Dr Janusz Janiec
IHR NFP Coordinator, National
Institute of Public Health,
Traditionally, the beginning of autumn is a busy time for meetings, seminars and conferences. The COVID-19 pandemic impacted our regular schedule quite a lot; nevertheless, many events took place online instead, in virtual form. Many, if not all, public health events of this kind were dedicated to the current pandemic, and in many, our HEALTHY GATEWAYS project was in attendance. All events were important, but one in particular was very special in many ways: the Virtual meeting of the Chief Medical Officers in the framework of Germany's EU Presidency 2020 on 29 September organised by Partners from RKI in collaboration with The Federal Ministry of Health in Germany. In this event, Professor Christos Hadjichristodoulou together with his team, delivered a keynote presentation, which resulted in bringing the topics that HEALTHY GATEWAYS is working on onto a higher level of discussion among all MS, triggering a fruitful and harmonised dialogue.
To sum up, one of the main outcomes of all the recent online meetings or trainings, in which our project was present, was a plea for harmonisation and standardisation of effective public health measures, the theme that HEALTHY GATEWAYS is working on since its first appearance under the name SHIPSAN many years ago.
In the current issue, the readers learn about the latest HEALTHY GATEWAYS developments from our regular section: “News from consortium”. Insite on of challenges in the different sectors of transport and PoE can be found in a theme section; into maritime sector from the perspective on Hamburg port and from Italian experience, into aviation again from Germany and from Lithuania with special focus on testing at the PoE.
Beginning with the next edition, our newsletter will be issued under the wings of a new editor. This means, the current issue is the last one for me in this role, which is why I would like to congratulate all the authors who published their articles, HEALTHY GATEWAYS for its deliverables presented in the issued newsletters, and above all, I would like to express my special gratitude to Elina, without whom we wouldn’t have a chance to read our newsletters. Thank you Elina for your dedication, enthusiasm, professionalism, and endless patience to all who wanted to contribute a lot but were quite often late!
Stay healthy and enjoy reading!
Dr Janusz Janiec
IHR NFP Coordinator, National
Institute of Public Health,
Prof. Christos Hadjichristodoulou
EU HEALTHY GATEWAYS Joint Action Coordinator, Professor of Hygiene and Epidemiology, Department of Hygiene and Epidemiology, Medical Faculty, University of Thessaly, Greece
The COVID-19 pandemic has impacted the day to day life of all citizens in Europe and beyond with great implications for Points of Entries and the transport sector. The EU HEALTHY GATEWAYS joint action continues to support the competent authorities in EUMS with all aspects of prevention and control in the context of COVID-19 with the following activities.
Contact tracing at Points of Entry
The effectiveness of rapid detection and containment of COVID-19 is interlinked with effective contact tracing. As described in previous issues, a working group was established including consortium members and representatives from EASA, EMSA, ECDC, ERA and IATA to develop an EU software application for digital Passenger Locator Forms (dPLF), so as to improve usefulness of PLFs during cross-border health threats. WHO HQ & WHO EURO have been invited and will designate focal points for the group. From the transport industry, Cruise Lines International Association (CLIA Europe) responded positively and will provide feedback for the cruise sector. Moreover, the International Union of Railways (UIC) invited the JA to present the dPLF project at their COVID-19 task force meeting and provided input on the rail sector. A number of working group meetings have been conducted and members are providing input on variables to include in each dPLF for aircrafts, cruise, ferries, land (bus, train, car). Working group members are also discussing how the EU application should be developed (e.g. options for when each dPLF should be completed, how long data should be stored, options for travellers with no email address/smart phone, how to ensure data quality, potential connections with contact tracing apps). In the next two months the first version of the application will be ready for pilot testing.
Model Memorandum of Understandings
The COVID-19 crisis has brought forward the need for intersectoral collaboration with all actors at Points of Entry in order to effectively prevent, detect and respond to public health events. The following models memorandums of understanding (MoU) are in the final stage of development by the consortium members before they will be disseminated to the competent authorities at Points of Entry.
- MoU for personal data exchange for the purpose of contact tracing in the field of public health
- MoU for coordination of response to public health events of mutual interest (Ground crossings)
- MoU for airport local competent authorities agreement of cooperation for responding to public health events
- MoU for port local competent authorities agreement of cooperation for responding to public health events
Supporting the restart of the cruise ship and ferries operations
In June 2020, the joint action developed two interim advice documents for the maritime industry:
To further support the competent health authorities in EU MS to perform focused inspections on board cruise ships as it is described in the interim advice document, EU HEALTHY GATEWAYS provided the following:
- Checklist for inspectors that will perform focused inspections on board cruise ships based on the advice document: This checklist addresses the suggested standards to be implemented on board cruise ships after lifting restrictive measures implemented in response to the COVID-19 pandemic, so as to ensure a level of preparedness to minimize the transmission of COVID-19 cases on board and have in place response measures if a case of COVID-19 is detected.
