On 30th January 2020, the WHO Director General has declared the outbreak of novel coronavirus 2019- nCoV as a Public Health Emergency of International Concern (PHEIC), based on the advice of the Emergency Committee under the International Health Regulations (2005).1 Following that determination, WHO did not recommend any travel or trade restrictions, based on the current information available.
Evidence on travel measures that significantly interfere with international traffic for more than 24 hours shows that such measures may have a public health rationale at the beginning of the containment phase of an outbreak, as they may allow affected countries to implement sustained response measures, and non-affected countries to gain time to initiate and implement effective preparedness measures. Such restrictions, however, need to be short in duration, proportionate to the public health risks, and be reconsidered regularly as the situation evolves.
Countries should be prepared for containment, including active surveillance, early detection, isolation and case management, contact tracing and prevention of onward spread of 2019-nCoV infection, and to share full data with WHO. In accordance with their obligations under the Article 43 of the International Health Regulations (2005), States Parties must inform WHO about additional health measures that significantly interfere with international traffic.
For countries that have decided to repatriate their nationals from Wuhan City, Hubei province, the following key considerations need to be made, in order to ensure the health and wellbeing of those involved in the repatriation. In addition, measures aimed at bolstering national preparedness capacities to prevent the further spread or importation of 2019-nCoV before, during, and after repatriation need to be considered.
Measures to be adopted before embarkation
- Advanced bilateral communication, coordination, and planning with the responsible authorities before departure.
- The aircraft should be properly staffed with sufficient medical personnel to accommodate the number of nationals anticipated, and that they are outfitted with appropriate PPE and equipment/supplies to respond to illness en route.
- The non-medical crew of the aircraft should be properly briefed and outfitted, as well as aware of the signs and symptoms to detect symptomatic passengers for nCoV.
- Exit screening, for example temperature measurement and a questionnaire, should be conducted before departure for the early detection of symptoms. Screening results should be shared with the receiving country.
- It is advised to delay the travel of the suspected ill travellers detected through exit screening to be referred for further evaluation and treatment.
Onboard the Aircraft
- The seating location of passengers inside the aircraft should be duly noted/mapped in case a passenger begins to display symptoms, so they can be isolated, and to furthermore take note of those in the immediate vicinity (ex: those within same row, and two rows in front and two rows behind) for the needed follow up upon arrival.
- In case suspected cases are detected on the aircraft, the cabin crew should inform and seek advice from a ground-based medical service provider at the point of entry of arrival through the control tower. In cases of severe illness, the pilot in command may consider diversion for the unwell passenger to the nearest point of entry receive the required treatment.
In the event of a respiratory illness en route, the following immediate steps may be taken to reduce exposure and limit transmission to other passengers or aircraft crew2:
- Designate one dedicated cabin crew member to look after the ill traveller, preferably one who has previously interacted with the passenger;
- Use appropriate personal protective equipment (PPE) when dealing with symptomatic patients (medical or surgical mask, hand hygiene, gloves);
- In all cases, the adjacent seat(s) of the patient should be left unoccupied, if feasible;
- Passengers seated in the close vicinity should have their information on itinerary and contact details recorded for further follow up, as potential contacts, using a Passenger Locator Form3. This information may be collected on a voluntary basis for the remaining passengers;
- The patient on the aircraft should adhere to respiratory/cough etiquette either by wearing a medical or surgical mask (if available and tolerated) or the patient could contain his cough or sneeze by using disposable tissue. If the patient cannot tolerate a mask, healthy travellers adjacent to the ill traveller may be offered masks;
- Practice hand hygiene (hand washing or hand rub);
- Handle any blankets, trays or other personal products used by the patient with respiratory symptoms carefully;
- In case of presence of spills (vomits, blood spills, secretions or others), practice environmental cleaning and spills-management;
- Handle all waste in accordance with regulatory requirements or guidelines;
- Notify the health authority at the point of arrival. The health part of the aircraft general declaration (Annex 9 of IHR) can be used to register the health information onboard and submit to point of entry health authorities, when requested by the country;
- Ensure the flight crew maintain continuous operation of the aircraft’s air recirculation system (HEPA filters are fitted to most large aircraft and will remove some airborne pathogens, depending on the size of the particulate or microorganism).
Upon arrival at the Point of Entry
- Entry screening: temperature screening alone may not be very effective as it may miss travellers incubating the disease or travellers concealing fever during travel, or it may yield false positive (fever of a different cause). If temperature screening is implemented, it should be accompanied with:
- Health messages: Dissemination of health messages and travel notices informing persons on signs, symptoms and where to seek medical support if needed.
- Primary questionnaire: Development and use of forms to collect information on symptoms, history of exposure and contact information.
- Data collection and analysis: Establishment of proper mechanisms for collection and analysis of data generated from the entry screening for the rapid evaluation and response.
Suspected cases detected at arrival
- Personnel and supplies: Trained personnel should be available for the early detection and initial evaluation of cases and equipped with the needed supplies.
- Interview and initial management: A separate space should be designated for the initial assessment of suspected cases and the interview of contacts.
- Fast track pathway and transport: A separate pathway should be delineated to rapidly refer suspected cases to the designated hospital/facility for further evaluation to avoid contact with the other passengers. Arrangement for safe transportation of suspected cases to the designated hospital/facility should also be in place.
- Contingency plan: A functional public health emergency contingency plan at point of entry should be in place to respond to public health events.
