Dutch Discussion on Public transport

By Arnold Bosman, on a personal title.

Issue

On 12 June, the Dutch Government decided that airline travel could commence operations as usual, based on scientific advice from the Dutch Ministry of Health. The advice had 3 main references:

1. COVID-19 Aviation Health Safety Protocol. Guidance for the management of airline passengers in relation to the COVID-19 pandemic. Issue no: 1.1 Issue date: 21/05/2020.
2. European Centre for Disease Prevention and Control. Considerations for travel-related measures to reduce spread of COVID-19 in the EU/EEA. ECDC: Stockholm; 2020.
3. RAGIDA MERS-CoV.

This issue behind the government guidance, is that it fails to make transparent what the scientific advice says, and what decision the policy makers have taken. On this page, I try to disentangle the matter.

The Government Guidance (using the 3 references above), concludes that:

• “The risk of transmission of SARS-Cov-2 during an air journey and its consequences for the Dutch epidemic can be limited by:

1. not to travel if you have symptoms;
2. dissemination of good information about infection risks in advance;
3. a triage / health check immediately before the flight;
4. adhering to strict hygiene;
5. optimal use of the 1.5 meters distance from each other and where this proves impossible, following a policy as implemented by public transport in view of the specific ventilation in the flight cabin;
6. perform adequate cleaning between air travel;
7. the possibility of rapid contact detection if a passenger or crew member subsequently appears to have had COVID-19 among the members.

Where a distance of 1.5 meters cannot be maintained in aircraft, contact between passengers and crew must be limited and, in accordance with the chosen policy in public transport, the wearing of a non-medical mouth cap can be considered.”

And specifies that;

• “Although the effect of the ventilation systems in aircraft on the transfer of COVID-19 has not been scientifically investigated, it is plausible that these vertical air flows with purified air and high ventilation rate limit the risk of possible transfer of SARS-CoV-2 between passengers. These ventilation systems must be used optimally for this, which means that they must be operational from the boarding of the passengers until all passengers have disembarked and that they must be regularly checked for operability.”

However, this document by the Ministry of Health omits the key message of the ECDC Technical Reports that it refers to: Travelling Increases COVID19 risks, even when full interventions are in place. For a Ministry of Health Guidance, that would have been an appropriate conclusion to start with, or at least to include.

Based on the Considerations of the Ministry of Health (12 June 2020), the Minister of health writes a letter to the Dutch Parliament:

1. “ At our request, RIVM (see appendix) has given advice on the safety on board of aircraft in connection with COVID-19. RIVM also gave advice on the protocols of the Dutch airports and airlines. The basis for the protocols lies in the EASA and ICAO guidelines, which are also followed by foreign airlines and airports. Dutch airlines and airports have aligned their protocols with the RIVM advice.”

And:

1. “ The combination of health check, the unique ventilation system, mouth masks and the possibility to carry out targeted source and contact research mean that restrictions on capacity on board are not considered necessary.”

That last statement comes as a complete surprise, as this is NOT the conclusion of the annexed Considerations of the Ministry of Health. On the contrary: the scientific facts as presented in the 3 reference documents, all point in the opposite direction.

Let’s see in detail what these 3 references say:

1. EASA protocol

The guidelines in this document should be considered a protocol for all European Airlines, as is clarified at the introduction: “ Their purpose is to serve as an aviation health safety protocol and to provide a source of best practice on how airport operators, aeroplane operators conducting commercial and non-commercial passenger transport operations (hereinafter aeroplane operators) and national aviation authorities can ensure the health and safety of passengers, as well as the staff and crew who serve them, by maintaining safe and secure operations whilst minimising the risk of virus transmission. This should complement the advice of public health authorities and help employers in their duties under the relevant legislation on protection of workers’ health and safety.”

Moreover, the guidelines explicitly state that the existing Safety Information Bulletins should first be taken into consideration, especially this one: https://ad.easa.europa.eu/blob/EASA_SIB_2020_02_R4.pdf/SIB_2020-02R4_1 Stating that:

• “Aircraft operators, irrespective of the area of aircraft operations, should provide a sufficient supply of face masks for the intended operations, with the quality meeting at least surgical standards. Face masks should be worn at all times by crew members having direct contact with the passengers or other individuals that are not part of the crew. The face masks should be replaced regularly (at intervals not exceeding 4 hours or as recommended by the mask manufacturer).”
• identify any passenger with symptoms of COVID19 (e.g. persistent cough), and report those on the health manifest of the flight and inform the health officer at the destination.
• “to ensure social distancing is practiced at all time, especially during the check-in, security check, pre-boarding, boarding and disembarkation procedures, as well as passport control, where applicable.”

