COVID-19 Testing and Travel: What Travelers Need to Know

While proof of vaccination is not currently required to travel, a negative COVID-19 test result is required to enter many countries, including the United States. According to On Call’s Chief Medical Officer, Dr. William Siegart, “A negative COVID-19 test result is certainly not an excuse to let one’s guard down, but it does help reduce the risk of spreading the virus to others.” Dr. Siegart says he’s seen an influx of inquiries about COVID-19 testing and travel, especially since the CDC rolled out their COVID-19 testing guidelines for travelers earlier this year, so he’s answering some of the most frequently asked questions and sharing some advice with would-be travelers:

What if a traveler received the COVID-19 vaccine or tested positive for antibodies? Does this person need a negative COVID-19 test or documentation of recovery from COVID-19 to enter the US?
Dr. Siegart: Yes.  Effective January 26, 2021, all air passengers traveling to the United States, regardless of COVID-19 vaccination or antibody status, must present documentation of a negative COVID-19 test result or documentation of recovery from COVID-19 to the airline.

What kind of documentation of the test result should a traveler present before boarding their flights?
Dr. Siegart: The test documentation must be verifiable and include identification of the person, the specimen collection date, and the type of test. The test must have been completed within three days before the flight and can be either a NAAT or antigen test.

If a traveler does an at-home test, is this considered acceptable documentation prior to entering the US?
Dr. Siegart: Yes, home tests are acceptable with some important stipulations. A home test that is a specimen collection kit subsequently tested in a laboratory is acceptable. The laboratory must meet the authorization and verification requirements of the country’s national health authority. The test report must be verifiable, which means it must be in paper or electronic form. Additionally, the report must include information that identifies the individual, specimen collection date, and type of test. The home tests coming on the market that provide a result at home are not acceptable.

What if a traveler recently recovered from COVID-19 – do they still need to get tested prior to entering the US?
Dr. Siegart: No. The CDC does not recommend repeating COVID-19 testing again in the three months following a positive COVID-19 test.  If the traveler has recovered from COVID-19 and meets the criteria to end isolation, travel will be permitted with documentation of the positive viral test associated with the recent COVID-19 illness, and a letter from the traveler’s health care provider or public health official that states they have been cleared for travel. The combined documentation of a positive COVID-19 test result with a letter of travel clearance are referred to as ‘documentation of recovery.’

If a traveler tests negative before their flight, do they need to get another test when they return to the US?
Dr. Siegart: It is currently recommended but not required that testing be performed within 3–5 days of return, and that travelers self-quarantine for seven days.  Even if the follow-up test is negative, self-quarantine remains for the full seven days.  If no post-travel testing is performed, self-quarantine is recommended for ten days. State and local recommendations may vary, so it is important to be aware of them and comply their recommendations or requirements. State and local recommendations may vary, so it is important to be aware of them and comply their recommendations or requirements. Moreover, it is advisable to discuss one’s situation with their healthcare providers in the context of their overall risk, potential for exposure, and presence of any symptoms in order to determine the best testing strategy for them.

Do travelers need to get tested before leaving the US? Where can travelers find a COVID-19 test abroad?
Dr. Siegart: The CDC recommends, but currently does not require, that travelers be tested within three days before departure from the US; however, it’s important to note that some destinations require COVID-19 testing before travel and/or after arrival. Additionally, according to the CDC, those who are fully vaccinated with an FDA-authorized vaccine do not need to get tested before leaving the US unless the destination requires it. For information on specific foreign country testing entry requirements and their respective testing availability please refer to the following US Department of State link: https://travel.state.gov/content/travel/en/traveladvisories/COVID-19-Country-Specific-Information.html.

For travelers looking for tests in the US, I advise travelers to first check with their primary care providers, who may know the best options for testing in their area. They can also look at their city and state health department websites for local testing information. COVID-19 testing is available free of charge at multiple health centers and select pharmacies with which the U.S. Department of Health & Human Services (HSS) has partnered. Travelers can also visit HHS’ website for more information about local COVID-19 testing availability: https://www.hhs.gov/coronavirus/community-based-testing-sites/index.html#nh.

How about for domestic travel? Do travelers need to get tested?
Dr. Siegart: Not anymore. As of April 2, 2021, the CDC stated that those traveling domestically within the US do not need to get tested or self-quarantine if they are fully vaccinated or have recovered from COVID-19 in the past 3 months.

What kind of COVID-19 tests are available?
Dr. Siegart: COVID-19 tests fall into two general categories: antibody and diagnostic. The antibody test determines whether there are antibodies to the virus that causes COVID-19 circulating in one’s blood.  Ordinarily, antibodies are produced by the immune system in days or weeks following an infection.  If antibodies are detected in the blood, it may mean someone currently has COVID-19 or that they’ve had the virus recently.  However, a positive antibody test can also mean an individual was infected with a different coronavirus.  For this reason, the antibody test is not particularly useful to the person who needs to know whether they are currently infected or not. The test may be more useful for public health surveillance and research purposes.