- Asynchronous e-learning course for inspectors that will perform focused inspections on board cruise ships:The objective of the course is to support personnel at competent health authorities in EUMS to perform focused inspections on board cruise ships and ashore facilities, to review procedures and plans in order to ensure measures mentioned in the “Interim advice for restarting cruise ship operations after lifting restrictive measures in response to the COVID-19 pandemic” are met both by cruise ship operators and port authority. To date (20/10/2020) a total of 20 port health officers are register.
- Scheduling at an EU level to avoid duplication of inspections: EU HEALTHY GATEWAYS can support the scheduling of inspections. The inspections will be scheduled in cooperation with the companies and the competent authorities.
- EU database to record inspections: EU HEALTHY GATEWAYS will support the conduct of focused inspections by providing a database to record the results of the focused inspections.
E-learning courses for PoE and COVID-19
Four asynchronous e-learning courses on preparedness and response at points of entry in the context of COVID-19 are currently under development by the joint action:
- Course 1: General course for PoE
- Course 2: Preparedness and response at ports
- Course 3: Preparedness and response at airports
- Course 4: Preparedness and response at ground-crossings
The first two courses will be completed by the end of the year.
Representation to European and International events
The joint action holds several coordination meetings with all European and International stakeholders keeping them informed of the joint action activities, and ensuring at the same time a harmonized and standardized approach between the different stakeholders.
Members of the consortium gave a keynote presentation titled “Challenges of cross-border contact tracing in the transport sector” at the Virtual meeting of the Chief Medical Officers in the framework of Germany's EU Presidency 2020 on 29 September 2020. The meeting gave the opportunity to present to the members of the Health Security Committee challenges faced highlighting at the same time possible solutions. Participating Member States acknowledged all challenges faced and supported the idea of establishing sustainable digital solutions at EU-level.
Moreover the activities of the joint action were presented in the following events:
- WHO training event in Turkmenistan. May 2020. Presentation title: Key considerations for exit and entry screening at border
- CLIA Executive Partner COVID-19 Webinar. 13 July 2020. Presentation title: EU Healthy Gateways Joint Action Update
- Medcruise Post COVID-19 Committee of experts - 2nd meeting. 5 August 2020. Presentation title: Interim advice document for restarting cruise ship operations after lifting restrictive measures in response to the COVID-19 pandemic. Post COVID-19 Committee of Experts meeting to analyse the situation in all 21 MedCruise Countries and discuss the safe resumption of the cruise operations.
- UIC Covid19 Task Force meeting. 22 September 2020. Presentation titled " EU HEALTHY GATEWAYS supporting ground-crossing means of transport during the COVID-19 pandemic"
- Supported the WHO-POE trainings in the Balkans. Two experts from the consortium presented at the training events (Dr. Thomas von Münster from University of Hamburg-Eppendorf, Germany and Dr. Janusz Janiec from the National Institute of Public Health-National Institute of Hygiene, Poland)
- European Public Health Conference and 16th World Congress on Public Health, Rome, Italy. 12-16 October 2020. A workshop was organised by the EU HEALTHY GATEWAYS joint action titled “Round table: Points of entry in light of the COVID-19 outbreak – a European perspective”. Moreover, the coordinator presented the COVID-19 outbreaks in transport & maritime, aviation and land borders at the workshop on HEALTH PREPAREDNESS organised by Chafea and DG SANTE.
- FRONTEX Workshop on Health and Safety at the Border: Needs, Challenges and Lessons Learned. 27-28 October 2020
- Seatrade Virtual - Destination Restart 101. 5-8 October 2020.
Cruise ship activities in the summer of COVID-19
Authors: Elisabeth Hewelt1 and Lena Ehlers1
1Hamburg Port Health Center, Germany
At the beginning of February 2020 the cruise vessel “World Dream” was noticed by the media as the first ship that was put under quarantine because of COVID-19-cases on board. Shortly after, it became publicly known that on board of the “Diamond Princess” multiple cases occurred. In retrospect several hundred persons were infected on this vessel.
Briefly after these events the cruise industry almost came to a standstill worldwide. This was well noticeable also in the port of Hamburg, third biggest European seaport and with generally more than 200 calls of cruise ships per year. After the quick repatriation of most of the passengers on board, many cruise ships were looking for a safe spot to wait and see what would happen. The port of Hamburg harboured up to seven cruise ships for several weeks. If possible the layover was used for shipyard work, but in some cases ships came to a complete standstill. This resulted in all kinds of problems of standstill-management (sanitation and medical problems as well as technical problems); from out of date medication in the board hospital, over vast amounts of unused dinnerware and not enough space to store it, to the danger of microbial activity in stagnant water.