The EASA report then continues:

“ aeroplane operators should ensure, to the extent possible, physical distancing among passengers. Family members and individuals travelling together as part of the same household can be seated next to each other. The seat allocation process should be modified accordingly. If physical distancing cannot be guaranteed because of the passenger load, seat configuration or other operational constraints, passengers and crew members on board an aircraft should adhere at all times to all the other preventive measures including strict hand hygiene and respiratory etiquette and should wear a face mask.”

What does this mean? In a standard seat configuration of a Boeing 737 or Airbus 320/321, where there are 6 seats per row (2x3), there should be a seat open between occupied seats, except for members of the same household.

Such seat configurations are currently fully booked, according to Dutch journalists.

In line with this, the Dutch Ministry of Health considerations (12 June 2020) state: “ The basic principle is that the 1.5 meter distance between people at airports, during check-in and boarding, and on board aircraft must be aimed for. To this end, passengers should be spread as much as possible in the aircraft and the catering and movements through the cabin to be minimized. Because the 1.5 meter distance cannot always be maintained on board an aircraft, the use of non-medical nose caps can be advised for passengers, in line with the advice for public transport.“ So that is OK.

However, they then continue: “ Because the passengers have previously been troubled by health complaints, this concerns the use of nose caps to prevent or reduce the small chance of pre-symptomatic transmission of the SARSCoV2. For the same reason, cabin crew members may also be advised to use non-medical nose caps for use in the cabin.” That contradicts the EASA guideline, that advise crew face masks “with the quality meeting at least surgical standards” The Dutch ministry does not clarify the scientific rationale (nor reference) for this deviation.

2. ECDC Technical Report

Reference 2 clearly states the travel-related risks for COVID19: “ Travel and tourism could lead to an increased risk of SARS-CoV-2 transmission amplification in at least two ways. The first is related to mobility of people and the risk of transmission following arrival at the point of destination, and the second to the gathering of people at various venues such as airports, resorts and similar settings. Public health measures applied specifically to or within the travel sector are intended to minimise the likelihood of COVID- 19 transmission on board various conveyances, at sites of embarkation/disembarkation and at destinations.” This means that

• ECDC recognizes the increased COVID19 risk due to:
  • gathering people at airports
  • transmission on board
  • transmission at sites of embarkation and disembarkation
  • transmission risk at destinations

The document continues: “Travel-related introduction and tourism-related spread within the EU/EEA and the UK contributed substantially to the transmission across and within countries during the early phase of the COVID-19 pandemic” Since the Netherlands is returning to the containment phase, with an aim to reduce endemic transmission as much as possible (though this has never been defined as the strategic goal by the Dutch governing coalition), travel related introduction and tourism related spread are again to be expected becoming substantial contributors to COVID19 transmission.

Indeed, this is specifically acknowledged by ECDC, as the report continues: “In a situation where some Member States have decreased transmission to very low levels, while in others the virus is still circulating, the role of tourism and travel-related transmission may become significant due to the possibility of the virus being re-introduced at multiple sites, causing further spread. Furthermore, a high level of tourism- related activities may increase the risk of over-crowding in certain areas or during tourist events, which in turn may increase spread.”

What are the risks?

• “SARS-CoV-2 is believed to be transmitted mainly via respiratory droplets and by direct contact. However, indirect contact with contaminated fomites is also believed to play a role in transmission. Moreover, transmission through aerosols cannot be excluded.”

