key: cord-1031357-b62w4z78 authors: von Tigerstrom, Barbara J; Halabi, Sam F; Wilson, Kumanan R title: The International Health Regulations (2005) and the re-establishment of international travel amidst the COVID-19 pandemic date: 2020-08-04 journal: J Travel Med DOI: 10.1093/jtm/taaa127 sha: e3a92502f507a6617f6bf64f049263d2e42422e7 doc_id: 1031357 cord_uid: b62w4z78 As countries modify or lift travel restrictions implemented in response to the COVID-19 pandemic, some variation in approaches is to be expected, but harmonization is important to re-establishing international travel. Despite challenges, the International Health Regulations (2005) and WHO recommendations can provide a balance of consistency and flexibility. pandemic, some variation in approaches is to be expected, but harmonization is important to reestablishing international travel. Despite challenges, the International Health Regulations (2005) and WHO recommendations can provide a balance of consistency and flexibility. The The first half of the year 2020 has seen all countries in the world close their borders or strictly limit international travel as a way to reduce the spread of SARS-CoV-2. After initial reactions that these restrictions were unnecessary and unlawful, 1 the reality now appears more complex. 2 Some early analyses suggest that travel restrictionsif implemented in an evidence-based and timely waycould be justifiable public health measures. 3 When the SARS-CoV-2 outbreak was declared to be a public health emergency of international concern (PHEIC) on January 30, 2020, the WHO did not recommend any restrictions on travel or trade. 5 Only two months later, however, border closures and significant restrictions on international travel had become the norm, as a range of influences, including domestic political pressures, led states to implement restrictions contrary to WHO recommendations. 6 These restrictions have had a dramatic effect: for example, a reduction in global air passenger traffic of up to seventy per cent is predicted for 2020, causing billions of dollars in estimated losses. 7 Despite the pandemic continuing and worsening in many parts of the world, some countries have begun to lift or modify restrictions. There is increasing pressure to allow cross-border traffic due to the impact of restrictions on supply chains and national economies. In order to accomplish this while mitigating the public health risks of increased travel, countries are exploring a range of different approaches, including one or more of:  Selective removal of restrictions for neighbouring countries or countries with similar epidemiological profiles (sometimes referred to as a "travel bubble" or "air bridge");  Broader removal of restrictions, with exceptions for countries assessed to be higher risk;  Replacing restrictions on entry with testing, quarantine, and/or mandatory contact tracing requirements;  Requiring quarantine for returning residents or travellers, as international arrivals increase; and  Adding or broadening exemptions for specific categories of travellers. As countries move forward with these changes, a harmonized and coordinated approach is critically important. 7 A patchwork of different approaches could impede efforts to safely restart tourism, 8 and variations in requirements can present practical difficulties. For example, there are different types of testing available, appropriate in different circumstances, 9 and testing may be required at different time points before departure or on arrival, depending on the destination. Consistent and appropriate testing requirements could prevent unnecessary burdens for travellers and service providers, 10 and a harmonized system to share test results can facilitate travel. 11 As another example, the utility of digital contact tracing apps would be enhanced if they were internationally interoperable. 12 A range of different organizations have introduced guidelines that aim to provide some consistency. As might be expected, much of this activity has occurred in Europe, aiming to restore the open borders and free movement that are the norm within the region. 13 Industry associations have also proposed harmonized measures. 14 The IHR (2005) provide for several mechanisms that could be used during and after a PHEIC to establish common approaches to public health and international travel. Although their role in an emergency receives the most attention, many provisions on public health measures also apply outside of the emergency context. Together, these provisions and WHO recommendations provide a framework for international travel during the pandemic and beyond. Once a PHEIC is declared, the WHO Director-General must issue Temporary Recommendations, which can include measures to be applied to persons or cargo to "reduce the international spread of disease and avoid unnecessary interference with international traffic." 4 Temporary Recommendations automatically expire after three months, unless they are modified or extended (again for three months). In the COVID-19 pandemic, Temporary Recommendations were issued on 30 January 2020 5 and again on 30 April 2020. 17 Neither recommended limiting international traffic, but in April, states were advised to implement "appropriate travel Given the expectation that the COVID-19 pandemic will continue in various forms for some time, one question is when the current PHEIC will end, and how this would affect WHO's role. Once issued, however, Temporary Recommendations can be modified or extended, even after a PHEIC has ended, although not indefinitely. 4 In addition, new Temporary Recommendations can be issued "as necessary for the purpose of preventing or promptly detecting its recurrence." 4 These provisions allow the WHO Director-General to provide guidance on re-establishing travel while addressing the continued risks of transmission and resurgence. In addition, Standing Recommendations can be issued at any time on the advice of a Review Committee, for "appropriate health measures" for "routine or periodic application," to address a specific health risk. 4 This process could be one way of making recommendations on an ongoing basis, although formal Standing Recommendations do not appear to have been issued previously. The IHR (2005) also contain a number of provisions regarding public health measures that member states can use at any time. For example, specific articles deal with points of entry, public health measures applied to travellers, treatment of travellers, and health documents. These could provide a framework to promote consistency in standards for testing or vaccination requirements or medical certificates. Challenges for the WHO's role include a loss of credibility given the lack of guidance on travel restrictions in earlier stages of the pandemic, as well as widespread disregard for recommendations that were given. In the absence of a multi-lateral agreement, bilateral or regional arrangements may proliferate, further undermining global governance initiatives. Although some variation between regions is to be expectedparticularly where, as in Europe, regional arrangements on free movement pre-existed the pandemicthe IHR (2005) Interim guidance. 29 May 2020. https://www.who.int/publications/i/item/controlling-the-spreadof-covid-19-at-ground-crossings (last accessed 21 July 2020). 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