key: cord-0811635-f7hutvou authors: Wilson, Mary E; Chen, Lin H title: Re-starting Travel in the Era of COVID-19: Preparing Anew date: 2020-06-27 journal: J Travel Med DOI: 10.1093/jtm/taaa108 sha: d9a2bdcc85aecfae167a3b29e262d46c93fb0bbd doc_id: 811635 cord_uid: f7hutvou Teaser: Travel, a major contributor to global economy, needs to adapt to the COVID-19 pandemic. Restarting business and travel share convergent considerations. Travel health preparation will require detailed assessment to specifically address COVID-19: the individual’s personal risk stratification, elements of travel, and policies imposed on each traveler and itinerary. Precise details of the trip will help to formulate beneficial recommendations. The COVID-19 pandemic has caused massive disruption of travel along with other aspects of life. The travel industry is a major part of the global economy. With 1.5 billion international tourist arrivals in 2019, the travel industry is the world"s 3 rd largest export category, and international tourism generated US$1.7 trillion exports in 2018, or nearly US$5 billion daily. 1 International tourism contributes immensely to global exports, accounting for 7% of global exports and 29% of the world"s services exports. 1 COVID-19 has dramatically affected the travel industry, and travel can help to vitalize economic recovery worldwide. Restarting business and travel share convergent considerations. Travel is essential for many types of business, accounting for 14% of international trips. 2 Travel for work also often encompasses leisure travel, visits to friends and family and other side trips. As businesses reopen and re-establish a new normal, business travel needs fresh assessments. 3 The COVID-19 pandemic will inevitably lead to redefining essential travel. The crisis provides an opportunity to stimulate expertise among travel medicine clinicians, to utilize and promote skills and knowledge to assist in the recovery and reopening of the economy. The ongoing COVID-19 pandemic requires detailed consideration of many factors especially in decisions about long-distance travel, although many of the same issues apply to domestic travel by car and return to the workplace and other daily activities. As COVID-19 erupted in Asia during the early phase, pre-travel evaluations weighed the "go-or-no-go" decision heavily. This continues to be a key determination and must incorporate assessment of the level of risk to that individual. Some activities can be controlled by the individual traveler in ways to manage or reduce risk. Also important to consider but outside of individual control are policy elements imposed on the traveler and the itinerary. With ongoing COVID-19 circulation in many parts of the world, preparation for travel must be detailed and expanded from the pre-COVID era. Three broad components include: 1) traveler"s personal risk stratification, 4 2) elements of travel, and 3) policies imposed by health insurance, employer, and government regulations at both origin and destination countries ( Table 1 ). The first component considers the individual traveler"s risk factors for severe COVID-19 disease (age and underlying diseases including cardiac, diabetes mellitus, obesity, hypertension, renal failure, respiratory disorder), threshold for risk (individual risk tolerance taking into account the necessity to travel and the nature of the trip), and assessment of immunityassuming that sufficient scientific evidence correlates the presence of antibodies to immunity. 5 Those at highest risk of death from SARS-CoV-2 (age 65 years and one or more high-risk conditions) may decide to defer international travel until an effective vaccine is available or there is some other game changer (see below). It is unlikely that circulation of the virus will have ceased in most parts of the world within 2020. The second component assesses trip details that may influence the risk of exposure to COVID-19 ( Table 1 ). The type of conveyance matters. Particularly challenging is ship/cruise travel with its exceptional vulnerability to COVID-19 illustrated 6 , which will require much more specific planning. A private vehicle that is disinfected meticulously between passengers is safer than crowded buses, trains, or subway systems. The airport location, size, volume of traffic, and time spent in them will influence the level of potential exposure, due to travelers co-mingling along the journey. Airplane-related exposure depends on the plane"s size, seating configuration, density of seats, commitment of airline to cleaning, and air exchange and filtering. The destination country"s level of risk is related to its socioeconomic status, capacity to identify and interrupt spread, and current level of SARS-CoV-2 circulation, which can change quickly. Accommodations also contribute possible exposures related to their measures to disinfect, limit density of guests, and promote physical distancing. Planned activities differ in their levels of Two resources provide insights on the health