NEWSLETTER Issue 11 – July 2020

27 July 2020/Categories: Newsletters

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EDITORIAL

Dr Janusz Janiec

IHR NFP Coordinator, National

Institute of Public Health,

Poland

Dear Readers,

It took around three months from the first detected SARS-CoV-2 case to reach one million cases all over the world, and only two weeks to reach two million. Currently, after a half a year we have more than 13 million detected cases worldwide. These numbers speak for themselves. The numbers could have been even bigger if we didn’t see the determination of many people and organisations at different levels around the globe, to combat the pandemic. However, they could possibly be slightly lower if efforts undertaken were more synchronised and harmonised. It is not always easy and possible, and that is why projects like EU HEALTHY GATEWAYS which offer/promote harmonisation of measures through its interim advice documents and activities is so valuable during times of international public health crisis. To learn more about what is new in the joint action, please take a closer look at the latest issues of the newsletter, especially the Coordinator’s update as well as the web portal. And don’t miss the epidemiological refresher from our Dutch partners from RIVM, which can help us better understand the numbers which try to describe the pandemic.

Stay healthy and enjoy the reading!

News from the consortium

New guidance documents developed by the joint action

The restoration of travel and tourism has been the focus in Europe during the last 2 months putting at the same time in the spotlight preparedness at points of entry (airports, ports and ground-crossings) in Europe to detect and respond to imported cases of COVID-19 after opening up borders. The European Commission has published a series of communications on this subject to facilitate EU Member States with the process of gradually lifting restrictive measures and border controls. EU HEALTHY GATEWAYS in line with this effort has developed three interim guidance documents; one general guidance for restoring transportation and two for the shipping industry. Further details are presented in recent publication section.

Development of an EU application for common digitalised Passenger Location Forms for all transport sectors

The joint action will develop an EU application for common digitalised Passenger Location Forms (PLF) for all transport sectors (air, maritime, ground crossings) to improve usefulness of PLFs during cross-border health threats. This additional task will be undertaken jointly by the Work Packages for air, maritime and ground-crossings and a small working group has been established for this purpose. Furthermore, the European Union Aviation Safety Agency (EASA) will be providing support for this project.

In the context of the COVID-19 pandemic, feedback was received from joint action participating countries that while paper-based PLFs have been widely used for contact tracing, these paper-based forms are not as efficient as they should be. With a large number of forms collected at local level, it is challenging for relevant authorities to locate and access the PLFs when needed for contact tracing activities. Furthermore, paper-based forms must be deciphered and input into an electronic format for the relevant authorities, which can be inefficient and time-consuming. This process takes unnecessary time away from other essential activities especially during COVID-19. Developing a digital PLF environment for all three transport sectors (air, maritime, ground-crossings) would allow for easier, more efficient and more rapid data collection, making contact tracing more effective. It would also make it easier on passengers and conveyance crew/medical staff involved in collection of contact details during cross-border checks. Furthermore, digitizing PLFs would allow for development of a European level common web interface under which national electronic PLFs for each EU MS will be developed.

All the national PLFs will be hosted under a common database. Each EU MS will have access only to their national dataset. Data exchange would occur through existing channels.

Considering the current pandemic situation and urgent need for EU MS to continue conducting essential activities in their countries while preventing and controlling disease transmission, the joint action believes this activity would support EU MS to contain the spread of SARS-CoV-2, particularly in upcoming weeks/months as countries gradually lift restrictive measures and border controls. Furthermore, a digital PLF environment on EU level would also facilitate contact tracing activities in the long-term and during future unexpected public health events/Public Health Emergency of International Concern (PHEIC).

Revised joint action work plan

The work plan of the joint action included amongst other activities, many face-to-face training courses, table top and simulation exercises, exchange of visits and high level sustainability meetings at European and National level. The travel restrictions and constraints imposed by the COVID-19 pandemic is forcing the joint action to reschedule and revise the work plan accordingly. Partners may be asked to prioritise activities according to current needs, and training courses, simulation exercises and other meetings could be organised online to avoid travel. By the end of July, the new timeline and activities will be shared with the consortium and stakeholders will also be informed via emails, the webportal and the newsletter. Finally, the coordinator and partners continue to collaborate closely with all relevant European institutions (DG SANTE, DG MOVE, DG NEAR, EMSA, EASA, ECDC, FRONTEX), international organisations (WHO HQ, WHO EURO, CDC) and transport and port representatives (CLIA, ECSA, INTERFERRY, ESPO) with regular coordination and consultation meetings.

