key: cord-0994703-infd2dkt authors: Zhou, Shu-duo; Han, Lu; Liu, Pei-long; Zheng, Zhi-Jie title: Global Health Governance for Travel Health: Lessons Learned from the COVID-19 Outbreaks in Large Cruise Ships date: 2020-12-02 journal: Glob Health J DOI: 10.1016/j.glohj.2020.11.006 sha: 6b59f4bccd04fa15791b4cda3d76f0f68e62f683 doc_id: 994703 cord_uid: infd2dkt The outbreak and global pandemic of COVID-19 have attracted a great deal of attentions to the problem of travel health. Cruise tourism is increasingly popular, with an estimated 30 million passengers transported on cruise ships worldwide each year. Safeguarding the health of cruise travelers during the entire travel is of ultimate importance for both the industry and global public health. Up to April 2020, nearly thirty cruise ship voyages had reported COVID-19 cases. The Diamond Princess, Grand Princess and Ruby Princess cruise ship had over 1400 total reported COVID-19 cases, and more than 30 deaths. Travel health transcends national borders and involves multilevel actors, thus needs global cooperation and governance. The global governance framework including problems, values, tools or regulations, and actors related to travel health were used to analyze the issues involved. Regulations and legislation at global and country level are required to prevent large-scale humanitarian crisis on travel health. Multilateral coordination, cooperation and collaboration mechanisms between governments, intergovernmental organizations, non-governmental organizations and industry are needed to build a better community of common destiny for travel health. Travel health is one of most important global health issues. With the development of modern transportation, international movement of people increased significantly. 1, 2 Accompanied with frequent entry and exit of a large number of international travelers, the likelihood of transmission and spread of various emerging and reemerging infectious diseases increases greatly. 3, 4 In general, travel health ranges from the prevention and control of infectious diseases to all health hazards as well as other public health emergencies. 5 Air travel and cruise travel are two common transportations for international travelers, especially for leisure travel, the average cruise time is about 7 days, which would involve traveler's health in many ways. 5, 6 Thus, this study focused mainly on cruise ship travels, and explored global health governance mechanisms for public health emergencies, such as the outbreak of infectious diseases. The growth of cruise ship industry has continued in the twenty-first century. 6 It was reported that nearly 21.7 million passengers traveled on cruise ships in 2014, and the number had increased to nearly 30 million in 2019. 7, 8 To meet these increasing trend of cruise travels, the industry increased the size and capacity of cruise ships, with large ships carrying as many as 5,000 passengers. Previous studies indicated that travels by maritime transport, typically the passenger ships played a major role in the transmission of the infectious diseases. 9 There are several possible reasons for this phenomenon. First, the cruise time is relative long for cruise ship travels, with a large number of people in close proximity, and a plenty of opportunities for interpersonal interactions and common activities, thus direct and indirect transmission can occur anywhere. 6, 10 Second, compared with entertainment facilities of cruise ships, sanitation facilities on cruise ship are relatively poor and medical care facilities indequate. 11 Third, passengers and crew numbers are often from different cultures, with different immunization and health status in a semi-closed and crowded environment, and they often visit different places where going from one place to another place in their long trip so they have chances to transfer infectious disease to different places. Fourth, a majority of passengers for cruise ships are often over 65 years old and may have one or more chronic diseases, thus more susceptible to infection. 3, 8 The cruise ships face many infectious pathogens and diseases of potential risks, such as gastrointestinal infections, respiratory infections, and skin infections. The World Health Organization (WHO) has documented more than 100 diseases outbreaks since 1970s, which caused huge threats to passenger health as well as economic losses to the tourism industry. 5 . The cruise industry chain involves various entities, including shipowner companies, operating firms, flag states, operating ports, and different countries of passengers. 12 The solutions to prevent and control the transmission and spread of infectious diseases among cruise ships crosses the boundaries of the state, involves a broader range of actors and needs multi-level and multi-sectoral cooperation. Previous studies focused on the micro level, taking a single port as the research object, and paying more attention to the relative countermeasure research on infectious diseases occurring on cruise ships. 3, 4, 13 Strengthening the core capacity of preparedness and developing cooperation mechanisms among multi-level actors with standard international norms are required in preventing and controlling the outbreaks of infectious disease in cruise ships. This study aimed to explore challenges and opportunities for travel health from the perspective of global health governance. We uses the basic elements of global health governance, including problems, values, tools or regulations, and actors of global health governance related to travel health for analysis. This study would provide an important reference for the preparedness and response mechanism of infectious disease outbreaks during travels. Global health governance is defined as "the use of formal and informal institutions, rules, and processes by states, intergovernmental organizations, and nonstate actors to deal with challenges to health that require cross-border collective action to address effectively". 