In order to reduce these risks, ECDC repeats the relevant interventions: “ Standard non-pharmaceutical countermeasures are the most important approach for controlling the spread of COVID-19 in all settings, including during travel. Such measures include physical distancing, hand hygiene and respiratory etiquette, as well as other infection prevention and control (IPC) measures (e.g. cleaning and disinfection of frequently touched surfaces and toilets, use of face masks, etc).” This list of interventions is not a ‘choose what you prefer’ list. It does not mean that each single intervention item can replace the others. Masks alone are not a good replacement for the lack of physical distancing. To make this explicit, ECDC states clearly in this technical report: “It must be noted that the use of a face mask complements but does not replace other personal protective and IPC measures.” And: “ travel service providers should still optimise physical distancing to the extent possible (e.g. by leaving an empty seat between passengers.”

The issue in many discussions will be: what is ‘to the extent possible’? Airlines might argue: this is not possible, or else we must double (or triple) the prices of tickets.

So what do you do as government? Well, that is a political choice. But please, do not cherry-pick scientific advice and then use science as an excuse for your choice. Be transparent. The public (your voters) deserve this, since you represent them.

ECDC is unambiguous at this point: “Passengers travelling on conveyances where the recommended physical distancing of 1.5−2.0 metres cannot be guaranteed should therefore be aware of the transmission risk even if face masks are used. Overall, the purpose of these measures is to mitigate the risk, however it cannot be fully eliminated.”

So: the bottom line is that no matter what measures you take in air-travel, there is always an increased risk of COVID19, even when all measures mentioned in this technical report are taken. And when less measures are taken (such as in case of the Netherlands’ decision to allow fully packed flights), the risks will be even higher.

Contact Tracing

(See also RAGIDA guidelines below) The ECDC Technical Report is also quite explicit in terms of relevant contact tracing when COVID19 occurs while travelling: “Contact tracing is a core public health measure, which aims to rapidly identify persons who have been in contact with a case, in order to reduce further onward transmission. ECDC‘s technical report Contact tracing: public health management of persons, including healthcare workers, having had contact with COVID-19 cases in the European Union - second update outlines the key steps of contact tracing. These steps are:

• i) to identify persons who may have been in contact with an infected person;
• ii) to trace and communicate with the identified contacts, and to provide information about suitable infection control measures, symptom monitoring and other precautionary measures, such as the need for quarantine;
• iii) to monitor the contacts regularly for symptoms. Contact tracing data are sensitive health data and appropriate data protection needs to be guaranteed at all stages of contact tracing, as well as during follow-up.

When a traveller develops symptoms upon arrival at the destination or during his/her stay, testing, diagnosis, isolation and contact tracing will take place in accordance with the local practice. Public health authorities will communicate with public health authorities in the country of origin if necessary for the purposes of contact tracing and this can be done via the Early Warning and Response System (EWRS). The follow-up of contacts in the country of origin are the responsibility of the public health authorities in that country. Fellow travellers exposed to a probable or confirmed case during travel should be followed-up by the public health authorities in the country where the traveller is staying. “

3. RAGIDA guidelines for MERS

These guidelines were updated in January 2020, following early reports of a novel Coronavirus emerging in China (Wuhan). The guidelines include instructions for contact tracing. Based on the literature review and expert advice, the following contacts of a Coronavirus patient are considered at high risk, and should be monitored:

• passengers seated two seats in all directions around the index case AND
• crew members serving the section of the aircraft where the index case was seated AND
• persons who had close contact with the index case e.g. travel companions or persons providing care.

The risk of passengers 2 seats in front and behind, is consistent with the 1.5 meter distancing rules.

This makes it even more remarkable that current journalist reports mention fully packed flights, with no spare seats between travellers. The chair of the Dutch Outbreak Management Team has even been recorded to have said during an interview that “flight tickets would become too expensive” if you force airlines to keep empty seats in between. Remarkable, as this is not a scientific argument, but a political one.

Conclusion

• The Minister of Transport, Public Works and Water Management, together with the Minister for Public Health advise the Dutch parliament that Distancing measures in airplanes are not necessary, according to the Considerations on COVID9 by the Ministry of Health
• The Considerations on COVID9 by the Ministry of Health do not seem to include such conclusion: on the contrary, they acknowledge that distancing is a key principle in COVID19 prevention. Yet, these considerations fail to include the most relevant conclusion by ECDC on travel-related COVID19 risk: no matter how many preventive measures you take, travel will always increase COVID19 risk. And the fewer measures, the higher the risk. Omission of distancing cannot be compensated by other measures.