Risk Assessment and Management of COVID-19 Among Travelers Arriving at Designated U.S. Airports, January 17–September 13, 2020

Philip Dollard, MPH; Isabel Griffin, PhD; Andre Berro, MPH; Nicole J. Cohen, MD; Kimberly Singler, DrPH; Yoni Haber, MBA; Chris de la Motte Hurst, MPH; Amber Stolp, MPAff; Sukhshant Atti, MD; Leslie Hausman, MPH; Caitlin E. Shockey, JD; Shahrokh Roohi, MPH; Clive M. Brown, MBBS; Lisa D. Rotz, MD; Martin S. Cetron, MD; Francisco Alvarado-Ramy, MD

Disclosures

Morbidity and Mortality Weekly Report. 2020;69(45):1681-1685. 

In This Article

Abstract and Introduction

Introduction

In January 2020, with support from the U.S. Department of Homeland Security (DHS), CDC instituted an enhanced entry risk assessment and management (screening) program for air passengers arriving from certain countries with widespread, sustained transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19). The objectives of the screening program were to reduce the importation of COVID-19 cases into the United States and slow subsequent spread within states. Screening aimed to identify travelers with COVID-19–like illness or who had a known exposure to a person with COVID-19 and separate them from others. Screening also aimed to inform all screened travelers about self-monitoring and other recommendations to prevent disease spread and obtain their contact information to share with public health authorities in destination states. CDC delegated postarrival management of crew members to airline occupational health programs by issuing joint guidance with the Federal Aviation Administration.* During January 17–September 13, 2020, a total of 766,044 travelers were screened, 298 (0.04%) of whom met criteria for public health assessment; 35 (0.005%) were tested for SARS-CoV-2, and nine (0.001%) had a positive test result. CDC shared contact information with states for approximately 68% of screened travelers because of data collection challenges and some states' opting out of receiving data. The low case detection rate of this resource-intensive program highlighted the need for fundamental change in the U.S. border health strategy. Because SARS-CoV-2 infection and transmission can occur in the absence of symptoms and because the symptoms of COVID-19 are nonspecific, symptom-based screening programs are ineffective for case detection. Since the screening program ended on September 14, 2020, efforts to reduce COVID-19 importation have focused on enhancing communications with travelers to promote recommended preventive measures, reinforcing mechanisms to refer overtly ill travelers to CDC, and enhancing public health response capacity at ports of entry. More efficient collection of contact information for international air passengers before arrival and real-time transfer of data to U.S. health departments would facilitate timely postarrival public health management, including contact tracing, when indicated. Incorporating health attestations, predeparture and postarrival testing, and a period of limited movement after higher-risk travel, might reduce risk for transmission during travel and translocation of SARS-CoV-2 between geographic areas and help guide more individualized postarrival recommendations.

On January 17, 2020, entry screening of air passengers arriving from Wuhan, Hubei Province, China, the epicenter of the COVID-19 outbreak at the time, began at three U.S. airports (Los Angeles International Airport, California; San Francisco International Airport, California; and John F. Kennedy International Airport, New York City, New York) receiving the highest volume of passengers arriving from Wuhan Tianhe International Airport (Table 1) (Figure). Beginning February 3, entry screening expanded to all passengers arriving from mainland China after the issuance of a presidential proclamation restricting entry to U.S. citizens, lawful permanent residents, and other excepted persons. These travelers were routed to one of 11 designated airports. On March 2, travelers from Iran were added.§ As Europe became a new epicenter of COVID-19, travelers from 26 countries in the European Schengen Area (effective March 14), the United Kingdom, and Ireland** (effective for both March 17) were added, and the number of airports to which passengers were routed expanded to 13. When travelers from Brazil†† were added on May 28, screening expanded to 15 designated airports.

Figure.

Number of travelers screened for COVID-19 and changes in screening program — 15 designated U.S. airports, January 17– September 13, 2020
Abbreviations: COVID-19 = coronavirus disease 2019; UK = United Kingdom.

Screening consisted of three steps. First, U.S. Customs and Border Protection officers identified and referred travelers for screening if they had been in one of the specified countries during the previous 14 days. Next, initial screening was conducted, which included observation for signs of illness, a temperature check using a noncontact infrared thermometer (fever defined as temperature ≥100.4°F [38°C]), administration of a questionnaire about signs and symptoms (fever, cough, and difficulty breathing) in the preceding 24 hours or exposure to a person with COVID-19 in the preceding 14 days, and collection of travelers' U.S. contact information. The third step included referral of ill travelers and those disclosing an exposure for additional public health assessment by an on-site medical officer; if indicated, travelers were sent to a local health care facility for medical evaluation. The threshold for sending symptomatic travelers for public health assessment and deciding which among those would be sent for medical evaluation varied during the evaluation period, reflecting evolution of CDC's definition for "person under investigation"§§ and operational considerations (e.g., testing capacity). Until March 20, travelers from Hubei Province were quarantined for 14 days upon arrival under federal or state authority.

All screened travelers received a Travel Health Alert Notice, an information card that advised them to stay home (or in a comparable setting, such as a hotel room) for 14 days after arrival and provided messaging on self-monitoring for COVID-19 symptoms and actions to take if symptoms develop. Traveler contact information was transmitted securely to state health departments via CDC's Epidemic Information Exchange (Epi-X). In addition to covering all costs for CDC personnel and contractors conducting screening, CDC transferred about $57 million to DHS to support the screening operation and incurred additional costs for equipment, travel, and housing of quarantined travelers. At the program's peak volume on March 20, designated airports were staffed with approximately 750 screeners, plus other supporting personnel.

During January 17–September 13, 2020, 766,044 travelers were screened (Table 1), 298 (0.04%) of whom met CDC criteria for referral. Travelers were referred because they had either been in Hubei Province (16, 5.4%), reported contact with a person with COVID-19 (four, 1.3%), or had signs or symptoms that triggered a public health assessment (278, 93.3%). Among the 278 persons who had COVID-19–like symptoms, the most common signs or symptoms triggering assessment were cough (73%), self-reported fever (41%), measured fever (17%), and difficulty breathing (13%) (Table 2). Forty (14%) of these travelers were medically evaluated at a local health care facility, and 35 (13%) were tested for SARS-CoV-2 using reverse transcription–polymerase chain reaction (RT-PCR); nine of the 35 tests returned positive results, representing 0.001% (one per 85,000) of all travelers screened. Fourteen additional travelers with laboratory-confirmed COVID-19 were identified through other mechanisms rather than as a direct result of entry screening: six via established processes with airlines and airport partners to detect ill travelers and notify CDC and eight through notifications about travelers who had received a positive test result in the United States or another country before travel.

CDC relied initially on existing federal traveler databases to obtain passenger contact information to share with states, but missing or inaccurate data prompted adding manual data collection to the screening process. Manual data collection resulted in 98.1% complete records (i.e., records contained both phone number and physical address). CDC sent state health departments contact information for approximately 68% of screened travelers. CDC did not send records processed 12 days after travelers' arrival, with insufficient contact data, or belonging to six states that opted out of receiving travelers' data because of competing response priorities. Analysis of traveler data submitted electronically by airlines during September 14–24, after discontinuation of manual data collection, and supplemented by previously untapped federal databases, showed that 22% of traveler contact information records had phone number and physical address.

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