Coronavirus: How to travel in Italy and elsewhere during the international outbreak

The map of Covid-19 spread around the world looks a lot different than it did just a week ago. While new infections are slowing down in China, they’re rapidly picking up pace around the globe.

Countries as far and wide as Bahrain, Kuwait, Austria, Spain, Brazil, and Afghanistan are now reporting cases. Newly discovered outbreaks in Italy, Iran, and South Korea have surged virtually overnight, suggesting the virus was already spreading widely within their borders and that the world is on the brink of a pandemic — or already in one. (To be clear, a disease outbreak can become a pandemic without being especially severe or fatal.)

Source: Johns Hopkins University Center for Systems Science and Engineering

It’s impossible to predict with certainty where the virus will show up next or where it may die down, which makes planning vacation and business travel trickier than usual.

Vacationers in Tenerife, Spain, certainly did not imagine their trip including a coronavirus hotel lockdown this week. People on the Diamond Princess cruise ship in Japan could not have foreseen spending their holiday in quarantine. Austrians trying to get home from Italy by train last weekend probably didn’t anticipate their schedules getting disrupted because of the virus.

That’s in addition to the border closures that have already happened around China and Iran, and the quarantines and travel restrictions in those and other countries that have often sprung up out of nowhere. These changes have had a significant impact on people’s lives and the global economy. And this may just be the start.

With international travel becomes increasingly fraught, here are some basic questions about how to assess travel safety, answered.

1) Are there any places I shouldn’t go?

The CDC has issued its highest-level travel alerts for South Korea and China, advising Americans to avoid traveling there for the moment. The two countries currently have the most coronavirus cases: more than 78,000 in mainland China, and 1,100 in South Korea.

Milan, in the Lombardy region, is just north of Italy’s coronavirus outbreak epicenter.
Diego Puletto/SOPA Images/LightRocket via Getty Images

As of this week, CDC is also warning travelers to Italy, Iran, and Japan to “practice enhanced precautions,” since these are the countries next on the list with the highest burden of illness.

But just because a country you plan to visit isn’t on the list right now doesn’t mean it won’t be there tomorrow. The outbreak is evolving rapidly and these advisories are likely to change in the coming days, so keep checking in with CDC. This map and list of travel restrictions from the Council on Foreign Relations is another good resource.

And keep in mind: The travel warnings are not entirely because of the risk of catching this new virus. Airlines have been canceling or scaling back flights, trains have been halted, and countries have been imposing sometimes arbitrary quarantines on travelers and citizens.

As Jennifer Nuzzo, an infectious disease expert and senior scholar at the Johns Hopkins Center for Health Security, told Vox: “I’m more concerned about the unpredictability of the [outbreak] response at this point. It would not be fun to go to China and get stuck there somehow. And coming back, you’ll be subject to additional screening” or quarantines.

2) Is the city or country I’m going to at immediate risk of an outbreak?

Some of the best research on that question comes from researchers at the University of Oxford, University of Toronto, and the London School of Medicine and Tropical Hygiene. They published studies a few weeks ago on the places most vulnerable to novel coronavirus infections. The big takeaway then was that cities in East Asia and Southeast Asia were most at immediate risk.

A woman, wearing a protective mask, walks in Kuwait City on February 26, 2020.
Yasser Al-Zayyat/AFP via Getty Images

Here are 15 of the top destinations where they predicted we’d see outbreaks next (also pay attention to the IDVI — the Infectious Disease Vulnerability Index — number. It’s a measure of a country’s ability to manage an infectious disease. Scores closer to zero mean they’re less prepared.) Note Japan, Singapore, and South Korea were among the places that topped the list — and as we’re seeing now, some of the biggest outbreaks outside of China are playing out in these countries.

Oxford Journal of Travel Medicine

Iran and Italy are also on the list, and over the last week, large outbreaks have emerged in these countries, too.

With the scope of this outbreak rapidly changing, the researchers just updated their models in a yet-to-be-published study focused on how the coronavirus disease will likely spread from Iran. They found Iran probably has thousands more cases within its borders than we currently know. And they predict that we can expect outbreaks with links back to Iran in Turkey, UAE, Iraq, Qatar and Georgia, among other countries. In Europe, they predict Germany, France, and Italy are also places at higher risk of imported cases from Iran.

This is a long-winded way of saying these places may be at immediate risk in the coming days and weeks, according to some of the best guesses available.

3) How should I assess my risk of catching the virus while traveling?

