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Position Paper 12: Guidance on Re-opening of Borders June 25, 2020Purpose: To inform consideration of re-opening borders on the transmission and spread of COVID-19Context: Countries implemented restrictions on international travel to control the COVID-19 pandemic, greatly affecting trade and negatively impacting the economy. To balance health risks with economic needs, many countries are gradually relaxing the restrictions. It is important to understand the potential impact of lifting borders in terms of the virus’ re-emergence in countries that have contained/suppressed the pandemic or sustain epidemic growth in countries yet to achieve control, as well as the effect of mitigation measures such as requiring quarantine on arrival. Summary and Recommendations: The impact of importation is greater after achieving control and determined by the level of transmission in Nigeria. Prior to lifting travel restrictions, a functioning Port Health Services monitoring and response system (such as testing and tracing passengers, isolation) should be in place to detect importation and tailor the control strategy. Decisions on border re-opening should take account of public health and political considerations. Re-opening borders requires close monitoring of the epidemic in source countries and should be done gradually. The month of July could be used to put measures in place to allow gradual re-opening.Evidence from countries that have re-opened their bordersThirty-seven countries recently changed their travel restrictions; of these 28 had a total border closure before the change and 20 opened only for countries with a low risk. Some countries relaxed restrictions on travel early in the epidemic, when the average daily new cases were increasing, while others relaxed these restrictions late in the epidemic when the average daily number of new cases were gradually falling (Annex 1 & 2). Most European countries opened or plan to open to only European countries; travelers from other regions are allowed only on certain conditions (e.g. residents or essential travels). Except for Singapore, which had suppressed the epidemic (having a decrease in the daily number of new cases), other countries such as India, Pakistan, Saudi Arabia, South Sudan and Zambia relaxed restrictions early in the epidemic while case rates were still rising. Others such as Germany, Hungary, Italy, and Thailand relaxed travel restrictions late in the epidemic but continued to suppress/contain the epidemic. Some countries instituted travel restrictions at borders (especially land borders) when there was a surge in cases in neighbouring countries (e.g. Zambia closed its border to Tanzania when the latter had a significant increase in new cases in a nearby district). Countries also implement other NPIs (gradual lifting of school closures, restrictions on public transport, work-from-home requirements, restrictions on social gatherings and public events, and limits on travel between regions/cities) to allow continuity of economic activities while minimising spread, as well as using strategies to test/trace/isolate.International guidance: WHO continues to advise against international travel restrictions given their ineffectiveness and negative impacts on society. The European Centre for Disease Control and Prevention (ECDC) states that available evidence does not support border closures, due to societal and economic disruption. However, a European roadmap to lifting containment measures holds that travel restrictions should first be eased between identified low-risk areas. With regards to quarantine, the ECDC recommends that travelers are treated as local residents and the same measures to prevent spread should be applied. It recommends that countries where there is no community transmission may consider implementing quarantine for travelers arriving from countries where there is community transmission. The effectiveness of quarantine is questionable when there is ongoing transmission in the destination country. The ECDC recommends using a robust monitoring system to identify any increase in the number of cases. Similarly, the U.K. Scientific Advisory Group for Emergencies (SAGE) notes that there is little justification for international travel restrictions when imported cases account for a small proportion of overall cases, while acknowledging that determining t tolerable risk for imported cases is a policy question taking into account non-science factors.,Findings from modelling: Limited data are available on the impact of international travel restrictions and border opening. Our modelling results for Nigeria show that the impact of travel restrictions and border opening is limited during community transmission. This is particularly evident at national level, where the impact of importation is not observable. We further investigated opening the airports on 1st July in Lagos and Abuja which, according to the National Bureau of Statistics (NBS), have the highest numbers of international arrivals. Results show that in the most extreme scenario (i.e. when all arrivals are COVID-19 positive individuals) the number of total infections, both symptomatic and asymptomatic, in the following month increases by around 3,900 cases (from 18,665 to 22,565) in Lagos and around 460 cases (from 58,067 to 58,527) in Abuja. The model also shows a possible average increment of hospitalized cases by 2 (up to 32 cases maximum), and no impact on deaths in Lagos