Can Pre-Flight Testing Help Restore International Travel?
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Can Pre-Flight Testing Help Restore International Travel?
Article today by Karen Walker, Editor-in-Chief at Air Transport World....
The depth and length of the impact of the COVD-19 pandemic on the air transport industry struck hard in October. In a grim update on the financial outlook for airlines, IATA said it expected them to burn through $77 billion in the second half of the year—or $300,000 per minute—and not become cash positive until 2022.
Second waves of the virus hit regions like the UK and Europe and some parts of Asia, prompting governments to return to stronger lockdowns and border shutdowns. The number of deaths in the US passed 213,000, the highest of any country, and the number of cases was climbing in many states.
The result is a significantly lower demand for air travel for far longer than predicted when the pandemic began. Adding to the criticality of the situation, many government-aid packages for airlines, including some 36 payroll support programs, have expired. They were implemented when most people believed the pandemic and economic situation would be improved by fall and more normal levels of demand for air travel would be resumed. Instead, air travel was down 75% in August versus a year ago and IATA forecasts it will still be down 68% by December.
“It is an unimaginably difficult time,” IATA director general and CEO Alexandre de Juniac said. “You will see more and more [airline] bankruptcies. It is critical and urgent.”
IATA, in unison with Airports Council International and other industry organizations, understandably has switched gears from trying to persuade governments to lift quarantines and border closures—a seemingly hopeless campaign while the coronavirus rages—to calling for 100% COVID-19 testing for all international passengers before their departure and return flights. Surveys show that 83% of participants would not consider air travel if there is a risk of being quarantined, but a similar percentage favors mandatory testing for all travelers.
Unanswered questions
IATA’s new position was not decided lightly, but there really is no choice. Yet it will be very difficult to implement and there are many unanswered questions. First, where and when will the tests be conducted and who pays for them? IATA believes the availability of viral antigen screening tests that are quick to give results (less than 15 minutes), cheap (less than $10), can be administered by a non-medical official and are highly reliable (around 98% valid result) will soon be widely available. That will make it possible for the tests to be conducted at departure airports, but this will require considerable work to administer in a way that does not cause crowding on the land side of terminals, which would be undesirable both from a distancing and a security point of view. IATA hopes that governments will foot the bill for tests, but that may be optimistic and problematic for states where taxpayers don’t see why they should “subsidize” those who choose to fly.
Then there’s all the details. Should testing include small children? How do governments, which have failed woefully to coordinate globally on their approaches to the pandemic, agree to a system of mutual recognition of each departure airport’s tests? Will labor groups worldwide support mandatory testing for all flight crews ahead of each flight? If quarantines continue in countries where people can easily cross borders via trains, cars or ferries, how will governments separate the flyers from the other travelers, or will they mandate tests for all international travelers? And what will be the criteria for ending mandatory testing?
So many questions. The global airline industry, however, cannot be sustained on domestic markets alone and the next big step in pandemic travel must be taken.
But whether mandatory testing, even if successfully implemented, will change the minds of those who choose not to fly until the pandemic is addressed is another matter. The industry has some pretty compelling statistics indicating that it is safe to fly, with there being a far higher risk of being struck by lightning than of catching the COVID-19 virus during a flight on a commercial airliner. IATA medical adviser David Powell said only about 44 people are thought to have caught the virus during a flight this year. That is among the 1.2 billion people who have flown, making the risk of transmission about one in 27.3 million. Even if some 90% of cases were not reported and the risk were 10 times higher, it would mean the likelihood of catching COVID-19 on a flight would be one in 2.73 million, making it “an uncommon event,” Powell said. He compared it to the much greater probability of being struck by lightning, a chance of between one in 500,000 and one in 1.2 million.
But the airline industry still hasn’t found the outside cheerleader, the celebrity, who can convey that safety message to the greater public, especially to those people they most need to convince: the majority that are staying grounded.
The depth and length of the impact of the COVD-19 pandemic on the air transport industry struck hard in October. In a grim update on the financial outlook for airlines, IATA said it expected them to burn through $77 billion in the second half of the year—or $300,000 per minute—and not become cash positive until 2022.