The situation is changing so fast it’s impossible to say precisely what a person’s risk is, even if they’re traveling to a place that hasn’t yet detected cases of Covid-19. But there are a few questions you can ask yourself when making a decision about whether to travel or not:

  • What’s your risk of severe Covid-19 disease? It’s really tricky to gauge an individual’s risk of catching the virus. In Iran two weeks ago, there were zero cases — and now there’s more than a dozen dead and potentially thousands of cases. So while it’s difficult to predict risk, scientists say that around 81 percent of Covid-19 cases experience mild infection; 14 percent are severe cases, meaning they experience serious symptoms like shortness of breath and/or lung problems; and 5 percent are deemed critical, going into respiratory failure, septic shock, or multiple organ failure.
    Of the people infected with the virus, at least in China, around 2 percent die. Individuals over the age of 50 are overrepresented among the severe cases and deaths, as well as people with underlying health conditions. So, someone who is elderly or immunocompromised from a chronic disease should think differently about their risk of severe infection “compared to a healthy 18-year-old,” said St. Michael’s Hospital in Toronto infectious disease physician Kamran Khan, an author on the modeling studies cited above.
  • How is your country, the country you’re traveling to, or any places where you may have stopovers dealing with this virus? You’ll want to read up before you travel on what, if any, policies all the countries you’ll pass through have in place in terms of controlling the virus. You’ll also want to know your own country’s policy on people who have visited places with coronavirus outbreaks.
    Are there any travel restrictions or advisories? If you go to a particular country and there’s an outbreak or you catch the virus, can you get home? Is your country repatriating citizens? Would the country you’re visiting quarantine you if you happened to have been in another country where the virus is spreading?
    “Essentially people have to do their research and be up to date on several different streams of information because travel may be disrupted in this era of an emerging outbreak,” said Isaac Bogoch, a professor at the University of Toronto who also authored the modeling studies. “But it is also very challenging to predict any changes in policies that may happen while one is traveling.”
CHINA WUHAN COVID-19 DOCTOR
A respiratory specialist in charge of about 30 critical Covid-19 patients writes encouraging words for a patient in a hospital in Wuhan in central China’s Hubei province on Feb. 25, 2020.
Photo credit should read Feature China/Barcroft Media via Getty Images
  • How comfortable are you with uncertainty? Given the rapidly evolving situation, you need to be okay with some uncertainty when you travel now. Would you be okay with a two-week delay getting home if you get stuck in a quarantine situation? Do you trust that the countries you’re traveling to would quarantine you safely? Unfortunately, these are questions travelers need to think about for the moment.
  • How would you feel being hospitalized in the place you’re traveling to? This is a worst-case scenario but worth considering, said Bogoch. If you’re going to a place with a higher risk of an outbreak, or already has cases within its borders, research the health system there and assess whether you’d feel comfortable staying in hospital should something go wrong. Relatedly, you’ll also want to check on whether your health insurance would cover the stay.

4) How does this coronavirus spread?

We don’t yet know how exactly how SARS-CoV-2 — the virus that causes Covid-19 disease — spreads, but we do have a lot of data on how MERS, SARS, and other respiratory viruses move from person to person. And that’s mainly through exposure to droplets from coughing or sneezing.

So when an infected person coughs or sneezes, they let out a spray, and if these droplets reach the nose, eyes, or mouth of another person, they can pass on the virus, said Nuzzo. In rarer cases, a person might catch a respiratory disease indirectly, “via touching droplets on surfaces — and then touching mucosal membranes” in the mouth, eyes, and nose, she added.

This means that when you travel, you want to keep your hands clean and avoid touching your face.

There’s also emerging evidence showing SARS-CoV-2 could spread through poop — known as the “fecal-oral” route of disease transmission. Researchers are on the lookout for potential airborne transmission, too. But these avenues of spread are less established.

5) Is there anything I should do to protect myself when traveling? Buy a face mask?

Just about every health expert Vox has spoken to has said there’s little evidence to support the use of face masks for preventing disease in the general population.

People wear medical masks as a precaution against coronavirus, walking around New York, on January 30, 2020.
Tayfun Coskun/Anadolu Agency via Getty Images

Masks are only useful if you have a respiratory infection already and want to minimize the risk of spread to others, or if you’re caring for someone who is sick or working in a hospital in direct contact with people who have respiratory illnesses. (Plus, there are reports of runs on masks and other supplies health workers need to stay safe.)

That’s why the CDC advises against the use of masks for regular Americans.

The best thing you can do to prevent all sorts of illnesses, Messonnier said, is “wash your hands, cover your cough, take care of yourself, and keep alert to the information that we’re providing.”

You’ll also want to protect yourself from financial losses related to travel. If you’re thinking about a trip in the coming weeks or months, make sure you are comfortable with the cancellation policy on your tickets and look into travel insurance. Even if you’re feeling good about your individual risk right now, you might feel differently by the time your departure date rolls around.

6) If I decide to travel, what should I do if I’m seated near someone who is sick?

Traveling next to someone who is coughing or sneezing isn’t very reassuring, but it’s not time to panic, either. “The risk of acquiring a respiratory infection through air travel is still extraordinarily low,” Bogoch said.

The risk does go up if you happen to be seated within six feet of a person with a respiratory infection. But even there, simple proximity doesn’t necessarily mean you’ll catch anything. Instead, the more infectious the person is, and the longer you sit near them, the higher your risk. If you’re not near the person for very long or they’re not very infectious, the risk is lower.

Just keep in mind: Considering all the new cases that have been found — and may soon be uncovered — in countries outside of China, it’s very possible this virus is more widespread than we know right now.

“The underlying burden of illness in regions [with new coronavirus cases] is much larger than what is being reported,” said Bogoch. “What we’re seeing is the tip of the iceberg.” At the same time, outbreaks and pandemics are the new normal, and they’re unlikely to end the era of global travel. So keep calm, carry on, and check those travel advisories.

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