THEMATIC SECTIONS

Closing EU internal borders – end of the Schengen group?

Authors: Paulina Nowicka, Janusz Janiec (National Institute of Public Health - National Institute of Hygiene (NIPH-NIH), Poland)

Closing of internal Schengen borders was introduced by many EU countries in the early stage of COVID – 19 pandemic in Europe. Effectiveness of this measures is rather difficult to assess as quite often it was introduced together with other restrictions and recommendations, and at different levels of pandemic situation in countries. Even the term “closed border” might meant something different in many countries as various groups were still allowed to cross borders under variety of conditions. Sometimes, crossing the border was also linked to entry screening like health check and temperature measurements or requirement of self-quarantine for 14 day after entering some countries.

As an example, closing borders in Germany was introduced on the 16^th of March, when the COVID-19 incidence per 100 000 population was 1,76 (1459 new cases per day), while in Poland the temporary border closure for foreigners was introduced on the 15^th of March 2020, at the very early stage of pandemic, when the incidence was 0.055 (21 new cases per day). All Polish citizens who had been at that time outside the borders could return to Poland. Upon return they were subjected to a mandatory 14-day quarantine. All the international passenger air and rail connections were suspended, apart from cargo transport.

Temporary ban on entry to Poland did not apply to all foreigners. Among those who were still able to enter Poland were: spouses and children of Polish citizens, persons with a Pole's Card, persons with the right of permanent or temporary residence in Poland or a work permit.

Also on the 15^th of March 2020 the ordinance on the temporary reintroduction of border control for persons crossing the internal border came into force. Control activities were carried out 24/7 and border control was accompanied by sanitary control. The State Fire Service, medical and sanitary services and the army were responsible for its implementation. The period for which border control of persons was temporarily re-established was extended 4 times, up to the 12^th of June 2020. During this time a total of 2 481 848 people were inspected on the internal border, at the entrance to Poland (the largest number on the border with Germany, 1 969 845)¹. Only during the first quarter of 2019, taking into consideration exclusively people crossing borders with non-Schengen countries, there were 11 068 900 crossings².

¹Komenda Główna Straży Granicznej, https://www.strazgraniczna.pl/pl/aktualnosci/8519,Tymczasowo-przywrocona-kontrola-w-liczbach.html, [2.07.2020]

²Komenda Główna Straży Granicznej, https://www.strazgraniczna.pl/pl/granica/statystyki-sg/2206,Statystyki-SG.html, [2.07.2020]

Nevertheless some countries which included this strict measure managed to keep their epidemic on a lower levels. Genetic findings³ from the United Kingdom suggested that there might have been 1356 independent introductions to the country of SARS-CoV-2 infection. Suggesting that sometimes this strict measure could be justified regardless of economic and social problem that may follow such a decision.

In this article we will not look how effective this measures were, but what are legal background for them. How and what international and European law and specifically Schengen Border Code say about this problem, what can be done and on what legal basis.

At the IHR level, in accordance with Article 18 paragraph 1 of the WHO recommendation addressed to States Parties relating to people may include the following advice:

Submission of people suspected of exposure to clinical-epidemiological observation,
Introduction of quarantine or other health protection measures for people suspected of exposure,
Isolation and treatment, if necessary, of affected people in cases requiring it,
Refusal of entry to people affected or suspected of exposure,
Refusal of entry to people not affected into the affected areas,
Checks at the point of exit and / or application of restrictions to people leaving the affected areas.