The situation concerning the cruise ships was in the beginning very shifting. As part of the Ship Sanitation Committee of German Federal States the Hamburg Port Health Centre (HPHC) created a written overview of the situation initially on a daily base, in the coming weeks, when the situation calmed down a bit, weekly. Daily status reports were submitted by the IHR-ports of Bremen and Bremerhaven, Hamburg, Kiel, Rostock and Wilhelmshaven. Subjects were a balanced distribution of incoming ships moored in the mentioned harbours and the German Bight as well as a constant exchange of information about the general situation, and urgent questions and topics concerning all ports. This exchange of information took also place between the Hamburg Port Health Center and the Central Command for Maritime Emergencies Germany (Havariekommando) and the Maritime Safety and Security Centre. As an alternative to the liability to pay costs for berthing in a harbour many companies decided to anchor their ships in the roadstead of the German Bight. The necessary deepwater roads are out of the 12 mile-zone and were at heyday (July 2020) used by up to five cruise vessels. At the beginning of the pandemic the ships often had a full crew of up to 1000 crewmembers per ship on board. Tender-boats were used to get crewmembers ashore for repatriation so that in the following weeks these numbers declined. Provision-trips or medical consultations with shoreside facilities were organized in the same fashion. Because of the hindered reachability of the ships anchored in the roadstead (journey time from the coastline to deepwater roadstead per ship approx. 3-4 hours) and the difficulty to estimate the health- and infection-situation on board of these vessels the Hamburg Port Health Centre did an on-side visit at the beginning of August 2020. With the generous help of the Hamburg water police two members of our team were able to get on board of one of the ships by waterway and get an overview of the situation. The visit to the roadstead was seen as an important contribution to the safety and health protection of the public and was performed without any problems.
Summarized, the handling of the COVID-19-pandemic on board of ships was a humongous logistical challenge for the national health services and the cruise lines. But the ones who suffered the most were the crewmembers, who had to stay on board, partly without proper means of communication to their families back home, repeatedly cancelled repatriation flights, uncertainty of pay and long periods of time on board which lead to a tremendous mental burden. In detail the management of laid-up cruise ships is difficult and further work is reserved.
Authors: Dr Mauri Dionisio1 and collaborators from Italian Healthy GateWays team1
1Ministry of Health, Directorate General for Health Prevention, Italy
The COVID-19 pandemic hit all productive activities together with a tremendous impact on the health conditions of the population of the entire world. The cruise industry has been even heavily stroked by the COVID infection due to the sharp cessation of all cruises around the world.
The restart of the cruises has thus been a necessity to restore, at least partially, an engine for the economy by considering all industrial and economical activities surrounding the world of the cruises. This goal, however, has been conducted bearing in mind the health of all people (guests, crew members, contractors, etc) which is the utmost priority of the Public Institutions: protecting public health is the priority and must come first.
The ‘Diamond Princess case’ at the beginning of the pandemic is still alive in our minds. It caused high concern throughout the world.
Hence it derives the obligation to have and share more stringent and restrictive measures.
A plan has been developed to restart the cruises through stepwise increases characterized by a strict adherence to all National and International Regulations and in accordance with the Scientific Societies (European Centre for Disease Prevention and Control –ECDC-, World Health Organization –WHO-, European Guidelines such as EU Healthy Gateways COVID-19_RESTARTING_CRUISES.PDF, Ministry of Infrastructure and Transport, National Health Institute -ISS, Robert Koch Institute).
Firstly a Protocol was developed with the aid of a group of experts containing all recommendations stemming from regulations and scientific recommendations. It has been prepared considering the evidence currently available about SARS-CoV-2 transmission (primarily human-to-human transmission via respiratory droplets or contact).
The main principles of reducing the spread of COVID-19 have been the social distancing, the personal hygiene and sanitation, the use of face masks, and a strong campaign of communication to increase the awareness of all people, on board and in the terminals (leaflets, infographics, TV screens, training, announcements).
As a second main step a careful selection of the crew members (CMs) and contractors must be carried out based on:
- questionnaires on health status
- swab tests made before leaving their home (if coming from high risk countries, according to the international update on the high risk countries)
- swab test performed before embarkation and isolation in a ashore accommodation while waiting the results of the PCR test
- embarkation with temporary restrictions, once embarkation is granted, with a 14-day temporary restriction on board (stay in cabin when not on duty, dedicated meal delivered to the cabin)
- Daily temperature measurement (either self measurement or done by health personnel).
All these measures have to be conducted in addition to the general rules above described (social distancing, hand hygiene, face mask, etc.).
These measures allow us to identify some individual who resulted positive to SARS-CoV-2 who was then entrusted to the shore side Health Authority for repatriation.