Diagnostic tests determine if an individual is currently infected with COVID-19. There are currently two types of diagnostic tests: molecular tests that detect the virus’s genetic material and antigen tests that detect specific proteins from the virus. Nucleic acid amplification (NAAT) tests fall in the category of molecular tests and include RT-PCR, LAMP, and TMA tests. The RT-PCR, LAMP, and TMA tests are nucleic acid amplification tests (NAAT) that detect SARS–COV–2 genetic material, the virus that causes COVID-19.  Depending on the test and manufacturer, a specimen is collected by nasopharyngeal swab, nasal swab, throat swab, or saliva sample. The specimen is then placed in a transport medium and sent to a diagnostic laboratory.

 Antigen tests detect viral proteins and can be completed within 15 minutes. The specimen is collected by swabbing the inside of the nose. Neither of the tests “hurt” per se, but there might be some very brief discomfort when the throat or nasal passage are swabbed. Sometimes a saliva specimen is utilized which involves no discomfort. Antigen tests are point-of-care tests that can be completed in a doctor’s office, clinic, hospital, or lab.

A home COVID-19 test is most often a collection kit that must be delivered to a lab for analysis and results. It does not provide a result at home the way a home pregnancy test would provide for example. Home testing kits are available as both antigen and PCR types. There are some home antigen tests that are performed completely at home on the market now, but they are not acceptable for meeting any imposed travel requirements or official documentation. Their accuracy compared to those completed in a lab is not confirmed.

Are there any tests that are considered more accurate than others? For example, some say the rapid tests are not as accurate as the molecular tests.
Dr. Siegart: Two factors we consider are the sensitivity and specificity of a test. Simply put, the sensitivity is the rate of false negatives and the specificity is the rate of false positives. The molecular (PCR) test is more sensitive than the rapid tests which are antigen based. No test is 100% accurate, and there is variation in the PCR tests depending on several factors, including how and when the specimen was acquired, viral load, and the design of the PCR assay. At present there is no “gold standard” test to diagnose COVID-19 with 100% certainty.

How accurate is the at home test?
Dr. Siegart: If the specimen is collected and packaged correctly, it isis it as accurate as one performed at a testing site.

It is imperative that individuals follow the test kit instructions for collection, packaging, and transport to the lab. If they do that the test is as accurate as the comparable PCR or antigen test performed at a testing center.

How much in advance of travel should an individual plan to get tested? How long does it take to get the results back?
Dr. Siegart: This is not a one-size-fits-all answer as different tests will come with different wait times for results. Having a flexible travel schedule and/or planning some buffer time between test results and the start of the trip can help to skirt around these gray areas. For example, the PCR test takes 2-5 days to receive results, whereas the most convenient and faster Antigen test provides results in 15 minutes. Regardless of which testing method a traveler chooses, it’s important to remember that even if one is promised a specific timeline for your results, there may be a delay, which could pose an issue for those traveling to destinations that require proof of a negative test. Also, it’s important to remember the new CDC guidelines which require a person to be tested within three days before their flight to the US.

In addition to the US, are there other destinations that require proof of negative test results for entry?
Dr. Siegart:  Depending on one’s intended destination, proof of a negative COVID-19 test within three days of travel may be required. Some countries require such proof as do some states in the U.S. On Call’s clients are encouraged to consult with us for the most up-to-date guidance on how to prepare for travel to their intended destinations, check the CDC’s Travel Recommendations by Destinations page, and review the U.S. Consulate’s website for their destination countries as well.

Does a negative test help guarantee traveler safety (and the safety of others) when traveling?
Dr. Siegart:  No, it does not. A negative test can be falsely reassuring. The PCR test is more accurate and has fewer false negatives than the Antigen test. However, because it is so sensitive, it may detect small bits of genetic material that have not cleared from the body due to an infection that is no longer active or contagious. All tests have some degree of false negatives and positives and must be interpreted clinically based on the context of exposure and presence or absence of symptoms. If COVID-19 exposure is very recent it may be too early for any test to detect. Testing should always be performed in consideration of the likelihood of exposure, current health condition, and the presence of any symptoms.  Someone who has had significant exposure and now has a fever and a cough and tests negative may be falsely reassured. Those individuals should self-quarantine pending follow-up with their healthcare providers and have repeat testing to make sure the first test was not falsely negative if there is any question. I also stress that the standard safety precautions should always be followed regardless of test status. Social distancing, wearing a mask, and hand hygiene cannot be overemphasized.

In addition to COVID-19 testing, what other factors should be considered before traveling?
Dr. Siegart: I always advise travelers to consider the availability of healthcare in their destination countries and how they will get home (or get to the nearest facility capable of properly treating their condition if they fall ill). This is important for all populations, but it can’t be stressed enough for higher-risk populations such as the elderly or those with pre-existing conditions. I also think it’s highly important for travelers and their organizations to do a thorough evaluation of existing policies, procedures and resources related to COVID-19 to ensure alignment of coverage between insurers, assistance services, and crisis management protocols prior to travel.

Do SARS-CoV-2 variants impact the accuracy of COVID-19 tests?
Dr. Siegart: Current mutations in the SARS-CoV-2 variants are in what is called the S gene that encodes the spike. Most of the molecular tests still detect the SARS-CoV-2 RNA because they detect more than one gene target.

The antigen test detects different virus proteins so mutations in the spike protein would not impact accuracy.

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