Second waves of the virus hit regions like the UK and Europe and some parts of Asia, prompting governments to return to stronger lockdowns and border shutdowns. The number of deaths in the US passed 213,000, the highest of any country, and the number of cases was climbing in many states.
The result is a significantly lower demand for air travel for far longer than predicted when the pandemic began. Adding to the criticality of the situation, many government-aid packages for airlines, including some 36 payroll support programs, have expired. They were implemented when most people believed the pandemic and economic situation would be improved by fall and more normal levels of demand for air travel would be resumed. Instead, air travel was down 75% in August versus a year ago and IATA forecasts it will still be down 68% by December.
“It is an unimaginably difficult time,” IATA director general and CEO Alexandre de Juniac said. “You will see more and more [airline] bankruptcies. It is critical and urgent.”
IATA, in unison with Airports Council International and other industry organizations, understandably has switched gears from trying to persuade governments to lift quarantines and border closures—a seemingly hopeless campaign while the coronavirus rages—to calling for 100% COVID-19 testing for all international passengers before their departure and return flights. Surveys show that 83% of participants would not consider air travel if there is a risk of being quarantined, but a similar percentage favors mandatory testing for all travelers.
Unanswered questions
IATA’s new position was not decided lightly, but there really is no choice. Yet it will be very difficult to implement and there are many unanswered questions. First, where and when will the tests be conducted and who pays for them? IATA believes the availability of viral antigen screening tests that are quick to give results (less than 15 minutes), cheap (less than $10), can be administered by a non-medical official and are highly reliable (around 98% valid result) will soon be widely available. That will make it possible for the tests to be conducted at departure airports, but this will require considerable work to administer in a way that does not cause crowding on the land side of terminals, which would be undesirable both from a distancing and a security point of view. IATA hopes that governments will foot the bill for tests, but that may be optimistic and problematic for states where taxpayers don’t see why they should “subsidize” those who choose to fly.
Then there’s all the details. Should testing include small children? How do governments, which have failed woefully to coordinate globally on their approaches to the pandemic, agree to a system of mutual recognition of each departure airport’s tests? Will labor groups worldwide support mandatory testing for all flight crews ahead of each flight? If quarantines continue in countries where people can easily cross borders via trains, cars or ferries, how will governments separate the flyers from the other travelers, or will they mandate tests for all international travelers? And what will be the criteria for ending mandatory testing?
So many questions. The global airline industry, however, cannot be sustained on domestic markets alone and the next big step in pandemic travel must be taken.
But whether mandatory testing, even if successfully implemented, will change the minds of those who choose not to fly until the pandemic is addressed is another matter. The industry has some pretty compelling statistics indicating that it is safe to fly, with there being a far higher risk of being struck by lightning than of catching the COVID-19 virus during a flight on a commercial airliner. IATA medical adviser David Powell said only about 44 people are thought to have caught the virus during a flight this year. That is among the 1.2 billion people who have flown, making the risk of transmission about one in 27.3 million. Even if some 90% of cases were not reported and the risk were 10 times higher, it would mean the likelihood of catching COVID-19 on a flight would be one in 2.73 million, making it “an uncommon event,” Powell said. He compared it to the much greater probability of being struck by lightning, a chance of between one in 500,000 and one in 1.2 million.
But the airline industry still hasn’t found the outside cheerleader, the celebrity, who can convey that safety message to the greater public, especially to those people they most need to convince: the majority that are staying grounded.
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The majority aren’t staying grounded because of fears about contracting the virus they’re staying grounded because of ridiculous quarantine rules introduced by various governments that make travel utterly pointless in their current form. Take Jersey for example - already testing on arrival - since the States recently decided to introduce the colour banding system for U.K. regions this makes the vast majority of areas Amber at the very least. This means five days isolation until your second test result. Since this policy has been introduced the passenger loads on LHR-JER have gone from very respectable to utterly dire. This has nothing to do with fears of travelling and everything to do with practicalities.