Based on Article 23 paragraph 1 of the IHR, subject to applicable international agreements and relevant IHR articles, a state party, for public health purposes, on entry and exit, may require, inter alia, a non-invasive medical examination, which is the least intrusive examination and can achieve the public health objective. Furthermore, according to the paragraph 2 on the basis of evidence indicating the existence of a threat to public health, obtained through the means referred to in paragraph 2. in accordance with paragraph 1 of this article, or by other means, States Parties may apply additional health measures in accordance with the IHR, in particular with regard to an affected or suspect traveller, deciding on individual cases, least intrusive and invasive medical examinations that could achieve the purpose of public health by preventing the spread of disease on an international scale. However, pursuant to Article 31 invasive medical examinations, vaccinations or other preventive actions may not be required as a condition of entry of a traveller into the territory of a State Party, unless, subject to Article 32, 42 and 45, the IHR does not prevent States Parties from requiring medical examinations, vaccinations or other preventive measures or evidence of vaccination or other preventive measures:

In a situation when it is necessary to determine whether there are public health threats,
As a condition of entry for travellers wishing to obtain a temporary or permanent right of residence,
As an entry condition for travellers, in accordance with Article 43 or Annexes 6 and 7,
Which can be carried out in accordance with Article 23.

If a traveller for whom the State party may require medical examinations, vaccinations or other preventive measures in accordance with paragraph 1 of this article, does not meet this requirement, or refuses to provide information or documents referred to in Article 23 paragraph 1 point a), the interested party may, subject to Article 32, 42 and 45, refuse the traveller the opportunity to enter. If there is an evidence indicating direct threat to public health, a state party may, in accordance with national law and to the extent necessary to combat such a threat, compel the traveller to undertake or recommend to the traveller, in accordance with Article 23 paragraph 3, to undertake:

The least invasive and least intrusive medical examination that can achieve the public health objective,
Vaccination or other preventive actions,
Additional established health measures that prevent or control the spread of the disease, including isolation, quarantine or subjecting the patient to clinical-epidemiological observation.

However, it should be remembered that a traveller with a vaccination certificate or other preventive measure issued in accordance with Annex 6 and, if applicable, Annex 7, cannot be refused entry because of the disease to which the certificate relates to, even if he comes from the affected area, unless the competent authorities have reliable information and / or evidence that the vaccination or other preventive actions have not been effective - as set out in Article 36 IHR.

CHAPTER II Schengen Borders Code regulates the issue of temporary reintroduction of border control at internal borders (Article 25 – 35). In such situation the relevant provisions of Title II shall apply respectively to Article 32.

Article 25 provides general framework for the temporary reintroduction of border control at internal borders. Article 26 introduce criteria for the temporary reintroduction of border control at internal borders. Article 27 implements procedure for the temporary reintroduction of border control at internal borders under Article 25.

In situation of temporary reintroduction of border control at internal borders the relevant provisions of Title II Schengen Borders Code shall apply respectively to Article 32.

So the following should be mentioned: Under the EU regulations, the reason for not admitting a third country national, in accordance with Article 6 paragraph 1 point e) Regulation (EU) 2016/399, is the threat to public health. Border traffic at external borders is subject to checks by border guards. Checks may also apply to means of transport and items in the possession of people crossing the border. The national law of the Member State concerned shall apply for searches. The above is provided in Article 8 paragraph 1. based on article 8 paragraph 2 on a random basis, at the minimum check-in at the external borders of people taking advantage of the right of free movement under Union law, border guards may check national and European databases to confirm that such people do not constitute a real, actual and sufficiently serious threat to internal security, public order, international relations of Member States or threats to public health. The results of these checks must not prejudice the right of entry for people with the right of free movement under Union law on the territory of a Member State as defined in Directive 2004/38 / EC. On the other hand, third-country nationals are subject to a detailed entry check including verification if the third country national concerned, his means of transport and the items carried by him do not constitute a likely danger to the public health of any of the Member States. Such a control includes direct verification of the people concerned and their entries, and, if necessary, entries related to items contained in the SIS and in national databases, as well as any possible actions to be taken as a result of the entry as per article 8 paragraph 3 point a) subpoint (iv). For people leaving, detailed check-in at the exit can also include checking entries in SIS for people and objects as well as information in national databases, which results from point (a). h) subpoint (iii). Article 14 provides the legal basis for the refusal of entry and the conditions and procedure for its issuance. The detailed rules for the refusal of entry are set out in Annex V, Part A.