In addition to these measures, all crew members are monthly monitored with the PCR on board.
Staff training on the signs and symptoms of COVID-19 is fundamental: crowd management, use of PPE, procedures related to prevention, surveillance, and response to any outbreaks. This will be checked every 30 days.
Implementation of medical staff and equipment on board
It is diriment to acquire a number of instruments to run both antigen tests and PCR. These devices have been located within the on board hospital area and are run by ad hoc graduated technicians/biologists hired for this specific purpose. Additional medical and/or nurse personnel have been added to the existing teams in order to support the on board equips during all embarkation/disembarkation procedures and health condition controls.
Once these long lasting preliminary activities were carried out, the Company is suggested to restart with short distance cruises limited to the Italian territorial waters and with Italian guest only in order to reduce the likelihood of guests coming from territories where the incidence of the COVID-19 diffusion is still above the threshold between low and high risk countries.
As a preliminary step a pre-booking is made online with preliminary questions to be answered. Accordingly, for instance people under quarantine or those who have been in contact with COVID-19 persons in the last 14 days or transited through countries with significant infection rate are denied to complete the registration process.
A health status questionnaire was also prepared according to the scientific data indicating that people with specific health impairments (chronic respiratory diseases, use of oxygen or ventilatory support, immunosuppressive therapies) are denied boarding. In addition to these conditions, heart diseases, chronic renal and liver diseases, diabetes, neoplasms, obesity can severely impair the health status: these persons have been thus recommended to seek proper medical advice. Also all guest aged 65 or more have been strongly advised not to travel.
Once a guest has passed these preliminary steps, he/she is allowed to proceed to the terminal for the further steps.
At this site, a temperature screening is carried out with the aid of a thermocamera.
In case of values above the threshold of 37.5°C, the person is left aside for a couple of minutes and then the thermal screening is repeated. In case of persisting values above 37.5°C, the person is sent to the secondary screening consisting of an interview conducted by a doctor through anamnesis, medical and laboratory examination with a second temperature measurement. The assessment will be carried out in a suitable area previously identified by the Port Authority in collaboration with the local health authority.
According to the decree of the Head of the Italian Ministry issued on Aug 7 2020, the “RT-PCR molecular tests will be performed by the medical staff on board as a percentage of 100% on passengers whose temperature, or the anamnestic and / or epidemiological evidence or the contents of the questionnaire lead to consider them as passengers in suspicious cases”.
All Ship Companies have to apply these recommendations in an even restrictive way by subjecting every passenger to a pre-embarkation antigenic test and, in case of positive result, to the PCR test.
The path in the terminal has been clearly established depending however on the size and availability of the rooms within each terminal.
After the thermal screening, the persons are guided to a swab registration area where a bar code is assigned. Each person is tested with a rhino-pharyngeal swab test collected by physicians and doctors in a pre-determined area.
The specimens are sent on board at defined time intervals where a group of technicians are running the antigenic test. Meanwhile the persons are sent to a waiting area, subdivided in cohorts, waiting for the results of the tests.
A negative response will authorize these passengers to proceed towards the gangway passing the usual security procedures. Those who are identified as positive, instead, are sent to a confined area where a physician is conducting an interview while the pharyngeal material previously collected is processed for PCR.
Both suspect case and close contacts (family members, companion, etc) are kept as a group and isolated from other groups in standby. Test positivity of one single person determines denied boarding for all group members.
In case of confirmed positivity to PCR, the person(s) is/are not allowed to embark. The Company has identified specific protected areas/facilities in different Italian regions where they can be temporarily transported via a protected transport and kept for further assessment prior to repatriation. The same situation is applied to crew members as well.
MEASURES TO PROTECT HEALTH AND PREVENT INFECTIONS ON BOARD
COVID-19 safety measures on board (Contact tracing)
In addition to the general rules (social distancing), the utmost attention must be paid to cleaning and disinfection by carrying out rigorous and strict sanitization procedures, an accordance with “European Manual of Hygiene Standards and communicable Disease Surveillance on Passenger Ship” –link: htpp://www.shipsan.eu/Home/EuropeanManual.aspx
It will be the Captain's responsibility to ensure that, at least once a day, a specific message will be included among the periodic announcements. It will stress to observe the rules of good behaviour, and will underline that the Shipping Company is following all the instructions of the WHO, the Local Health Authorities and the Administration Flag.
Moreover Guests are kindly advised to avoid any non-essential contact.
They are even sensitized to use stairs, when possible; if the use of lifts is considered, this must be done with restrictions on the maximum number of users, in agreement with social distancing and, in any case, the use of face mask will be mandatory.
In order to reduce interactions between guests, crew and between guests and crew it is suggested to divide them into cohorts. Different cohorts should avoid any interactions, if possible.