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It may help, but only to a point. I think the airlines are fighting a war on two fronts. I can only speak for myself but I believe others may think more or less along the same lines, which is that it's not only the flight which may be a concern but other aspects of travel. For example, I may test negative at the airport outbound and then spend two weeks at a holiday resort. On my return I test positive at the airport and have to quarantine for two weeks (or whatever it is these days). Now I can't get home and I may become ill and need hospitalisation locally. Consequently, at present, airport testing would not inspire me to travel again. In other words (in my case anyway) it's not necessarily the flight which concerns me but the entire trip. Therefore, I choose to remain grounded.
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Re: testing.
Just to give a perspective from a real case.
Three members of my family (a whole household - one of them a nurse) contracted Covid19 in September. Happily all got through it.
One of them (male) never tested positive. He had three tests and despite being unwell with all the symptons, all tests were negative (the other two householders both tested positive).
An anti-bodies test subsequently "confirmed" he had had Covid19 all along (which was pretty obvious anyway).
Make of that whatever you will.
Just to give a perspective from a real case.
Three members of my family (a whole household - one of them a nurse) contracted Covid19 in September. Happily all got through it.
One of them (male) never tested positive. He had three tests and despite being unwell with all the symptons, all tests were negative (the other two householders both tested positive).
An anti-bodies test subsequently "confirmed" he had had Covid19 all along (which was pretty obvious anyway).
Make of that whatever you will.
I have little faith in pre-flight testing changing the odds of coming down with Covid after a flight
Can it restore confidence.
Absolutely! even shuffling seats around and boarding practices makes the punters feel good. If it were aboard a sinking cruise ship we all know that moving deck chairs calm worried folks down
Can it restore confidence.
Absolutely! even shuffling seats around and boarding practices makes the punters feel good. If it were aboard a sinking cruise ship we all know that moving deck chairs calm worried folks down
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At this point, few are so scared of the virus itself that they wouldn't step out of their homes and engage with all the normal activities, albeit with safety measures in place. And that includes travel. The number of people who fear getting infected on a plane these days is a lot lower than 6 months ago. Most of those who do have genuine concerns related to their age and physical condition which, absolutely reasonably, make them go the extra mile to protect themselves.
The problem why the "test and travel" concept would still be highly unappetising to everyone whose trip is not essential is uncertainty. If you're asymptomatic or unlucky enough to trigger a false positive result, your trip will be snatched away from you two hours before departure. If it's a family, that's even worse because everyone will go into quarantine instead of a vacation. Hence, many will prefer local holidays not involving this sort of gamble until something smarter comes into place. Like maybe the realisation that imported cases are no longer a big problem (unless you're New Zealand or one of the few other places where the dreaded lurgy isn't widespread). Or a decent vaccine and an immunity certificate instead of any entry restrictions.
The problem why the "test and travel" concept would still be highly unappetising to everyone whose trip is not essential is uncertainty. If you're asymptomatic or unlucky enough to trigger a false positive result, your trip will be snatched away from you two hours before departure. If it's a family, that's even worse because everyone will go into quarantine instead of a vacation. Hence, many will prefer local holidays not involving this sort of gamble until something smarter comes into place. Like maybe the realisation that imported cases are no longer a big problem (unless you're New Zealand or one of the few other places where the dreaded lurgy isn't widespread). Or a decent vaccine and an immunity certificate instead of any entry restrictions.
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I'm afraid I don't see how pre-flight testing is going to help.
The IATA claims contradict reality as it is at the moment and for the foreseeable future.
The IATA claims contradict reality as it is at the moment and for the foreseeable future.
- The pre-flight quickie Lamp test identifies just 60% of infections, so er 40% are missed (aka Swiss cheese)
- The more reliable, but still less-than-perfect PCR test takes days and even then is only about 80% reliable, making it impractical for all sorts of reasons.
- Is each member of the crew going to be tested before each flight also? If not, more Swiss cheese holes.
- The charge for the Lamp test is £80 pp. So, assuming tested both ways, a family of 4 is facing a round-trip bill of £640 just for tests. Given the industry evidence of passenger duty price elasticity, this makes it a non-starter for holiday trips and most likely all but really essential business trips.