in three months. In Abuja, because the peak of the infection seems to not yet have been reached, results show a possible increase of 20 hospitalized cases (up to a maximum of 442) in three months, with possibly up to 5 additional deaths. Similar results can be observed in other cities with international airports, suggesting that a gradual reopening of borders will not have a high impact on the epidemic. Previous modeling related to influenza pandemics suggest border closures can delay the introduction of the virus but only if complete and rapidly implemented in the early phases of an epidemic.Appendix 1. Travel restrictions/border re-opening, level of epidemic and other NPIs for selected countries in Africa, Asia, and Europe CountriesStage of epidemic when restriction was relaxedTravel restrictionsCurrent status/level of the epidemicStatus of other NPIsCountries in early stages of the epidemicIndiaRelaxed travel restrictions on when the number of cases was increasing.- 19th May 2020: relaxed travel restrictions but ban arrival from some regions. It has particularly opened Its border to some regions and some groups such as foreign businessmen, foreign healthcare professionals, engineers, technicians, managerial and design specialists with recognized invitation from Indian facilities The number of cases has been increasing with about 8000 cases per day- All public schools remain closed until further notice- Recommend working from home- Public events remained cancelled- Restrictions on gatherings of 10 people or less-Recommend not leaving house with exceptions for daily, exercise, grocery shopping and essential travelPakistanRelaxed travel restrictions when the number of new cases was increasing- 9th June 2020: Relaxed travel restrictions but ban arrival from some regions- Updated 18th June 2020: Inbound commercial flights are suspended until further notice; however outbound international flights are operating at some airports. Returning nationals and residents must quarantine for 14 days upon arrival. Lockdown has been extended in some provinces, and restrictions differ between regions. The average number of new cases has been increasing daily- All public schools remain closed until further notice- Recommend closing (or work from home) for some sectors or categories of workers- Public events remained cancelled- Restrictions on gatherings of 10 people or less-Recommend not leaving houseSaudi ArabiaRelaxed travel restrictions when the number of new cases was increasing- 6th June 2020: Relaxed travel restrictions but ban arrival from some regionsThe average number of new cases has been increasing with about 2300 per day- All schools remain closed- Recommend working from home-Public events remained cancelled- restrictions on gatherings between 11-100 people-Restrictions on public transport-Recommend not leaving the houseSouth SudanRelaxed international travel restrictions when the number of cases was increasing steadily.- 12th May 2020: Opened all borders when the average number of cases was 20 per day. Some measures were put in place. The measures include wearing of face masks, social distancing and spraying of all aircrafts on arrival. International travelers are also required to produce medical certificates from countries of origin declaring them Covid-19 free and be subjected to 14-day quarantine upon arrival to South Sudan.- 14th June 2020: Closed all borders when the daily average number of new cases was 87.- Closure of airports for international and domestic passenger flights until 28 June 2020. This excludes scheduled cargo, humanitarian aid and technical and humanitarian support flights; airlines operating in the oil fields; and evacuation flights for foreign nationalsNumber of cases has been increasing daily- All public schools remain closed until further notice.- Recommend closing (or work from home) for some sectors or categories of workers- Public events remained cancelled- Restrictions on gatherings of 10 people or less- Restrictions on public transport- Recommend not leaving house with exceptions for daily exercise, grocery shopping, and 'essential' trips ZambiaRelaxed international on restrictions when the number of cases was increasing- 8 May 2020: Relaxed border restrictions. A mandatory 4-day quarantine at government health facilities for all persons entering Zambia is in place until further notice. - 11 May 2020: closed border with Tanzania after the border district recorded its highest single day increase of 76 new cases. This was to allow for cleaning, disinfection, an COVID-19 testing to be conducted. -16 May 2020: reopened border with Tanzania to fright transport while people remain banned from crossing the border until further notice.Number of cases has been increasing daily- All public schools remain closed until further notice.- All tourist visas remain suspended until further notice.- Social gatherings of more than 50 people are bannedCountries in later stages of the epidemicBelgiumSteady decline in number of new cases- From a total border closure to implementation of ban arrival from same regions on the 9 May 2020.Daily number of new cases has continued to fall- Implemented contact tracing, opened schools, opened most sectors of business- No restriction to public transport, no restriction to domestic travelDenmarkSteady decline in number of new cases- From a total border closure to implementation of ban arrival from same regions on the 25 May 2020Daily number of new cases has continued to fall- Phased opening of schools, limited use of public transport, opened up sectors of businessFinland Relaxed international travel restrictions twice. First when the number of daily cases started to decline (14 May) and when the number went down below 20 per day from >150 at peak (15 June).