In addition, in general the subject matter is also covered by Article 4, Article 11, article 15, Article 17, Article 18. Decision no 1082/2013 / on serious cross-border threats to health and repealing Decision No 2119/98 / EC. The technical indication of the procedure for the Entry / Exit System can be found in Article 8a Regulation (EU) 2017/2225 of the European Parliament of November 30 2017 amending Regulation (EU) 2016/399 as regards the use of the Entry / Exit System.

In conclusion, border closure decisions remain within the competence of national governments however the decision should comply with Schengen Code. Above mentioned legal acts show that the temporal measure introduced on internal Schengen borders have strong legal grounds, and were foreseen in the legislation, to combat public health events of international concern, however the scale of COVID-19 pandemic and its impact on crossing the borders unprecedentedly surprised many.

Note: The article is based on report “Legal grounds for responding to serious public health threats of cross-border significance in the aspect of land border crossings in European Union countries determined by international law, the world Health Organisation (WHO), European Union (EU).” prepared by legal advisors under EU Healthy GateWays JA

³Pybus O, Rambaut A, du Plessis L., et al. Preliminary analysis of SARS-CoV-2 importation & establishment of UK transmission lineages, https://virological.org/t/preliminary-analysis-of-sars-cov-2-importation-establishment-of-uk-transmission-lineages/507, [2.07.2020]

COVID-19 at points of entry – Collecting Europe’s experiences to learn for the future

Author: Doret de Rooij, National Institute of Public Health and the Environment (RIVM), Netherlands

In the first 1.5 years, many efforts have been made by the consortium of the EU Joint Action Healthy Gateways to support points of entry in the preparedness and response to public health threats [1]. A network and stakeholder overview has been developed, several training-of-trainers sessions have been conducted and many guidelines and documents developed to support countries in the implementation of core capacities at their designated ports, airports and ground-crossings.

With the COVID-19 pandemic, POEs faced significant challenges in operational preparedness and response. Initially in January and February 2020, the news was dominated by the severity and transmissibility of the SARS-CoV-2 virus, its global spread and the measures taken by countries at points of entry [2]. The EU Joint Action Healthy Gateways went into emergency mode and started to provide evidence- and practice-based advice to Europe’s professionals dealing with COVID-29 at points of entry.

In the current literature on COVID-19, the majority of studies covering points of entry report on the effectiveness of public health measures, such as entry- and exit screening [3], hygiene measures [4], or combinations [5]. Other studies use develop forecasting models to research the contribution of travel to the spread of COVID-19 [6, 7]. However, no actual data from POEs is available yet, regarding the challenges and needs POE face. In this way, they are not yet researched as an acting entity.

Harvesting the experiences and challenges of the professionals involved with the response to COVID-19 at POE is pivotal to continuously improve COVID-control, as many countries gradually release the (total) lockdown and it is likely that traffic at POE will increase in the coming months. Equally, it is pivotal to draw lessons for future crises from current experiences.

Therefore, we, a team of several partners in the Joint Actions started a study to collect these experiences. We invited national partners and local professionals to participate in interviews. Several countries have reacted and participate in the study, but data collection will continue for some more weeks. The results of this study can be used soon to serve this collaborative workforce better, and, in the long term, to analyze the COVID-19 crisis from a point of entry perspective. We focus on adequate capacity, capability and the organizational effectiveness experienced during the first months of the outbreak. And we collect the recommendations for the operational readiness [8] that is required for the coming months in which travel and trade will increase.