This measure allows a potential case of COVID-19 and related contacts to be managed more effectively. It also reduces the number of exposed persons to the potential case of COVID-19.
It would be optimal to maintain the separation between cohorts both on board and ashore.
If this is not possible on board, this should be guaranteed for ashore activities.
However, the use of Contact Tracing technological methods developed by the Company must make possible to avoid delays in the implementation of health measures.
Contact Tracing should begin as soon as possible, even without waiting for test / swab results.
Crew members working in contact with probable or confirmed COVID-19 cases should have the cabin positioned so that they have a minimized access to common areas.
All guests must be assessed in relation to their risk of exposure and classified as "in close contact with high risk of exposure" or "low risk of exposure".
“High-risk people” must complete a printed format prepared by the Company, and will also have to remain in their cabins or in a ground structure identified by the Port Authorities.
If the test/swab result is positive all close contacts are quarantined, if no symptoms appear within 14 days of the last exposure, the contact is no longer considered at risk of developing Covid 19 disease.
All other “low risk” guests must only fill in the print format made available by the Company (their contact details and places of residence for the next 14 days).
On-board isolation of suspected and confirmed COVID-19 cases
If it is not possible to disembark the confirmed cases within 24 hours, in accordance with the contingency plan, the number of cabins intended for isolation / quarantine is set at around 5% of the number passengers and 5% of the number of the crew.
In case of possibility of disembark, the mentioned percentages are reduced to 1%.
This calculation mechanism only applies in the initial stages of restarting operations and it is meant to be revised according to changes in the pandemic situation.
Measures to manage the risks associated with the ship-to-shore interface
Ship Companies must instruct their Cruise ships to interface with all shore based Entities, (including personnel who may come on board) in order to communicate their needs and requirements and make possible to establish effective control measures and risk reduction (refer to: “Guide to ensure a safe on-board interface between ship and ground personnel “ and to Circular IMO 4202 / Add. 16 and 6 May 2020 - annex 7).
Considerations and areas of improvement
Further step towards obtaining and sharing protocols is based on the comparison and integration of inspection data, in order to draw up a unique “check list” that makes the protocols uniform and shared. EU Health Gateways has developed a protocol to facilitate performance of focused inspections based on the “Interim advice for restarting cruise ship operations after lifting restrictive measures in response to the COVID-19 pandemic” (https://www.healthygateways.eu/Portals/0/plcdocs/EU_HEALTHY_GATEWAYS_COVID-19_RESTARTING_CRUISES.pdf?ver=2020-07-08-131911-653)
A checklist is included; it is not a comprehensive list. National and local rules should be considered and this checklist should be read and used together with the above mentioned advice documents.
The present procedure, here summarized in the main items and aspects, defined all steps in order to be as complete as possible. It has been presented to all Coast Guard officers, to the Port and Health Authorities of the call ports before commencing the cruise activity. There was an overall good acceptance and positive consideration were expressed for the detailed measures and for the care of the activities aimed to preserve the health and safety of all people on board.
Nevertheless, after having started, some issues emerged and were object of immediate improvement also through conjoint meeting with the above Authorities. Hereby summarized is a list of the main situation faced needing immediate adjustment:
The tasks necessary for the restart of the cruise activity implied incredible efforts not only during the preparation phase but also with ongoing and continual adjustments.
With the hope that this severe pandemic contingency will leave us useful teaching and the certainty that the huge resources that had been required to face it, will not be wasted.
Acknowledgements: Authors would like to thank for his contribution Dr Alfredo Andreis by Carnival Maritime GmbH.
Authors: Kristina Militzer1, Jan Heidrich1, Thomas von Münster1, Martin Dirksen-Fischer2
1 Institute of Occupational and Maritime Medicine
2 Hamburg Port Health Centre
The COVID-19 pandemic is spreading on a global scale; everyone and every sector in every part of the world needs to adapt to these unprecedented circumstances.
The COVID-19 pandemic also has a major impact on aviation. In March 2020, travel restrictions have been imposed and many countries have closed their borders. Consequently, the number of flights per day decreased drastically. Half a year later, in September 2020, the daily variation of flights is still 55% below the level of equivalent days in 2019 (see graph 1). Within Europe, the intra-Europe flow is the main flow. In numerical terms this means that for example on 6 October 10,807 intra-European flights operated which reflects 30 % of the previous year's amount. At the beginning of October 2020, most active flows were domestic flows led by flights within France, Norway, Turkey, and Germany in fourth position. The busiest non-domestic flows were between UK and Germany, Russia and Turkey and between Germany and Italy (Eurocontrol 2020).
Graph 1: Daily Variation (Flights) compared with equivalent days in 2019 (Eurocontrol 2020)
Aircrafts can cover large distances in a very short amount of time with the risk of carrying asymptomatic, presymptomatic or symptomatic but infectious passengers on board. Hence, aviation can contribute to the speed and extend of the COVID-19 pandemic across continents, national borders and also within single countries (Candido et al. 2020).