infrastructure and support for tourism that may help a traveler determine the appeal of a destination during the pandemic ( Table 2 ). The global health security index (GHSI), a determination of healthcare facilities and public health infrastructure, is a massive collaborative effort of multiple organizations. The GHSI is a detailed and comprehensive framework that assesses a "country"s capability to prevent and mitigate epidemics and pandemic": prevent emergence or release of pathogens; detect and report epidemics of potential concern; respond rapidly and mitigate spread; have sufficient robust health system to treat the sick and protect health workers; comply with international norms. It also assesses overall risk environment and country vulnerability to biological threats. The GHSI can give prospective traveler some idea of the preparedness of a country. Unfortunately, some countries that scored well on the GHSI failed to successfully contain COVID-19. The other, produced by the Organisation of Economic Cooperation and Development (OECD) provides an overview of COVID-19"s impact on each country and the policy responses targeting tourism ( Table 2 ). The third component addresses policies for which the traveler lacks control: health insurance, employer mandate, and government regulations. Persons planning travel must be aware of health insurance policy regarding coverage if they should become severely ill abroad with COVID-19. Persons who engage in non-essential travel while a national travel advisory is in place will face difficulties if they need to make insurance claims. Employers may issue travel restrictions that differ from national guidelines, and government regulations even differ between states in the US. If lockdowns are reimposed, travelers risk being stranded abroad or quarantined on a ship. Opening borders are decisions outside of the control of travelers or travel medicine providers. Restarting safe travel assumes that testing to identify acute infection in symptomatic persons and screening their close contacts is widely available. When travel resumes, it involves some elements under personal control and those that the individual cannot control (Table 1) . Elements for which the traveler has partial control during travel include the use of mask; frequency of handwashing; types of meetings with others; number of persons at meetings; types of activities. Travelers need to be aware of risks from large sports events, concerts, mass eventsespecially indoors. In general, many outdoor activities are safe when accompanied by physical distancing 2 meters. Travelers must to do homework on the trip details and assemble background information to develop a comprehensive plan for safe travel. The 2020 travel kit has expanded and should include abundant supply of hand sanitizer, masks, sanitizing wipes, thermometer, and possibly pulse oximeter for some. The travel medicine clinician can assist individuals to make informed choices about whether to travel, which trips to choose, and how to make travel safer. Table 2 lists reliable public online resources relevant to assessing COVID-19 risk at destinations, transmission situation, their policies and requirements, and healthcare preparedness. Key evidence needed that will affect decision-making are those related to COVID-19 immunity. Limited data have demonstrated that persons with significant disease develop neutralizing antibodies that may protect them against reinfection and reduce disease severity in the shortterm, and some tests correlate with virus neutralization. 5, 7-9 However, evidence is needed to define threshold for protection, duration of antibody persistence and immunity, and assess interruption of transmission. Until answers are available, it is impossible to make truly informed decisions about whether those previously infected can safely travel and resume work and other activities without masks, physical distancing, and other precautions. Potential game changers that could allow some or many individuals to travel more freely include: Even when "game changers" arrive, travel will likely differ from the pre-COVID-19 era. Some COVID-19 era precautions may continue in order to avoid the threat of future pandemics. The COVID-19 pandemic once again illuminates the pivotal role that travelers play in emerging infectious diseases and their spread. 11 The crisis also highlights the importance of travelers" health in global health security. Awareness of the need for pre-travel advice and intervention may rise. 12 UN World Tourism Organization. Tourism Highlights Global travel patterns: an overview Business travel-associated illness: a GeoSentinel analysis COVID-19 Immunity Passport to Ease Travel Restrictions? Public Health Responses to COVID-19 Outbreaks on Cruise Ships -Worldwide Virological assessment of hospitalized patients with COVID-2019 SARS-CoV-2 infection protects against rechallenge in rhesus macaques Severe Acute Respiratory Syndrome Coronavirus 2-Specific Antibody Responses in Coronavirus Disease