References

European Union Healthy Gateways Joint Action. EU Healthy Gateways Joint action preparedness and action at points of entry (ports, airports, ground crossings). 2018 [cited 6 May 2020]. Available from: https://www.healthygateways.eu/.
Shoichet CE. 93% of people around the world live in countries with coronavirus travel bans. CNN. 2020 (cited 6 May 2020) Available from: https://edition.cnn.com/travel/article/countries-with-travel-restrictions-coronavirus/index.html.
Quilty, B.J., et al., Effectiveness of airport screening at detecting travellers infected with novel coronavirus (2019-nCoV). Euro Surveill, 2020. 25(5).
Hirotsu, Y., et al., Environmental cleaning is effective for the eradication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in contaminated hospital rooms: A patient from the Diamond Princess cruise ship. Infect Control Hosp Epidemiol, 2020: p. 1-8.
Mouchtouri, V.A., M. Dirksen-Fischer, and C. Hadjichristodoulou, Health measures to travelers and cruise ships in response to COVID-19. J Travel Med, 2020.
Zhong, P., S. Guo, and T. Chen, Correlation between travellers departing from Wuhan before the Spring Festival and subsequent spread of COVID-19 to all provinces in China. J Travel Med, 2020.
Zhuang, Z., et al., Preliminary estimation of the novel coronavirus disease (COVID-19) cases in Iran: A modelling analysis based on overseas cases and air travel data. Int J Infect Dis, 2020.
World Health Organization. First global face to face meeting of the WHO Operational Readiness Task Force. WHO 2017. Available from: https://www.who.int/hac/events/who-operational-task-force-meeting-2017/en/.
World Health Organization. International health regulations (2005). World Health Organization. 2008.
European commission Eurostat. Decision No 1082/2013/EU of the European Parliament and of the Council of 22 October 2013 on serious cross-border threats to health and repealing Decision No 2119/98/EC (Text with EEA relevance). Official journal of the European Union 5.11.2013:L293. [cited 6 May 2020]. Available from: http://data.europa.eu/eli/dec/2013/1082/2013-11-05.

Epidemiological refresher: how to calculate case fatality rate during the ongoing epidemic

Authors: Evelien Belfroid, Doret de Rooij (National Institute of Public Health and the Environment (RIVM), Netherlands)

Since the COVID-19 pandemic is still a serious problem in the EU and other parts of the world, it is important to keep collecting and analyzing epidemiological data. As the outbreak evolves, also the epidemiological data evolve.

One important measure during outbreaks is the case fatality rate (CFR). The case fatality rate of a disease is the proportion of deaths from a certain disease compared to the total number of people diagnosed with the disease for a certain period of time. In this way, it is a measure of the severity of the disease.

During an outbreak the CFR can be over- or underestimated. As the COVID-19 pandemic is still unfolding, the outcome of a case (recovery from COVID-19 or death due to COVID-19) is not known yet for all the cases. The majority of COVID-19 infections are asymptomatic or mild, and do not require hospitalization. This may lead to an underestimation of the total number of cases. In addition, test strategies (criteria for performing a COVID-19 test and testing capacity) also affect the number of identified cases, and subsequently the CFR. As the pandemic unfolds, test strategies were changed based on new insights or capacity which has an impact on the CFR.

In the same way, the numerator also depends or the test policy. WHO disseminated advice on how to define fatalities due to COVID, but these might be applied differently in different situations. For example, is a positive confirmed PCR test needed, or is fatality with COVID-like symptoms enough? Lastly, the numerator may be affected by the population affected by the disease. If the majority of COVID cases are found in risk groups, one would expect a higher case fatality rate. This number cannot be generalized for a whole area or country.

In short, the case fatality rate is a useful number to monitor outbreaks, but be careful with comparing the numbers over different situations and always have close look how the numerator and denumerator are defined.

RECENT PUBLICATIONS

EU HEALTHY GATEWAYS publications

Interim advice for restarting cruise ship operations after lifting restrictive measures in response to the COVID-19 pandemic (Version 1 - 30 June 2020)

The purpose of this document is to provide general guidance to EU/EEA MS and to cruise lines about options for measures on travel and tourism that could be applied after lifting the restrictive measures implemented in response to the COVID-19 pandemic.

Interim advice for preparedness and response to cases of COVID-19 on board ferries after lifting restrictive measures in response to the COVID-19 pandemic. (VERSION 1, 24/06/2020)

This guidance is addressed to ferry companies, as well as competent public health authorities at ports. The objective of these guidelines is to provide recommendations on preventive measures that ferries should implement to protect passengers, crew members and onshore personnel, as well as to create an environment of trust in the maritime transport of passengers by ferry.

General guidance for restarting transportation activities to serve tourism after lifting restrictive measures in response to the COVID-19 pandemic (Version 1 - 15/05/2020)

The purpose of this document is to provide general guidance to EU/EEA MS about options for measures that could be considered to be applied to the transport sector for tourism after adapting to the context of both national and local frameworks. These options could become applicable after lifting the current restrictive measures implemented in response to the COVID-19 pandemic and in order to restart tourism.

