scope:

FOREWORD

This manual has been prepared by aviation health experts led by the International Civil Aviation Organization (ICAO) with support from the United States Centers for Disease Control and Prevention (CDC), European Centre for Disease Prevention and Control (ECDC), Aerospace Medical Association (AsMA), and others, and it has been reviewed by the World Health Organization (WHO). Contributions from other United Nations organizations, governments and industry stakeholders ensured the practical applicability of this guidance in the aviation sector, no matter how big or small the State and no matter what scale of COVID-19 challenge they face. Together, these experts and stakeholders form the ICAO Collaborative Arrangement for the Prevention and Management of Public Health Events in Civil Aviation (CAPSCA) programme. CAPSCA brings together international, regional, national and local organizations to work together to improve preparedness planning and response to public health events that affect the aviation sector.

CAPSCA developed this guidance in close collaboration with the ICAO Council Aviation Recovery Task Force (CART), which requested updated guidance on the inclusion of COVID-19 testing, vaccination and its interdependencies with other risk mitigation tools for those States that choose to include testing and vaccination as elements of their overall COVID-19 risk management process.

The CART has published updated recommendations to States in the High-Level Cover Document (HLCD) including Recommendations 13, 17, 18 and 19 on testing and vaccination, respectively quoted below:

Recommendation 13: "Member States using testing in their COVID-19 risk management strategy should apply the approach outlined in the ICAO Manual on COVID-19 Cross-border Risk Management (Doc 10152), recognizing that robust testing strategies allow for early detection of potentially infectious travellers. However, testing may not be universally recommended by public health authorities as a routine health screening method due to priority and resource considerations."

Recommendation 17: "Member States should implement and recognize certificates of testing, recovery and vaccination based on the protocol, minimum data set and implementation approaches outlined in the ICAO Manual on COVID-19 Cross-border Risk Management (Doc 10152) to facilitate air travel. States are encouraged to ensure such certificates are secure, trustworthy, verifiable, convenient to use, compliant with data protection legislation and internationally/globally interoperable. Proof of vaccination could be based upon the World Health Organization (WHO) International Certificate of Vaccination or Prophylaxis (ICVP) and should be issued in an internationally/globally interoperable format aligned with the technical specifications and guidance outlined by the WHO. Existing solutions should be considered and could incorporate a visible digital seal - non-constrained (VDS-NC) or other interoperable formats from regional or global intergovernmental bodies, or internationally recognized organizations."

Recommendation 18: "Member States should facilitate access for air crew to vaccination as quickly as possible as recommended by the WHO Strategic Advisory Group of Experts on Immunization (SAGE) Stage II for air crew who work on aircraft that carry goods and no passengers and Stage III for other aviation workers."

Recommendation 19: "Member States are encouraged to promote, to the greatest extent possible, a harmonized and inclusive approach to facilitate international travel and entry of fully vaccinated and recovered passengers. In this regard, Member States should consider alleviating or exempting testing and/or quarantine measures for individuals who have been fully vaccinated or those with a history of previous SARS-CoV-2 infection who are no longer infectious. The alleviations and exemptions should be made in accordance with a State's accepted risk threshold, national framework, the COVID-19 situation and the multilayer risk management framework described in the Take-off: Guidance for Air Travel through the COVID-19 Public Health Crisis. In view of the global unequal access to vaccines and the unsuitability or intolerance of use of vaccines by some individuals, vaccination should not be a prerequisite for international travel."

In addition, the CART revised Recommendation 14 in the HLCD concerning Public Health Corridors (PHCs) as follows:

"Member States considering the formation of a Public Health Corridor (PHC) should actively share information with each other to implement PHCs in a harmonized manner. To facilitate the implementation, the ICAO Implementation Package (iPack) on establishing a PHC is available to States, in addition to PHC-specific tools published on the ICAO website and the application (App) providing a template PHC arrangement between States."

CART guidance aligns with updated WHO guidance:

a) with regard to PHCs, the WHO supports exploring bilateral, multilateral and regional agreements across countries, particularly with neighbouring countries and others of socioeconomic importance, with the aim of facilitating the recovery of key activities for which international travel plays an important role, such as tourism or the movement of a cross-border workforce¹;

b) testing and vaccination can be considered as part of national multilayered risk mitigation strategies. The WHO has stated that proof of vaccination should not be required as a condition of entry or exit to a country; and

c) the WHO suggest that proof of vaccination could be based upon the ICVP or, if digital, should be issued in an interoperable format aligned with the technical specifications and guidance outlined in the Digital Documentation of COVID-19 Certificates: Vaccination Status technical specifications and implementation guidance document. The format recommended by ICAO ("visible digital seal for non-constrained environments" (VDS-NC)) is one possible option.

Furthermore, the WHO recommends, based on growing experiences from countries where national authorities continue to review and adjust their travel-related measures to facilitate non-essential international travel, in addition to prioritizing international travel for essential purposes as defined by national authorities, applying measures that take into account individual travellers' transmission risk, depending on their infection status, vaccination status and/or recovery status².

