A week ago, we blogged about a scenario loosely based on our whether our colleague should travel to China in light of the emerging novel coronavirus outbreak. Since then, the outbreak has surged in China, with multiple cities on lockdown, and many countries banning incoming flights from China, or refusing entry to passengers arriving from or transiting through mainland China in the past 14 days, the presumed incubation period of the virus. Safe to say, our colleague cancelled his trip. With the WHO declaration of a public health emergency of international concern, and cases reported in 23 countries, people might now be wondering, should they travel internationally elsewhere in Asia, or even at all?

Rapidly growing numbers

First – let’s have a look at the latest numbers for the outbreak. Worldwide, there were 14 557 confirmed cases by the end of Sunday, the vast majority of which are in China. The majority of cases outside China are still occurring in people who have recently travelled from affected provinces in China, but there is confirmed human-to-human transmission in several other countries, including the US. The first death outside of China has been reported in the Philippines.

I travel frequently for work, particularly in Southeast Asia, so I have personal cause to reflect on any risks. It’s important to remember that there is no official advice or evidence to support travel restrictions outside of China. Undue travel and trade restrictions can worsen the economic impacts of outbreaks, without reducing their spread.

On Sunday night I transited through Singapore Changi airport. About 24 hours beforehand, Singapore banned all non-resident visitors who had been in mainland China in the past 14 days from entering Singapore. This measure comes as Singapore confirmed its 18th case of coronavirus, all of which were in people recently arrived from China.

The travel restrictions in place mean that there should have substantially reduced the risk that anyone in the airport on Sunday or Monday was currently infected with novel coronavirus.

Masking the problem?

There was a marked increase in the number of people wearing face masks in the airport and on the flights I took. As pointed out in our last blog, masks are most effective when worn by people who are sick, to reduce the risk of transmitting virus to others. The surgical masks that most people were wearing reduce risk of infection if someone sneezes or coughs in your face, but these masks aren’t as effective for reducing the risk of airborne transmission via small airborne particles, which can pass through the mask.

So were people wearing masks in the airport and while flying protecting themselves effectively from novel coronavirus? Probably not. This is what I noticed:

  • In the airport, quite a few people wore their mask to cover their mouth, but not their nose. Others had pulled their mask down to their chin.
  • On my outbound flight from Singapore, half or more passengers were wearing face masks. But almost everyone took them off during the meal service (and see the next comment about touching your mask).
  • Some people wearing surgical masks were touching them and readjusting them constantly. Touching a face mask, especially one that doesn’t seal tightly, means you can transmit virus from your hands to your face. If wearing a mask means you touch your face more often, you could just be increasing your chance of picking up a whole range of run-of-the-mill viruses in addition to novel coronavirus, especially if you’re not washing your hands.
  • Speaking of washing your hands – this is one of the most effective general hygiene measures people can take to prevent any respiratory-borne virus. With tentative emerging evidence that coronavirus can spread via the fecal-oral route, I hope that mask wearing does not provide a false sense of security that distracts from this key prevention measure.

There is no advice from any health body in the world that general members of the public outside of China should be wearing face masks. Singapore is providing four face masks per household, but advising the public to reserve these for people who are sick. Governments are warning against stockpiling face masks, which can contribute to mask shortages.

Regional readiness

The risk of further spread of novel coronavirus outside China is highest in countries with relatively weak health systems, which limits their capacity to detect and respond to an outbreak. The risk of novel coronavirus outbreaks in these settings was the basis for the WHO declaration of a public health emergency of international concern, because many countries have much weaker capacity than China or high-income countries to detect and contain spread.

Last year, we led a landmark assessment of the current state of preparedness for health security threats in 22 countries in Southeast Asia and the Pacific. We highlighted the relatively limited capacity to prevent the emergence of a new disease of animal origin (a zoonosis), such as the novel coronavirus, throughout the region. Capacity to detect new viruses in animals, before they cross over to humans, is particularly weak. Other consistent challenges across settings included laboratory capacity to detect emerging priority pathogens, which is weak outside of capital cities, and the lack of a sufficiently resourced field epidemiology workforce.

Risk communication is another key challenge. Countries with weak health systems often also have low public trust in governments. The rate of spread of novel coronavirus in China pales in comparison to the rate of spread of misinformation on social media platforms about the nature of the threat.

The best approach to improving coordinated global action to prevent, detect and respond to emerging infectious diseases is to strengthen health systems, support One Health initiatives, and improve multisectoral action on health security threats. My own work travel for the next few months is focused on technical support to address antimicrobial resistance through a One Health approach in Indonesia, and malaria elimination in the Greater Mekong Subregion. It is vital that efforts to contain coronavirus do not distract from continuing efforts to strengthen regional health security more broadly.

Should you travel to less developed countries in Southeast Asia? Based on currently available information, there is no reason to avoid travel for health reasons, and the risk of economic harm through cancelling travel is real. Should you wear a mask? Possibly, but it’s probably most useful for protecting against air pollution

Phnom Penh air quality and weather daily forecast

All in all, it’s a reminder that as an international health community, we’re actually quite quick to take action in response to emerging infectious diseases, but taking action on more widespread but familiar hazards such as air pollution, which kills 7 million people worldwide every year, proves nearly intractable.