Additionally, there is a risk of on-board transmission of SARS-CoV-2 during a flight or during the time spent at airports (check-in area, boarding procedure, baggage claim, etc.). Both passengers and cabin crew/airport personnel can transmit SARS-CoV-2 to others and are exposed to the risk of contracting COVID-19. Evidence for the on-board transmission of SARS-CoV-2 is limited but first case reports have been published (e.g. Khanh et al. 2020, Speake et al. 2020).
To ensure safe travelling in the air transport sector, precautionary measures to prevent the transmission of SARS-CoV-2 need to be implemented. In this context, Healthy Gateways published an Advice for aircraft operators for preparedness and response to the outbreak of 2019-nCoV acute respiratory disease and as well an Overview of personal protective equipment (PPE) recommended for personnel, crew and passengers at points of entry and on board conveyances in the context of the COVID-19.
In case there is an infectious passenger or crew member on board contact tracing is crucial. Passenger Locator Forms (PLFs) help to identify and manage contact persons of the index case on board of aircrafts. This contributes to the interruption of a further spread of the disease. Due to short flight times combined with the fact that some persons infected with SARS-CoV-2 show no symptoms, the need of contact tracing might only become obvious after passengers have already disembarked.
In Germany, every passenger arriving from a designated risk-area needs to complete a PLF. The Robert Koch Institute (RKI) disseminates which regions or countries are considered a risk area in Germany. This can change quickly and hence the amount of aircrafts as well as passengers arriving in Germany from designated risk areas is varying. Aircraft and airport operators and all associated stakeholders need to flexibly adapt to these changes. By the time of writing, printed PLFs are distributed and collected by airline staff and afterwards handed over to the competent health authority at the respective airport in Germany. This results in an enormous organizational and work effort. For instance at Hamburg Airport, the oldest and fifth-biggest airport in Germany, airplanes are arriving from designated risk areas on a daily basis. For the whole month of September more than 40.000 PLFs were collected at Hamburg Airport. These PLFs needed to be sorted and assigned to the competent public health office. This process is currently supported by German Armed Forces. Other European countries such as Croatia, Greece, Lithuania and Slovakia already have digital systems in place where passengers can complete PLFs online. Digitalisation of this process is also being planned in Germany but is not yet implemented. Healthy Gateways is preparing a uniform European application of digital PLFs (see for example Healthy Gateways Newsletter, Issue 11).
Passengers arriving from designated risk areas at German airports can do a COVID-19 test free of charge. At Hamburg Airport, the German Red Cross is in charge of such a testing station. Not every passenger takes advantage of this test offer immediately after arrival at Hamburg Airport but anyway some hundreds of tests are being conducted daily.
Candido DS, Claro IM, de Jesus JG, Souza WM, Moreira FRR, Dellicour S, Mellan TA, du Plessis L, Pereira RHM, Sales FCS, Manuli ER, Thézé J, Almeida L, Menezes MT, Voloch CM, Fumagalli MJ, Coletti TM, da Silva CAM, Ramundo MS, Amorim MR, Hoeltgebaum HH, Mishra S, Gill MS, Carvalho LM, Buss LF, Prete CA Jr, Ashworth J, Nakaya HI, Peixoto PS, Brady OJ, Nicholls SM, Tanuri A, Rossi ÁD, Braga CKV, Gerber AL, de C Guimarães AP, Gaburo N Jr, Alencar CS, Ferreira ACS, Lima CX, Levi JE, Granato C, Ferreira GM, Francisco RS Jr, Granja F, Garcia MT, Moretti ML, Perroud MW Jr, Castiñeiras TMPP, Lazari CS, Hill SC, de Souza Santos AA, Simeoni CL, Forato J, Sposito AC, Schreiber AZ, Santos MNN, de Sá CZ, Souza RP, Resende-Moreira LC, Teixeira MM, Hubner J, Leme PAF, Moreira RG, Nogueira ML; Brazil-UK Centre for Arbovirus Discovery, Diagnosis, Genomics and Epidemiology (CADDE) Genomic Network, Ferguson NM, Costa SF, Proenca-Modena JL, Vasconcelos ATR, Bhatt S, Lemey P, Wu CH, Rambaut A, Loman NJ, Aguiar RS, Pybus OG, Sabino EC, Faria NR. Evolution and epidemic spread of SARS-CoV-2 in Brazil. Science. 2020 Sep 4;369(6508):1255-1260. doi: 10.1126/science.abd2161. Epub 2020 Jul 23. PMID: 32703910; PMCID: PMC7402630.