- And all this at a time when restrictions are tightening over the winter as the second wave takes hold, making more travellers more cautious anyway.
Great thread - many of the non medical issues listed above such as cost and being turned away at the airport are probably more relevant than the science.
No test that is only 60% effective is going to cut the mustard. The PCR is getting quicker and cheaper but although 97% eficacious, that depends on getting virus on the swab - even a trained healthcare worker fails in 20% of cases. The false positive is only 1% but this applies to the entire population, so if you tested just at Heathrow, 800,000 a year would be falsely stopped at the terminal.
We can calculate the efficacy of a combination of PCR swab plus isolation plus testing for symptoms - this is what we do in the UK for hospital admissions. 7 days isolation and a negative swab and no symptoms misses only 1 in 130,000 cases and so can be said to protect the border, but the swab has to be done after 3-4 days, not on arrival
Personally I believe we will have a vaccine within weeks and I worry the politicians are mucking around. The initial vaccines have been bought and are being manufactured but will need to be stored very cold. Now is the time to organise this and plan to get the vaccine to every high street so it can be rolled out in days. Serco and the army are no better at vaccinating than track and tracing !
No test that is only 60% effective is going to cut the mustard. The PCR is getting quicker and cheaper but although 97% eficacious, that depends on getting virus on the swab - even a trained healthcare worker fails in 20% of cases. The false positive is only 1% but this applies to the entire population, so if you tested just at Heathrow, 800,000 a year would be falsely stopped at the terminal.
We can calculate the efficacy of a combination of PCR swab plus isolation plus testing for symptoms - this is what we do in the UK for hospital admissions. 7 days isolation and a negative swab and no symptoms misses only 1 in 130,000 cases and so can be said to protect the border, but the swab has to be done after 3-4 days, not on arrival
Personally I believe we will have a vaccine within weeks and I worry the politicians are mucking around. The initial vaccines have been bought and are being manufactured but will need to be stored very cold. Now is the time to organise this and plan to get the vaccine to every high street so it can be rolled out in days. Serco and the army are no better at vaccinating than track and tracing !
An interesting debate.
I have knowledge, but limit my disclosure as not wishing to advertise, of some testing kits available in the UK today and certified by a credible laboratory of having a certainty in excess of 90%. The team trying to distribute them are good people but are limited by the decision making processes of large organisations.
There are good options out there.
I have knowledge, but limit my disclosure as not wishing to advertise, of some testing kits available in the UK today and certified by a credible laboratory of having a certainty in excess of 90%. The team trying to distribute them are good people but are limited by the decision making processes of large organisations.
There are good options out there.
Heathrow were lauding the approval of the trial of these new testing centres for flights to Italy and HK, yet had quite a significant flaw... no foreigners can get into HK at present. So there is very little difference. Yes, it reduces the need for laborious private testing within 3 days of flying, but doesn't make a difference for probably 50% of each flight who would be terminating at HKG.
Everywhere east of DXB has the closed sign up. There is no sensibility - countries in the APAC region are going for an elimination strategy rather than to contain and manage like in Europe. It is unsustainable. When is it going to end? A vaccine is not an exit strategy (quote from Fauci earlier this year) and may not work to a level where the virus is totally eliminated; even Vallance said this a few days ago.
Australia are not reopening their border for another YEAR and NZ not to open their borders until 2022! It is absolutely crazy. Why work in aviation in this region?
Everywhere east of DXB has the closed sign up. There is no sensibility - countries in the APAC region are going for an elimination strategy rather than to contain and manage like in Europe. It is unsustainable. When is it going to end? A vaccine is not an exit strategy (quote from Fauci earlier this year) and may not work to a level where the virus is totally eliminated; even Vallance said this a few days ago.
Australia are not reopening their border for another YEAR and NZ not to open their borders until 2022! It is absolutely crazy. Why work in aviation in this region?
It didn't catch the Russian seamen who are now isolating in CHC.
Who knows what the politicians may decide, but the science offers some good news.