As part of its CART endeavours, CART has updated the fourth edition of the Take-off: Guidance for Air Travel through the COVID-19 Public Health Crisis (TOGD)³, originally issued in June 2020 and revised in September 2021. The fourth edition of the TOGD reflects technological and medical advancements and provides the latest operational and public health guidance related to air travel reflecting technological and medical advancements. The recommended multilayer risk management strategy has been supplemented with considerations on testing protocols and proof-of-results certification interoperability, considerations for testing and vaccination, as well as including evidence of vaccination for crew and passengers. Guidance on the establishment of PHCs has been expanded and guidance on the transition to routine operations in the future has been added.

The third edition of this manual was revised in close collaboration with CAPSCA. It provides updated detailed guidance on risk management, PHCs, information on current scientific developments regarding Variants of Concern (VOC), COVID-19 testing, vaccination, proof of recovery, health certificates, the interdependencies of public health risk mitigation measures within a State's multilayer risk management framework and considerations for transitioning to routine operations in the future. This guidance supplements the measures already outlined in the CART HLCD and TOGD⁴ and provides a risk management process to facilitate States' assessments of the applicability of a combination of measures available today. Given the dynamic nature of the COVID-19 pandemic, this manual is intended to be a living document and will be updated as new information becomes available.

COVID-19 testing, managing recovery from previous infection and vaccination, if applied according to the guidance contained in this manual, could reduce reliance on measures that restrict air travel and the movement of persons arriving in a country, such as quarantine, which evidence suggests is a disincentive to several important categories of travel, of which the following list is non-exhaustive: pilot certification, pilot simulator training, essential business flights and tourism for some States that are dependent on inbound tourism for economic sustainability. In addition, proof of recovery or vaccination could reduce the need for additional COVID-19 testing, enabling quicker movement of air crew and passengers through check-in and customs procedures, and reduce costs for travellers and States. Restoring confidence in aviation is a key priority.

Note.― There are many available serologic assays (antibody tests) that measure the antibody response to SARS-CoV-2 infection, but at the time of publication of this manual, the correlates of protection were not well understood. The use of serologic assays is not recommended to prove recovery status given the limitations that are outlined in the scientific brief "COVID-19 natural immunity"⁵.

Quarantine may still apply for persons infected with SARS-CoV-2, as well as known close contacts of persons diagnosed with COVID-19, while self-isolation, self-quarantine or other measures could be applied for other individuals in accordance with a State's assessed risk tolerance.

In implementing testing and vaccination as components of States' overall COVID-19 multilayered risk management strategy, they are reminded that an effective application of a multilayered risk strategy, including testing and vaccination, is one in which:

a) States perform a risk assessment⁶ using epidemiologic criteria including, but not limited to, disease incidence and prevalence, new variants, disease trajectory, national testing strategy ⁷ , screening capabilities, hospital capacity and robustness of contact tracing and status of national vaccination strategy;

b) States share the results of the risk assessments, the local epidemiology (including genomic sequencing of VOC, if possible) and transmission scenarios in the departure and destination countries or areas, as well as the public health and health system capacity and performance to detect and care for returning travellers and their contacts with other States to facilitate the opening of air routes or PHCs;

c) States consider their risk tolerance, and issues such as socio-economic and human rights, as a part of their risk assessment;

d) States that choose to use testing for screening purposes in aviation after consideration of national testing capacity8 and the local epidemiology in departure and destination countries, apply a cut-off value, based on evidence generated from asymptomatic individuals, for sensitivity and specificity as high as possible (with a minimum of 95 per cent sensitivity and specificity for molecular tests; and a minimum of 80 per cent sensitivity and 97 per cent specificity for rapid antigen tests) to reduce inaccurate test results, although these values might change as science matures⁹;

e) States that use testing and vaccination as part of their multilayer risk management strategy take into account any recent test results, proof of recovery from COVID-19 and vaccination status, when considering the need for additional post-arrival testing or quarantine; including the duration of quarantine, when addressing higher risk scenarios; and

f) States harmonize their procedures to the maximum extent possible.

This manual describes the risk management measures that can be applied; how epidemiology can be used to advise States in developing a risk management strategy; possible testing protocols that might be put in place where there is differential prevalence and therefore risk; vaccination as an effective mitigation factor including a series of examples to help States in their decision-making processes; and information and tools to assist States with sharing of information regarding the implementation of public health risk mitigation measures and the recognition thereof in order to open air routes and global travel.

Note.- The content of this manual is largely based on information and studies conducted prior to the emergence of the Delta variant. At the time of publication of this manual, the scientific information regarding the Delta and other variants was limited but was included in this version. Further updates will be needed as more information becomes available.

Scientific evidence that supports the guidance contained in this manual are available on the CAPSCA website¹⁰.

^6. WHO guidance on Considerations for implementing a risk-based approach to international travel in the context of COVID-19

^7. Scientific brief on COVID-19 diagnostic testing in the context of international travel

^9. SARS-CoV-2 antigen-detecting rapid diagnostic tests: An implementation guide