EUROCONTROL Comprehensive Assessment for Wednesday, 07 October 2020. Available at: https://www.eurocontrol.int/sites/default/files/2020-10/covid19-eurocontrol-comprehensive-air-traffic-assessment-07102020.pdf
HEALTHY GATEWAYS: Interim Advice For Preparedness And Response To Cases Of 2019-Ncov Acute Respiratory Disease At Points Of Entry In The European Union (Eu)/Eea Member States (Ms). 2020. Available at: https://www.healthygateways.eu/Portals/0/plcdocs/EU_HEALTHY_GATEWAYS_2019-nCoV_AIRCRAFTS_4_2_2020_F.pdf?ver=2020-02-05-102326-010
HEALTHY GATEWAYS: WHO, WHERE, HOW - Overview of personal protective equipment (ppe) recommended for personnel, crew and passengers at points of entry and on board conveyances in the context of the covid-19 pandemic. 2020. Availbale at: https://www.healthygateways.eu/Portals/0/plcdocs/EUHG_PPE_Overview_24_04_2020_F.pdf?ver=2020-05-20-201841-010
Khanh NC, Thai PQ, Quach HL, Thi NH, Dinh PC, Duong TN, Mai LTQ, Nghia ND, Tu TA, Quang N, Quang TD, Nguyen TT, Vogt F, Anh DD. Transmission of Severe Acute Respiratory Syndrome Coronavirus 2 During Long Flight. Emerg Infect Dis. 2020 Sep 18;26(11). doi: 10.3201/eid2611.203299. Epub ahead of print. PMID: 32946369.
Speake H, Phillips A, Chong T, Sikazwe C, Levy A, Lang J, et al. Flight-associated transmission of severe acute respiratory syndrome coronavirus 2 corroborated by whole-genome sequencing. Emerg Infect Dis. 2020 Dec. https://doi.org/10.3201/eid2612.203910
Robertas Petraitis, Brigita Kairiene, Rolanda Lingiene, Giedre Aleksiene
National Public Health Centre under the Ministry of Health, Lithuania
Some key facts
After the diagnosis of the first case of COVID-19 until the 16th of October, 2020 7106 cases of COVID-19 (in accordance with the applied case definitions and testing strategies) have been reported, including 112 deaths (and 32 COVID-19 infected people died of other courses)1. According to the results of the epidemiological investigations, almost 10 percent of all cases were imported.
Consultation and control of travellers at point of entries
The day when Lithuania’s responsible institution (National Public Health Centre under the Ministry of Health (NPHC) started the implementation of COVID-19 management activities at the points of entries was the 25th of January, 2020. NPHC specialists consulted persons returning or arriving to the
Republic of Lithuania from foreign countries by aircraft or ferry about any symptoms of COVID-19 and its preventative measures. The main attention was paid to those who returned from China, this due to the fact that COVID began here. Later other countries were included: (Northern) Italy, Hong Kong, Iran, Japan, South Korea, Singapore and others. According to the statistical information, provided by European Centre for Disease Prevention and Control the list of COVID-19 affected countries increased and additional measures were implemented at all points of entries (port, airports and ground crossings): travellers temperature measurement, collection of completed passenger locator forms, consultation of travellers at the point of entries. Later on, there was made a decision to organize targeted laboratory testing conducted at points of entry for travellers incoming to the Republic of Lithuania. During testing period, in airports there were tested 3354 incoming travellers, this identified 57 COVID-19 cases; in ports there were tested 9033 incoming travellers, identified 16 COVID-19 cases; at ground crossings there were tested about 20 incoming travellers, identified 0 COVID-19 cases2.
Currently all the travellers who are coming to the Republic of Lithuania are obliged to fill out Passenger form (https://keleiviams.nvsc.lt/en/form) online before travel by all modes of transport (aircraft, ferry, train, bus), to get the specific QR code and provide it for the registration to the carrier before boarding. If travellers come to the Republic of Lithuania by their own means of transport, they are obligated to fill out Passenger form online within 12 hours after their specific time of arrival in Lithuania.
We want to emphasize, that specialists from NPHC working at the points of entries received very much support from military, other public health institutions, Lithuanian Red Cross Society and the Order of Malta Relief Organization.
COVID-19 management lessons learned at the points of entries (ports, airports and ground crossings) should be shared amongst stakeholders in the different countries. We can all learn from each other and adjust accordingly.
2 Personal communication, 15 October 2020
EU HEALTHY GATEWAYS publications
Considerations for implementing a common strategy for testing of travellers for SARS-CoV-2 at international airports in EU MS (Version 2 - 17 October 2020)
This report was prepared after a request from the European Commission's Directorate-General for Health and Food Safety (DG SANTE). An ad-hoc working group was established with members from the EU HEALTHY GATEWAYS joint action consortium.