A vaccine will have to reduce the risk of death or being on a ventilator or infection others by more than 50% - that is what the US FDA has decided. Hit any of those and you get an emergency use authorisation if the vaccine is also safe. Now that isnt very good for aviation as many countries may baulk at reopening their borders with still a 49% chance of visitors bringing in the plague. However some studies last week suggested just the first of the 2 doses of vaccine we will get stops the virus replicating in the nose. If true we may see a covid vaccine certificate like the smallpox vaccine certificate 40 years ago that allowed the vaccinated to travel
I am a glass half full person but I do believe the tunnel isnt that long and we will see the light. I know how important that is for so many on this thread.
A vaccine will have to reduce the risk of death or being on a ventilator or infection others by more than 50% - that is what the US FDA has decided. Hit any of those and you get an emergency use authorisation if the vaccine is also safe. Now that isnt very good for aviation as many countries may baulk at reopening their borders with still a 49% chance of visitors bringing in the plague. However some studies last week suggested just the first of the 2 doses of vaccine we will get stops the virus replicating in the nose. If true we may see a covid vaccine certificate like the smallpox vaccine certificate 40 years ago that allowed the vaccinated to travel
I am a glass half full person but I do believe the tunnel isnt that long and we will see the light. I know how important that is for so many on this thread.
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Miles Magister
Important point: certified by what criteria?
We know that the in-vitro accuracy of the swab test is pretty high, but both the quality and timing of the swabbing can introduce significant false negatives rates.
The first manufacturers reports on antibody tests reported accurate -- but misleading -- results, as all the positive blood samples were taken from hospitalised patients (and hence from people who had been seriously ill).
Important point: certified by what criteria?
We know that the in-vitro accuracy of the swab test is pretty high, but both the quality and timing of the swabbing can introduce significant false negatives rates.
The first manufacturers reports on antibody tests reported accurate -- but misleading -- results, as all the positive blood samples were taken from hospitalised patients (and hence from people who had been seriously ill).
The issue for the industry is not passenger confidence in their ability to travel without undue risk. It is the confidence of national governments in the effectiveness of anti-virus mitigations, in other words, confidence that aviation is not contributing to the spread of the virus. Once that is achieved, people will start to travel in the knowledge that they aren't going to be suddenly quarantined or similar. Pending a vaccine, preflight and/or arrival testing will be a key part of the process, at least according to the professors of epidemiology I heard speak recently; they also all commented that the speed and accuracy of tests is improving rapidly and that there are now products entering the market with accuracy in the 97%+ range.
Leaving antibody testing out of the equation (they only tell you if you have had the virus, not whether you have an active infection), the risk of a false positive result (for genetic material or antigen) is less of a problem than a false negative. The false negatives lead to infectious people entering the system, which then means you have to rely on the other mitigations to prevent transmission - those people who refuse to wear a mask, wash their hands, maintain social distancing when possible, etc. And for very small numbers who have a false positive there is always the prospect of a re-test; some can be done in a matter of minutes. And although any false results are unhelpful, the many correct outcomes suggest it is likely to be our best way forward.
I have a friend flying for a ME airline who tested positive on return to his home base and was ordered into quarantine, which surprised him as he felt fine and his departure test had been clear. A second test a couple of days later was also positive but he was still asymptomatic. A subsequent antibody test proved he had indeed been infected and recovered from Covid-19 even though he had no symptoms at any stage. The track and trace system worked out he had probably picked it up during his layover in the USA. Had he not been tested, the operator would have no idea about the risk at the US end, and the authorities would be dealing with all the people he infected after his return. That is the sort of process that boosts government confidence.
Leaving antibody testing out of the equation (they only tell you if you have had the virus, not whether you have an active infection), the risk of a false positive result (for genetic material or antigen) is less of a problem than a false negative. The false negatives lead to infectious people entering the system, which then means you have to rely on the other mitigations to prevent transmission - those people who refuse to wear a mask, wash their hands, maintain social distancing when possible, etc. And for very small numbers who have a false positive there is always the prospect of a re-test; some can be done in a matter of minutes. And although any false results are unhelpful, the many correct outcomes suggest it is likely to be our best way forward.
