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Covid-19 and community mitigation strategies in a pandemic

BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m1066 (Published 17 March 2020) Cite this as: BMJ 2020;368:m1066

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Is Entry Restriction Really Effective for the Prevention of COVID-19 Spread?

Dear Editor

We have taken interest in the recently published video by Ebrahim et al.(1) They have nicely demonstrated the community mitigation strategies of pandemic coronavirus 2019 (COVID-19). As a key community mitigation strateg, they recommended travel restrictions, including reduced flights and public transport and route restrictions without compromising essential service. In fact, as a control measure, many countries have banned the entry of travelers from other countries. However, this measure can affect global trade and travel, thereby inducing an economic slowdown and undermining diplomatic relations between countries. Despite these negative impacts, entry restrictions are widely adopted as part of the effort to prevent the spread of COVID-19. However, are entry restrictions capable of producing the desired effect?

To scrutinize the effect of travel restrictions implemented around the world in the wake of the H1N1 influenza pandemic in 2009, public health experts such as Mateus et al.(2) conducted a meta-analysis of 23 relevant studies in the United Kingdom in 2014. They found that entry restrictions reduced the incidence of new cases of influenza infection by less than 3%. Furthermore, they concluded that entry restrictions did not lead to an effective control of the flu outbreak in a particular area, although such measures could delay the peak of endemic or pandemic progression of infectious diseases for weeks or months.

In addition, in 2020, Errett et al.(3) recently reported a lack of evidence on the preventive effects of entry restrictions between countries after a systematic review of studies investigating global infectious diseases, such as severe acute respiratory syndrome (SARS), Middle Eastern respiratory syndrome (MERS), Ebola virus disease (EVD), and Zika virus disease (ZVD). Thus, entry restrictions may be effective in managing the spread of virus at an early stage, enabling planning and implementation of necessary measures. However, the influx of viruses and subsequent spread could not be prevented despite travel restrictions. In particular, the study noted that the effect of entry restrictions was less significant in densely populated cities.

Hence, evidence on the effects of entry restrictions implemented to block the influx of 2019-nCoV is still lacking. Restricting incoming travelers without considering the long-term effects may result in negative economic and diplomatic consequences. However, entry restriction for travelers from foreign countries has the advantage of allowing time to prepare medical equipment and hospital beds for treating patients infected with 2019-nCoV. Therefore, each country should determine whether it is best to restrict incoming travelers based on an appropriate analysis of its national economy, diplomatic status, and COVID-19 preparedness.

References
1. Ebrahim SH, Ahmed QA, Gozzer E, et al. Covid-19 and community mitigation strategies in a pandemic. BMJ 2020;368:m1066. doi: 10.1136/bmj.m1066
2. Mateus AL, Otete HE, Beck CR, et al. Effectiveness of travel restrictions in the rapid containment of human influenza: a systematic review. Bull World Health Organ 2014;92(12):868-80D. doi: 10.2471/BLT.14.135590
3. Errett NA, Sauer LM, Rutkow L. An integrative review of the limited evidence on international travel bans as an emerging infectious disease disaster control measure. J Emerg Manag 2020;18(1):7-14. doi: 10.5055/jem.2020.0446

Competing interests: No competing interests

25 March 2020
Donghwi Park
professor in medical school
Min Cheol Chang
Ulsan University Hospital, University of Ulsan College of Medicine, 877 Bangeojinsunghwndo-ro, Dong-gu, Ulsan, 44033, Republic of Korea