14 There are five elements of global health governance: 1) Problems, global health governance needs to grasp the issues accurately; 2) Values, global health governance often occupies the moral high ground for global health development, equity and security. 3) Regulations, the tools used for global health governance; 4) Actors, global health governance includes a wide range of actors, such as states, intergovernmental organizations, non-governmental organizations, and private actors; 5) Results, timely evaluation of the effectiveness of global health is 6 needed. 15 The problems to be solved are the core element of global health governance, and the actors are the main body who take responsibility for the problems. The confirmed cases of COVID-19 on cruise ship had been reported worldwide. During the outbreak of COVID-19, many states banned cruise ships from entering their ports, and crew members or passengers were not allowed to disembark, leading to the cruise ships drifting on sea, further exacerbating the spread of the COVID-19 in cruise ships. Taking the Diamond Princess as an example, in the process of isolation on board ships, the Japanese government found themselves ill-equipped with insufficient resources. The United States, as a country where cruise companies were located, was very slow to act, and had not responded to Japan's urgent consultation requests. The flag country, the United Kingdom, was nonresponsive and took no action at all. 12 The COVID-19 pandemic exposed several global health governance issues in travel health. First, there is no clear international cooperation mechanisms among involving nations in response to public health emergencies. Second, the core capacity to public health emergencies was insufficient, including medical supply stockpiles and medical staffing. Third, existing regulations relevant to the governance for travel health in case of a public health emergency are not sufficiently binding to the state actors, lacking unified implementation standards and clearly defined roles and responsibilities of state and nonstate actors. Travel and trade have become the main factors leading to the spread of infectious diseases worldwide. 10 For cruise ships, travelers often come from different countries or regions, once an outbreak of an infectious disease occurs, it may cause the disease to spread in many countries around the world in a short time. Therefore, on one hand, the governance of infectious diseases in travel health is to maintain global health security and reduce the impact of the disease on the health of global residents. On the other hand, as an outbreak of infectious diseases causes significant and negative impact on politics, economy, tourism, trade, and even the whole social development, a global governance for these issues could minimize the side effects. Only through the international cooperation mechanisms, we can build a community of common destiny for travel health and guarantee global health security. During the outbreak, many States banned the cruise ships from entering their ports, which posts important moral dilemma, for which a state has moral responsibility to safeguard its citizens on the one hand and individuals on cruise ships have rights to be saved and protected. Furthermore, when the COVID-19 cases occurred in the cruise ships, the flag states, the cruise-operating countries, and the countries where the home ports were located blamed each other, which violated the concepts of unity and mutual assistance of the relevant actors. The aforementioned practices are not conducive to the construction of a community of common destiny for travel health. The International Health Regulations ("the IHR") were adopted by the World Health The United Nations Convention on the Law of the Sea (UNCLOS) defines the rights of countries to apply their national sanitary laws while the ship is at port and within 24 nautical miles of land. 21 The first paragraph of the 94 article of the UNCLOS provides that each country shall effectively exercise jurisdiction, control over administrative, technical and social matters on ships flying its flag. According to the regulations mentioned above, when a cruise ship is in the high seas area, the flag state is obliged to exercise jurisdiction over its own ships. After the cruise ships dock, the ships shall be jointly governed by the flag state and the port state. Yet, the problem is that there is no uniform implementation standard for these principled provisions, leading to the unclear responsibilities of different relevant States in response to public health emergencies in cruise ships. IMO is a specialized agency of the United Nations (UN) for the purpose of safety and security at sea as well as prevention of marine pollution. 