I have a friend flying for a ME airline who tested positive on return to his home base and was ordered into quarantine, which surprised him as he felt fine and his departure test had been clear. A second test a couple of days later was also positive but he was still asymptomatic. A subsequent antibody test proved he had indeed been infected and recovered from Covid-19 even though he had no symptoms at any stage. The track and trace system worked out he had probably picked it up during his layover in the USA. Had he not been tested, the operator would have no idea about the risk at the US end, and the authorities would be dealing with all the people he infected after his return. That is the sort of process that boosts government confidence.
If 98% valid test equates to a 1 in 50 chance of a false positive test, then that's another barrier to flying. That's a 10% chance of one of a family of five getting a false positive, or two crying families at the departure gates of every flight.
What would increase numbers flying, is guarantees of quick refunds on cancelled flights, and actual help getting flights home after cancellation. Also consistent and safe procedures on boarding and disembarking.
What would increase numbers flying, is guarantees of quick refunds on cancelled flights, and actual help getting flights home after cancellation. Also consistent and safe procedures on boarding and disembarking.
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Testing on arrival, even if you have to wait a few hours for the results, is the best way to eliminate the 14 day isolation. There's just no point in traveling right now outside the air bridges. Shame.
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Perhaps the German approach is the best one for now. No testing at all for travellers from areas designated as safe on the basis of a set, transparent rolling number of cases. That's about enough of a stimulus for non-essential travellers to direct their attention there. If there's still someone who insists on going into a high-risk area, they need to either test negative before their return trip and present a time-stamped certificate at the German border - or they need to get tested at a designated test centre in Germany and self-isolate until such time as their result is out and negative.
I fully understand airport and airline operators pushing for this as they are experiencing massive damage to their businesses as we are, but isn't the concept of airport testing fundamentally flawed because of the biology of the disease?
As I understand it, according the the WHO there is an incubation period which averages 8 days from exposure to symptoms. However incubation can be as short as 2 or 3 days, but in 10% of people is 14 days or longer. We only test positive when we become infectious around 1-2 days before symptoms start. Hence, and most importantly, we test negative for the majority of the incubation period. Asymptomatic carriers also have the same variable incubation period until they too are infectious, although they may never know it. We stop being infectious around 10 days later. Note the distinction between infected (we have it in us) and infectious (we can give it to others).
So as an example, and if the Donald Trump timelines are to be believed, he was infected in the Rose Garden ceremony Sunday, tested negative Monday, Tuesday and Wednesday (assuming he was tested every day, which hasn't been confirmed), tested positive Thursday and was taken ill Friday, i.e. he was on the shorter side of the range observed.
Assuming the tests are accurate (and as others have pointed out, much of the existing testing isn't perfect) a negative test only says we were not infectious on the day of the test. A test at the airport immediately before departure may give confidence that you are safe to fly, but it says nothing about whether you are incubating the disease and will go on to become infectious in the next week or two. Nor does a negative test at the arrival airport.
As I understand it, according the the WHO there is an incubation period which averages 8 days from exposure to symptoms. However incubation can be as short as 2 or 3 days, but in 10% of people is 14 days or longer. We only test positive when we become infectious around 1-2 days before symptoms start. Hence, and most importantly, we test negative for the majority of the incubation period. Asymptomatic carriers also have the same variable incubation period until they too are infectious, although they may never know it. We stop being infectious around 10 days later. Note the distinction between infected (we have it in us) and infectious (we can give it to others).
So as an example, and if the Donald Trump timelines are to be believed, he was infected in the Rose Garden ceremony Sunday, tested negative Monday, Tuesday and Wednesday (assuming he was tested every day, which hasn't been confirmed), tested positive Thursday and was taken ill Friday, i.e. he was on the shorter side of the range observed.
Assuming the tests are accurate (and as others have pointed out, much of the existing testing isn't perfect) a negative test only says we were not infectious on the day of the test. A test at the airport immediately before departure may give confidence that you are safe to fly, but it says nothing about whether you are incubating the disease and will go on to become infectious in the next week or two. Nor does a negative test at the arrival airport.