- 14 May 2020: From total boarder closure to ban for non-Schengen area. No leisure travel recommended within the Schengen area - 15 June 2020: No restrictions from specific countries with low risk (Finland and Norway, Denmark, Iceland, Estonia, Latvia and Lithuania).- Non-leisure travel possible form EU and UK but self-isolation for 14 days recommended.- Ban for travelers from non-EU countries. No increase since the ease of travel restrictions. Stable with around 20 cases per day.- Started relaxing other NPIs. Opening of school and lifting of stay-at-home recommendation.- Testing recommended for patients with suspecting symptoms.- Test capacity: 13,000 tests per day.Implementation of surveillance of symptoms.France Relaxed international travel restrictions when the number of cases became stable at low level.- 2 June 2020: Opened for a few selected countries from the total border closure. Plan to start accepting travelers from EU. - 15 June 2020: No restrictions for travelers from EU.No increase since the ease of travel restrictions. Stable with around 400 cases per day.- Since 11 May, lockdown measures are gradually being relaxed, including opening of schools and shops. Testing recommended for anyone with symptoms.- Launched a contact-tracing app.Germany Opened it border to neighboring countries when the number cases went down substantially (>5000 to <1000 per day).- 16 May 2020: Opened the border for France, Switzerland, and Austria.- 15 June 2020: Open to EU. Travelers from the third countries restricted.No increase. Stable with around 300 cases per day.- Gradual relaxing of NPIs including opening of schools. Immense testing capacity (up to 160,000 tests per week). - Contact tracing app launched.Hungary Since 4 May, in the middle of decline in the number of cases, Hungary started to relax the international travel restrictions.- Total border closure until 4 May. Gradually allowed travelers from neighboring countries and then EU with quarantine at home required.Declined continued despite relaxing of NPI and the daily number of cases is stable at around 10.- Gradual relaxing of NPIs including lifting of school closure and stay-at-home requirement. - Contact tracing app launched.ItalyGradually declining in daily number of new cases - Arrival ban from same regions to no restriction implement on the 1 June 2020Steady decline in daily number of cases from the 28th March 2020- Some level of school closed, no restriction on public transport, restrictions on gatherings of 10 people,recommend work from home, implemented contact-tracingSingaporeImplemented relaxation in travel restriction when daily number cases were on a rise- 10th April 202 from ban arrivals from same regions to quarantine on arrival from some or all regionsSince 27th April, there has been a gradual decline in daily number of new cases- Implemented contact tracing, phased opening of schools, restrictions on gatherings of 10 people or less, opened up some sectors of businessThailandSteady decline in number of new cases- From a total border closure to implementation of ban arrival from same regions on the 4 May 2020Maintained a low number of new cases- Schools closed, recommend no to travel between regions/cities, restrictions on gatherings between 101-1000 peopleAppendix 2 Daily number of cases (7-day rolling average) and the level of travel restrictions2525841422400233054887142Level of travel restrictions0 - no restrictions; 1 - screening arrivals; 2 - quarantine arrivals from some or all regions; 3 - ban arrivals from some regions; 4 - ban on all regions or total border closure00Level of travel restrictions0 - no restrictions; 1 - screening arrivals; 2 - quarantine arrivals from some or all regions; 3 - ban arrivals from some regions; 4 - ban on all regions or total border closure473286716213700-28829010604500-309880170180005001065703400right000-321310-1050200Appendix 3. Modelling MethodologyThe model is a SEIR compartmental model with a daily time-step. Age-specific and geographical heterogeneity is added to study transmission in key populations. The population divided by sex and 3 age groups (0-14, 15-59, 60+), we also consider the sub-population of women of reproductive age (15-49). The population in Lagos City is divided between residents of the following districts: Agege, Ajeromi Ifelodun, Alimosho, Amuwo, Apapa, Ifako Ijaye, Ikeja, Kosofe, Lagos Island, Lagos Mainland, Mushin, Odofin, Oshodi Isolo, Shomolu, Surulere. The model is initialized on 16 March when the first 3 cases of COVID-19 were notified. In Abuja the model is initialized on 19th March when the first case of COVID-19 was notified. The model is calibrated to data on notified cases and deaths from NCDC. Data on international air travel passengers were collected by the National Bureau of Statistics for the second quarter or 2019.The analysis in this paper is purely the work of the?Nigeria COVID-19 evidence synthesis group* for use by the PTF. Unauthorized use or publication of this material without the permission of the PTF is prohibited.* The Nigeria COVID-19 evidence synthesis group?is chaired by Prof Ibrahim Abubakar, scientific and technical advisor to the PTF.?References ................
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