10 The COVID-19 pandemic has exposed many problems on roles and responsibilities of different actors. First of all, during the epidemic, the travel health system did not provide appropriate risk warnings and alert about traveling on cruise ships, which led to an increasing number of cruise ships with infections to some degree. Second, the core capacity of the points of entry (PoE) is insufficient to deal with public health emergencies. Third, the response of some countries has neither been well prepared nor remotely adequate, for example, the government actions of UK and the US only focused on "arrivals from high risk regions quarantined" until early March, 23 causing the lack of cooperative actions between the relevant actors. Fourth, for the private actors, especially cruise companies, when an infectious disease breaks out, how to better control and prevent it from spreading further is an urgent problem to be solved. The resolution of all these problems depends on the relevant actors making timely changes. The States are the main actors that take the most responsibility when it comes to the governance for infectious diseases during the trip. 28 For state actors, it is necessary to prepare for peacetime and wartime in response to public health emergencies. To solve the problems caused by infectious diseases in the process of travel, preparing well in travel medicine is the best way to move the gate forward. Travel medicine refers to arming the traveler with education, vaccination, medical supplies, and resources to keep the diseases at bay. 24, 25 Before the travel, firstly, the health care provider must assess the current health status of travelers to confirm the underlying illness; secondly, doctors should review the itineraries to give advices on local disease patterns and current outbreaks of destinations; thirdly, according to the health status and disease patterns of destinations, required, routine and recommended immunizations should be given to the travelers; fourthly, the doctors should give sufficient advices to travelers on how to stay healthy and how to self-medicated or seek medical care if ill. After the travel, the doctors should timely assess the traveler who were ill, with the symptoms as well as geography and epidemiology. 26 The State Parties should develop, strengthen and maintain public health core capacities related to public health emergencies at designated points of entry under the requirements of the IHR 2005. At all times, the PoEs should have capacities to provide an appropriate medical service and adequate staff, equipment and premises, provide access to equipment and personnel for the transport of ill travelers, provide trained personnel for the inspection of conveyances, ensure a safe environment for travelers, and control the vectors and reservoirs in and near points of entry. When responding to the events that may constitute a public health emergency of international concern, the PoEs should have the essential capacity to detect event, take preliminary standard response at the port, assess the event risk at the port level and on board the ship, and take timely response measures to the event. It is necessary for the PoEs authority to establish public health assessment interview places, which provide adequate space to assess ill travelers or those suspected of being ill. 28 For the Ruby Princess cruise ship, all the passengers disembarked without quarantine, which reflects the inadequate of core capacity and insufficient supervision of the PoEs in Sydney. When infectious diseases outbreak in cruise ships typically in high sea, the flag states should take responsibility for the ships. However, most of the time , many shipping companies fly the flag of certain country for reasons of tax savings or convenient procedures, and the flag states may have no ability to deal with the public health emergencies. 29 In such cases, the cooperation mechanism among different countries should be formed. The country of the ship operating company, the country of the ship 's main business, and the countries of passengers, should work together to solve the problems. To repatriate the passengers or crew members to their own countries, the responses required the coordination of different sectors of the countries, including Ministry of Foreign Affairs, Ministry of Health, Hospitals, local public health departments. Efforts are needed to contain transmission on board and prevent further transmission on disembarkation and repatriation. As the core agency of global health governance, the WHO plays a leading role in the response to public health emergencies. In the COVID-19 pandemic, many countries refused to call cruise ships at ports. The adoption of these measures has exceeded the scope of the WHO's temporary recommendations. According to the IHR (2005), the State Parties shall submit to the WHO public health reasons for taking these measures within 48 hours. However, in practice, many countries have not really complied with IHR regulations and cannot provide them in time. 30 This led to the long-term drifting of the cruise ships at sea, further aggravating the spread of the virus inside the cruise ships. On the other hand, the IHR(2005) set specific requirements for port capacity building in various countries, but the capacity building of many ports does not meet the required standards. This problem is particularly prominent in the events of the Diamond Princess cruise ship and the Ruby Princess cruise ship. As a specialized agency under the UN for maintaining maritime safety, the main tasks of IMO currently focus on marine international trade, maritime safety, and prevention of marine pollution. How to respond to incidents that threaten public health safety caused by infectious diseases has not been clearly included in the scope of responsibilities. However, responding to public health emergencies requires close cooperation between the IMO and public health departments, such as the WHO and national disease control departments. The current status is this cooperation provision is ambiguous or has not been invoked. The continuous deterioration of the COVID-19 epidemic has gradually increased its impact on the cruise industry. At the same time, the epidemic has raised higher requirements on the safety, health and emergency responses of cruise ships. On one hand, cruise companies need to increase technological innovation to meet the challenges posed by public health events and strength the core capacity in response to the public health emergencies; on the other hand, they need to cooperate with other charitable organizations or insurance institutions to set up corresponding liability funds to mitigate the pressure of public health events on cruise companies and the coastal countries and to motivate the countries more willing to accept cruise ships in the epidemic. 