic countries, evidence of COVID-19 vaccination would need to be provided to allow entry into specified countries (6).
There is a recognised weakness in the IHR process, in that travellers without certificates, or false (unofficial) Yellow Fever vaccine certificates are able to enter through weak health border controls (7, 8). Robust border enforcement would overcome weak controls, but a more secure and reliable system for recording COVID-19 vaccination status would also be necessary to overcome counterfeit hard copy certificates. Nigeria has attempted to replace hard copy yellow fever certificates with e-certificates for this reason, but this has been reported to still have security loopholes(9).
I believe there is a responsibility for the international community with the WHO and other stakeholders, to develop a secure (possibly digital), globally accessible, interoperable, (10) individually unique (possibly biometric or identity document linked) certification which can be trusted by all members of the UN, as a true record of vaccination against COVID-19.
At this moment in August 2020 the pandemic is rapidly evolving so the future can only be guessed and hoped for.
- World Health Organisation. UNWTO World Tourism Barometer and Statistical Annex, Update July 2020. 2020. p. https://www.e-unwto.org/doi/epdf/10.18111/wtobarometereng.2020.18.1.4.
- International Air Transport Association. Air Passenger Market Analysis June 2020. IATA; 2020. p. https://www.iata.org/en/iata-repository/publications/economic-reports/air-passenger-monthly-analysis—june-20202/.
- World Health Organisation. Brieﬁng Note – Tourism and COVID-19, Issue 2. Tourism in SIDS – the challenge of sustaining livelihoods in times of COVID-19. Madrid2020. p. https://www.e-unwto.org/doi/epdf/10.18111/9789284421916.
- International Air Transport Association. IATA Economics’ Chart of the Week 30 July 2020. IATA; 2020. p. https://www.iata.org/en/iata-repository/publications/economic-reports/Five-years-to-return-to-the-pre-pandemic-level-of-passenger-demand/.
- Smith TC. Vaccine Rejection and Hesitancy: A Review and Call to Action. Open forum infectious diseases. 2017;4(3):ofx146-ofx.
- Vanderslott S, Marks T. Health diplomacy across borders: the case of yellow fever and COVID-19. Journal of Travel Medicine. 2020.
- Wilder-Smith A, Leong WY. Importation of yellow fever into China: assessing travel patterns. Journal of Travel Medicine. 2017;24(4).
- Schonenberger S, Hatz C, Buhler S. Unpredictable checks of yellow fever vaccination certificates upon arrival in Tanzania. J Travel Med. 2016;23(5).
- Adepoju P. The yellow fever vaccination certificate loophole in Nigeria. The Lancet. 2019;394(10194):203-4.
- Maurer W, Seeber L, Rundblad G, Kochhar S, Trusko B, Kisler B, et al. Standardization and simplification of vaccination records. Expert Review of Vaccines. 2014;13(4):545-59.