Other publications

Communications from the Commission about COVID-19 and transport

· The European Commission presented on 13 May, guidelines and recommendations to help Member States gradually lift travel restrictions, with all the necessary safety and precautionary means in place. All available guidance and communications on safely resuming travel are available here.

· Re-open EU – new web platform to help travellers and tourists. On 15 June, the European Commission launched ‘Re-open EU’, a web platform that contains essential information allowing a safe relaunch of free movement and tourism across Europe.

ECDC ERA COVID-19 Rail Protocol Recommendations for safe resumption of railway services in Europe

The European Union’s Agency’s for Railways (ERA), the European Commission, and the European Centre for Disease Prevention and Control (ECDC) have developed the guidance available here.

Updated EASA Guidance

Aircraft Cleaning and Disinfection available here.
Management of Crew Members available here.

EASA—ECDC COVID-19 Aviation Health Safety Protocol

The European Union Aviation Safety Agency (EASA) and European Centre for Disease Prevention and Control (ECDC) issued a joint document defining measures to assure the health safety of air travellers and aviation personnel once airlines resume regular flight schedules following the severe disruption caused by COVID-19. The document is available here.

IMO-UNCTAD Joint Statement

Circular Letter No.4204/Add.21 (8 June 2020) - Joint statement IMO-UNCTAD – Call for collaborative action in support of keeping ships moving, ports open and cross-border trade flowing during the COVID-19 pandemic. The document is available here.

IMO—Crew changes and repatriation of seafarers – a key issue explained

IMO has included in their website a comprehensive FAQ about crew changes and repatriation of seafarers. The FAQ are available here.

Scientific articles

Exploring the Roles of High-Speed Train, Air and Coach Services in the Spread of COVID-19 in China

Yahua Zhang, Anming Zhang, Jiaoe Wang, Transp Policy (Oxf). 2020 Aug;94:34-42. doi: 10.1016/j.tranpol.2020.05.012. Epub 2020 May 26.

Abstract: To understand the roles of different transport modes in the spread of COVID-19 pandemic across Chinese cities, this paper looks at the factors influencing the number of imported cases from Wuhan and the spread speed and pattern of the pandemic. We find that frequencies of air flights and high-speed train (HST) services out of Wuhan are significantly associated with the number of COVID-19 cases in the destination cities. The presence of an airport or HST station at a city is significantly related to the speed of the pandemic spread, but its link with the total number of confirmed cases is weak. The farther the distance from Wuhan, the lower number of cases in a city and the slower the dissemination of the pandemic. The longitude and latitude coordinates do not have a significant relationship with the number of total cases but can increase the speed of the COVID-19 spread. Specifically, cities in the higher longitudinal region tended to record a COVID-19 case earlier than their counterparties in the west. Cities in the north were more likely to report the first case later than those in the south. The pandemic may emerge in large cities earlier than in small cities as GDP is a factor positively associated with the spread speed.

Identification of critical airports for controlling global infectious disease outbreaks: Stress-tests focusing in Europe.

Nikolaou, P. and L. Dimitriou. J Air Transp Manag, 2020. 85: p. 101819.

Abstract: As the global population increases and transportation connectivity improves in quality and prices, the demand for mobility increases, especially in long-haul services. According to the 2017 report of the European Commission in Mobility and Transport, the performance of all modes for passenger transport (roadways and airways) are reaching record highs. Although the benefits of the increased demand for mobility are substantial and welcome, an effort should be paid such as to ameliorate possible threatening side-effects that may also arise. As World Health Organization (WHO) denotes and as has been evident from the global COVID-19 epidemic outbreak, infectious diseases can be spread directly or indirectly from one person to another under common exposure circumstances such as air transportation (especially long-haul airline connections) that may act as the medium for transmitting and spreading infectious diseases. In this paper, analytical and realistic models have been integrated, for providing evidence on the spread dynamics of infectious diseases that may face Europe through the airlines system. In particular, a detailed epidemiological model has been integrated with the airlines' and land transport network, able to simulate the epidemic spread of infectious diseases originated from distant locations. Additionally, a wide set of experiments and simulations have been conducted, providing results from detailed stress-tests covering both mild as well as aggressive cases of epidemic spreading scenarios. The results provide convincing evidence on the effectiveness that the European airports' system offer in controlling the emergence of epidemics, but also on the time and extent that controlling measures should be taken in order to break the chain of infections in realistic cases.