This report provides an analysis of options for laboratory testing methods(PCR, antigen rapid tests), timing of laboratory testing of travellers including advantages and limitations, practicalities regarding triage of passengers, and how to get information about orientation of passengers and setting up “corridors” according to the risk zones (green, orange, red, grey).
The report is available here
Educating, training, and exercising for infectious disease control with emphasis on cross-border settings: an integrative review
Doret de Rooij, Evelien Belfroid, Christos Hadjichristodoulou, Varvara A. Mouchtouri, Jörg Raab, Aura Timen, for the EU HEALTHY GATEWAYS Joint Action consortium
Global Health 16, 78 (2020). DOI: https://doi.org/10.1186/s12992-020-00604-0
Introduction: Points of entry and other border regions educate, train, and exercise (ETEs) their staff to improve preparedness and response to cross-border health threats. However, no conclusive knowledge of these ETEs’ effectiveness exists. This study aimed to review the literature on ETEs in infectious disease control concerning their methods and effect, with an emphasis on cross-border settings and methods that enlarge ETEs’ reach.
Methodology: We systematically searched for studies in the databases Embase, Medline, Web of Science, PsycInfo, ERIC, and Cinahl. After successively screening titles and abstracts, full-texts, and citations, 62 studies were included using in- and exclusion criteria. Data were extracted using a data-extraction form. Quality assessment was performed. We developed a theoretical framework based on which we analyzed the ETE context (target group, recruitment, autonomy, training needs), input (topic, trainers, development and quality of materials), process (design, duration, interval, goals), evaluation (pre-, post- follow-up tests), and outcome (reaction, learning, behavior, and system).
Results: We found a limited number of published evaluations of ETEs in general (n = 62) and of cross-border settings (n = 5) in particular. The quality assessment resulted in seven ETE methodologies and 23 evaluations with a ‘good’ score. Both general studies and those in a cross-border setting contain a low-moderate detail level on context, input, and process. The evaluations were performed on reaction (n = 45), learning (n = 45), behavior (n = 9) and system (n = 4), mainly using pre- and post-tests (n = 22). Online learning methods have a high potential in enlarging the reach and are effective, particularly in combination with offline training. Training-of-trainer approaches are effective for learning; new ETEs were developed by 20–44% of participants until six months after the initial training.
Conclusion: Our study reveals a limited number of publications on ETEs in infectious disease control. Studies provide few details on methodology, and use mainly short-term evaluations and low level outcomes. We call for more extensive, higher-level evaluation standards of ETEs, and an easy and sustainable way to exchange evaluations within the workforce of infectious disease control in cross-border settings. The theoretical framework developed in this study could guide future development and evaluation of ETEs in infectious disease control.
Peer-reviewed scientific articles on COVID-19 and transportation
The list of articles on COVID-19 and transportation has been updated and currently includes 151 peer reviewed articles. Check the updated list here
HEALTHY GATEWAYS publications
Check out the updated list of publications in Conference proceedings/Workshop and in journals here
The web-portal remains an important means of disseminating the joint action activities and deliverables to the stakeholders of the joint action. The web-portal has about 23.000 users and about 42.000 unique page views since its launch. Most importantly the interest of stakeholders is reflected in the number of downloads of the interim advice documents for COVID-19 developed by the joint action.
Table 1: Web-portal analytics
Quarterly Number of views
January 2020-April 2020
Quarterly Number of views
May 2020-August 2020
Total Number of views
October 2018-August 2020
Unique page views
Table 2: Number of downloads of key deliverables from the web-portal
Number of downloads
Public health measures at points of entry
Advice for ship operators for preparedness and response to the outbreak of COVID-19
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.
WHO, WHERE, HOW: Overview of Personal Protective Equipment (PPE) recommended for staff at Points of Entry and crew on board conveyances in the context of COVID-19 pandemic
Interim advice for restarting cruise ship operations after lifting restrictive measures in response to the COVID-19 pandemic (Version 1 - 30 June 2020)
Advice for health authorities and ship operators who have decided to suspend sailings and for the long-term docking of ships at the ports of EU/EEA MS during COVID-19 pandemic
Advice for aircraft operators for preparedness and response to the outbreak of 2019-nCoV acute respiratory disease
Preliminary advice for preparedness and response to cases of COVID-19 at ground crossings (buses and bus stations) in the European Union (EU)/ European Economic Area (EEA) Member States (MS)
Exit and entry screening at points of entry
Advice for reducing droplet transmission of COVID-19 on board conveyances by using face masks
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)
Suggested procedures for cleaning and disinfection of ships during the pandemic or when a case of COVID-19 has been identified on board (VERSION 2 - 20/04/2020)
Preliminary advice for preparedness and response to cases of COVID-19 at ground crossings (trains and rail stations) in the European Union (EU)/European Economic Area (EEA) Member States (MS)