31 This study explored travel health issues, mainly infectious diseases during travels from a perspective of global health. To our knowledge, it is the first study that examined the problems considering the five critical elements of global health governance. With the popularity of traveling by cruises, how to prevent and control the outbreaks of infectious diseases is of great importance for global health security as well as economic growth. The global health governance actors should make clarity the values for a community of common destiny for health, build a sound regulation system step by step and form more durable, equitable and better funded forms of cross-border cooperation mechanisms to solve the issues completely. We believed that our study would shed light on the issues of travel health. International regulations for global health governance are critical tools and grippers when handling cross-border health issues. When it comes to the IHR 2005, WHO has limited legislative powers and law enforcement powers, and relevant regulations are more of a guiding norm. 32 Establishing a disciplinary mechanism for the IHR 2005 that all WHO member states abide by and strengthening binding force of the IHR 2005 on the states are key measures to consolidate the WHO as the core of global health governance. In addition, when revising the international conventions, more specific provisions on "jurisdiction" should be added in response to the epidemic based on the principle of giving priority to saving lives, so that state actors can more effectively provide assistance within their ability. Meanwhile, IMO's convention system needs to be supplemented and improved for epidemic management. To be specific, mandating the prevention and control of infectious diseases as part of the roles and responsibilities of IMO and enhancing the collaboration between IMO and public health sectors, such as WHO, are urgently needed for global governance of infectious diseases in cruise ships. Multilevel actors are involved in travel health, and corresponding measures should be taken, respectively. For State Parties, a well-built system of travel health is the foundation for the preventing and controlling of the infectious diseases during travels. 27 Also fulfilling the IHR 2005 core capacity requirements of PoEs, strengthening the human resource capacity building and maintaining routine and emergency capacities are all necessary to protect global health security. 33 Compared with China's rapid action to the Costa Serena Cruise, which docked Tianjin port and the government has made in-time and effective response to deal with the emergency within 24 hours, 34 the Diamond Princess and others cruises showed the developed countries also poorly prepared for the public health emergency and strengthening the core capacities building is urgently needed. The concept of a community of common destiny for travel health requires the State Parties initiate bilateral and multilateral cooperation to form the joint prevention and control mechanism of the infectious diseases. 32 For the intergovernmental organizations, clearing the scope the responsibility, summarizing the shortcoming of the existing regulations and improving them are the key to dealing with the public health emergency like the COVID-19 pandemic. The private sectors, such as the cruise companies, should assess the risks of a public health emergency, make an effort in solving structural defects of ventilation and isolation of cruise ships and enhance the ability for public health emergency responses in case of an outbreak. The outbreak of COVID-19 in the cruise ships highlights the importance of global health governance in travel health. In the era of globalization, resolving such crises requires strengthening cooperation between governments, intergovernmental organizations, and the private sectors under the constraints of sound international regulations. At the same time, as a State Party, it is necessary to build and improve the health service system for travel health, strengthen core capacity of the port, and establish a comprehensive emergency response mechanism for public health emergencies. By strengthening a community of common destiny for travel health can global health security be better maintained. Cruise ship tourism in Belize: The implications of developing cruise ship tourism in an ecotourism destination. Ocean and Coastal Management Contact infection of infectious disease onboard a cruise ship An epidemiological study of rates of illness in passengers and crew at a busy Caribbean cruise port Estimating the risk of communicable diseases aboard cargo ships Zhi-gang Gao. 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LH, PL and ZZ made critical revisions on the manuscript and provided implications of the study findings. All the authors gave final approval of the version to be published.