Estimating COVID-19 outbreak risk through air travel.

Daon, Y., R.N. Thompson, and U. Obolski. J Travel Med, 2020.

Abstract: Background: Substantial limitations have been imposed on passenger air travel to reduce transmission of SARS-CoV-2 between regions and countries. However, as case numbers decrease, air travel will gradually resume. We considered a future scenario in which case numbers are low and air travel returns to normal. Under that scenario, there will be a risk of outbreaks in locations worldwide due to imported cases. We estimated the risk of different locations acting as sources of future COVID-19 outbreaks elsewhere. Methods: We use modelled global air travel data and population density estimates from locations worldwide to analyse the risk that 1364 airports are sources of future COVID-19 outbreaks. We use a probabilistic, branching-process based approach that considers the volume of air travelers between airports and the reproduction number at each location, accounting for local population density. Results: Under the scenario we model, we identify airports in East Asia as having the highest risk of acting as sources of future outbreaks. Moreover, we investigate the locations most likely to cause outbreaks due to air travel in regions that are large and potentially vulnerable to outbreaks: India, Brazil and Africa. We find that outbreaks in India and Brazil are most likely to be seeded by individuals travelling from within those regions. We find that this is also true for less vulnerable regions, such as the United States, Europe, and China. However, outbreaks in Africa due to imported cases are instead most likely to be initiated by passengers travelling from outside the continent. Conclusions: Variation in flight volumes and destination population densities create a non-uniform distribution of the risk that different airports pose of acting as the source of an outbreak. Accurate quantification of the spatial distribution of outbreak risk can therefore facilitate optimal allocation of resources for effective targeting of public health interventions.

WHAT’S NEW ON THE WEB PORTAL

Updates

· NEW COVID-19 ADVICE for the passenger shipping industry here

· New versions of Passenger Locator Forms for aircrafts, cruise ships, ferries and ground crossings available here

· New WHO/Europe catalogue of technical support, trainings and other means of assistance related to the COVID 19 pandemic for Point of Entry (updated 22 May 2020) available here

Web-portal Analytics

The web-portal has served as the main means of disseminating information to stakeholders during the COVID-19 crisis.

The web-portal analytics presenting a noticeable increase in users, page views and the number of downloads of the COVID-19 guidance documents demonstrate the importance of the webportal as a communication and dissemination tool.

Category	Quarterly Number of views January 2020-April 2020	Total Number of views October 2018-April 2020
Page views	15,275	24,544
Unique page views	11,342	17,142
Users	5,432	6,780

Number of views (2742)

Documents to download

ISSUE_11_V2_FINAL

Name/Surname	Authority	Country
Prof. Christos Hadjichristodoulou	Laboratory of Hygiene and Epidemiology, University of Thessaly	Greece
Dr. Miguel Dávila-Cornejo	Ministry of Health, Consumption and Social Welfare	Spain
Dr. Mauro Dionisio	Ministry of Health	Italy
Univ.-Professor. Dr.med Volker Harth (MPH)	Institute for Occupational and Maritime Medicine (ZfAM)	Germany
Dr. Robertas Petraitis	National Public Health Centre under the Ministry of Health	Lithuania
Dr Nina Pirnat	National Institute of Public Health	Slovenia
Dr Peter Otorepec	National Institute of Public Health	Slovenia
Dr Janus Janiec	National Institute of Public Health - National Institute of Hygiene Department of Epidemiology	Poland
Mrs Eirian Thomas	Public Health England	UK

Thematic Section	Section Editor	Authority	Country
Air transport	Jan Heidrich	Hamburg Port Health Center	Germany
Chemical Threats	Tom Gaulton	Public Health England	UK
Ground -Crossings	Brigita Kairiene	National Institute of Public Health	Lithuania
Maritime transport	Barbara Mouchtouri	Laboratory of Hygiene and Epidemiology, University of Thessaly	Greece
Training	Corien Swaan	National Institute of Public Health and the Environment	Netherlands