The COVID-19 pandemic shows no sign of abating as new variants continue to appear. These variants are highly transmissible and are now responsible for the majority of viral transmission among unvaccinated populations worldwide.
The delta variant ( B 1.617.2) of the SARS CoV2, first detected in India in December of 2020, has now spread to at least 100 countries . This variant, along with the alpha (B.1.1.7) (UK) and gamma (P.1) (Brazil) variants, have been detected in Barbados. It is as yet unknown whether community spread of the delta and gamma variants is occurring , as this would require widespread, genomic surveillance that BAMP has repeatedly called for.
We believe that the rise in the delta and the even more transmissible delta plus ( B1.617.2/AY.1) variants in our source markets presents a unique threat to Barbados’ fragile health system. The higher attack rate and reproduction number of newer variants implies that in a population with just under 30% vaccinated, community spread could lead to a sharp rise in cases in the months ahead.
Barbados has a high population density, an aging population, a high proportion of persons with non-communicable diseases, a single tertiary care hospital that faces regular challenges in healthcare delivery and social and economic fragility, made worse by the pandemic. A sustained surge in cases in this environment will compromise healthcare delivery .
We have made four observations from the available scientific data:
- Several case series and reports indicate that, particularly with the delta variants, a small proportion (<1-9%) of people with full vaccination may have breakthrough infection.
- The available vaccines seem to effectively reduce transmission of all variants but this reduction may not be large enough to protect a predominantly unvaccinated population.
- We should no longer consider the rates of infection of COVID-19 in a monolithic way when looking at what is happening in countries, but consideration should be given to the rates of vaccine uptake and the infection rates in the unvaccinated.
- Countries with insufficient testing and low or no genomic surveillance may appear to have low infection rates but may have a high proportion of latent and undetected variant infections.
BAMP therefore makes the following recommendations:
TRAVEL PROTOCOLS
Countries of Interest: Should reflect those with increases in cumulative cases per 100,000 but also those with steep increases of the delta, gamma or lambda variant among their unvaccinated population. In addition, all countries with low testing rates, relative to the size of the population and no genomic surveillance, should also be included on this list. The consideration of which countries should be considered ‘countries of interest’ should be reevaluated weekly and the criteria for inclusion or exclusion should be publicly known. We suggest a division into countries of interest and countries of concern with the latter category being reserved for those with the highest rates of transmissible variant per capita e.g. South Africa, Brazil, India. The latter would be subject to visa restrictions and ten (10] day quarantine.
Bubble Countries: While we understand that the concept of the travel bubble is to facilitate movement from countries with low infection rates within the region, we urge constant monitoring of the situation. Insufficient testing and contact tracing may lead to a failure to detect a rise in cases. We must be willing to nimbly react and to remove countries from the bubble should this occur. Which countries remain in the bubble should be determined weekly.
Pre-Flight Testing: The availability of standard PCR tests at the country of origin has become an issue, particularly with travelers from the USA and CANADA. In these countries an administered standard PCR test is not only expensive but in some cases requires significant travel to obtain. We therefore recommend that all travelers get the best available test in the country of origin. A standard PCR test done 72 hrs or less, before arrival is still preferred. Where this in not available, a Rapid PCR or Lateral Flow test can be administered or obtained by observed self-swabbing, as close to the time of travel as possible (24 hrs before travel or at the airport prior to departure). Tests that will not be accepted include: unobserved, self-administered tests, COVID home-test kits and LAMP tests.
Fully Vaccinated Travelers: If the FV traveler has not passed through a Country of Interest within 21 days, they should prepare to quarantine for a maximum of 3 (three) days on arrival. The best Rapid PCR* or a standard (NAAT) PCR test on island would be administered as the second test administered no less than 48 hrs after arrival. While in quarantine, FV visitors will be confined to hotel or villa space with GPS electronic monitoring bracelets tracking movement. They would not be allowed to use a public beach, gym or spa on the property . FV Barbadian Nationals and Residents may apply to the CMO to quarantine at home if they live alone or have exceptional medical circumstances. All other FV Barbadians and Residents should pay significantly reduced rates ( government subsidized) for a three-day quarantine at a designated hotel (s).
Unvaccinated Travelers: The protocol for the unvaccinated or partially vaccinated traveler would remain as five (5) days in quarantine at their expense within a hotel room. The exit test from quarantine would be administered on day five.
Third Test: Recognising that people will convert to COVID positivity between five and eight days. We propose that, with an electronic contact tracing app fully operational, all travelers (FV and UV) should have a third test on day eight (8) if they are still on island. The third test may function as the departure/exit test if it falls within 72 hours of departure. This test would be a Rapid PCR test* and would increase community disease surveillance.
Mixed Vaccines: While the hard evidence for this remains unverified by large clinical trials for effectiveness, the scientific premise for a better immunologic reaction by mixing vaccines is sound. Therefore, we recommend that we only accept mixing of mRNA vaccines ( Pfizer and Moderna) and AstraZeneca (AZ) followed by Pfizer vaccine or the other way around, until more studies are published.
OTHER RECOMMENDATIONS:
- No testing of travelers on arrival at the airport.
- Creation of satellite testing facilities at selected hotels , with oversight by the BDSPHL and assistance from the BTMI, to facilitate ease of testing of all visitors to the island.
- Cost of testing on arrival and on departure should be borne by visitors or incorporated into their cost of stay.
- Locals and residents returning from travel will be tested at the Gymnasium at no cost.
- Integration of all private testing laboratories into the testing capacity with real time reporting.
- Bubble tours for cruise passengers should only involve fully vaccinated persons (crew, passengers, transporters, those at attractions) and vaccination status should be verified by the Port Health Authority and/or the COVID Monitoring Unit, preferably using electronic upload of vaccination certificates.
- Airlines and cruise ships should confirm vaccination status of crew on flights/cruises.
- Mandatory routine surveillance of frontline/essential workers who are unvaccinated, either every week or every two weeks, according to risk profile. We recommend that wherever hazard pay is being paid, the cost of ongoing surveillance testing be deducted from hazard pay.
- Targeted campaigns must be created to promote vaccination of all frontline/essential workers and forums to discuss concerns of these workers should be ongoing.
- Mandatory vaccination of frontline healthcare workers, ideally but not necessarily ,in the context of a choice of vaccines.
- Urgent institution of regularly reported community surveillance for all variants.
- Community surveillance programmes (regular testing) for COVID-19 within vulnerable groups or communities.
- Integration of GPS technologies into contact tracing for all persons on island who will be encouraged to download a contact tracing app
- Six foot social distancing for indoor venues
- Continued mask wearing in public spaces.
Dr. Lynda Williams for
BAMP COVID-19 TASK FORCE
JULY 25, 2021
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