- Disinfection of the Aircraft: In accordance with the aircraft make and model, usage of preferred cleaning chemicals and methods should be consulted to properly disinfect the aircraft. A segregated space at the PoE and trained personnel should be available to clean the aircraft after disembarking passengers.
Non-suspected passengers’ arrival into the country
- Risk communication: Prepare countries to communicate rapidly and transparently with the population and ensure the involvement of media to support the spread of the right messages and avoid rumours4. Countries should communicate with their public early and effectively to mitigate stigma or discrimination and avoid panic, in line with the principles of Article 3 of the IHR.
- Health measures: If there is evidence of an imminent public health risk from the arriving passengers, the country may, in accordance with Article 31 of the IHR and in alignment with its national law, deeming the extent necessary to control such a risk, compel the traveller to undergo additional health measures that prevent or control the spread of disease, including isolation, quarantine or placing the traveller under public health observation. In the absence of an established quarantine law, countries should ensure emergency contingency protocols to support quarantine.
If the country decides to put arriving passengers, those not displaying symptoms, in a quarantine facility, the following needs to be considered, in accordance with Article 32 of the IHR:
- Infrastructure: there is no universal guidance regarding the infrastructure for a quarantine facility, but space should be respected not to further enhance potential transmission and the living placement of those quarantined should be recorded for potential follow up in case of illness.
- Accommodation and supplies: travellers should be provided with adequate food and water, appropriate accommodation including sleeping arrangements and clothing, protection for baggage and other possessions, appropriate medical treatment, means of necessary communication if possible, in a language that they can understand and other appropriate assistance. A medical mask is not required for those who are quarantined. If masks are used, best practices should be followed5.
- Communication: establish appropriate communication channels to avoid panic and to provide appropriate health messaging so those quarantined can timely seek appropriate care when developing symptoms.
- Respect and Dignity: travellers should be treated, with respect for their dignity, human rights and fundamental freedoms and minimize any discomfort or distress associated with such measures, including by treating all travellers with courtesy and respect; taking into consideration the gender, sociocultural, ethnic or religious concerns of travellers.
- Duration: up to 14 days (corresponding with the known incubation period of the virus, according to existing information), may be extended due to a delayed exposure.
Health Care Workers: trained personnel should be assigned for the observation and follow up of these passengers in the quarantine facility. These health care workers should be equipped with the basic PPEs and commodities needed to deal with the suspected cases (medical/surgical masks, gowns, gloves, face shields or goggles, hand sanitizers and disinfectants). Additional commodities are needed for surveillance, lab and clinical management of the 2019-nCoV6. Additionally, they should be trained on case definitions, infection prevention and control measures, and the initial management of suspected cases to perform the following interventions7:
- Active surveillance: to identify suspected cases;
- Isolate suspected cases and ensure safe transport: strictly adhere to infection prevention and control (IPC) measures and social distancing procedure to prevent potential spread of the infection to others;
- Collect laboratory samples: to test for the 2019-nCoV in the national reference laboratory or international laboratories in the absence of the lab testing capacity;
- Manage cases clinically: Identify ambulances and designated health facilities to refer cases to for the necessary isolation, treatment and follow up. Adhere to strict IPC measures to prevent the spread of the infection among health care workers or other patients;
- Trace contacts: to identify other potential cases within the quarantine facility, test, isolate and treat as necessary. Extend and adapt quarantine period to correspond to the incubation period of the delayed exposure;
- Share data: on the number and description of cases with WHO using the WHO reporting forms and in accordance to Article 6 of the IHR.
Other Support Staff: personnel responsible for administrative work and cleaning service should also be trained and properly briefed on signs and symptoms of the disease and provided with appropriate PPEs, as needed.
1 Statement on the second meeting of the IHR emergency committee regarding the outbreak of the 2019- nCoV: https://www.who.int/news-room/detail/30-01-2020-statement-on-the-second-meeting-of-the-international- healthregulations-(2005)-emergency-committee-regarding-the-outbreak-of-novel-coronavirus-(2019-ncov)
2 WHO Handbook for the management of public health events in air transport: https://www.who.int/ihr/publications/9789241510165_eng/en/ Public health PLF http://www.icao.int/safety/aviation- medicine/Pages/guidelines.aspx
3 Public health PLF http://www.icao.int/safety/aviation-medicine/Pages/guidelines.aspx
4 WHO Guidance on risk communication and community engagement for 2019-nCoV: https://www.who.int/publicationsdetail/ risk-communication-and-community-engagement-readiness-and-initial-response-for-novel-coronaviruses-(-ncov)
5 WHO Interim Guidance. Advice on the use of masks in the community, during home care and in health care settings in the context of the novel coronavirus (2019-nCoV) outbreak, 28 January, 2020. https://www.who.int/publications-detail/advice-on-theuse-of-masks-the-community-during-home-care-and-in- health-care-settings-in-the-context-of-the-novel-coronavirus-(2019-ncov)-outbreak?fbclid=IwAR1m0- 3pzqy3vfY11WrHcn_WKEpzg0bZpe0eWTbBkxkwqgoLKtTdd4kV_8o
6 WHO disease commodity package for the 2019- nCoV: https://www.who.int/publications-detail/disease-commoditypackage—novel-coronavirus-(ncov) 7 Technical advice on surveillance, laboratory, management and infection control are available on the WHO website: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance