The aircraft engines power down as disembarking passengers rummage through their carry-on bags for documents in readiness for immigration. This is Kigali International Airport, a busy regional hub. The country has implemented an innovative electronic tracking system to stop the domestic spread of COVID-19 from arriving passengers.

It starts with a pre-departure COVID-19 test done through the standard polymerase chain reaction (PCR) method, and which must be valid no more than 72 hours. Travellers fill an online form, load their test results and a booking confirmation from one of the designated hotels. They are then issued with a unique code to present on arrival.

At the airport international passengers are then required to take a second PCR test which is administered by a health worker. The process takes less than an hour and once done, visitors proceed to one of the over 80 designated transit hotels for a quarantine—nationals provide their contact details and head home—to await test results that are ready in 12 to 24 hours.

Results from the tests done on arrival are posted on an online portal accessible via a code. Hotels checking out guests report on an online COVID-19 surveillance dashboard that results have been issued. If tests turn out positive, a close follow-up is given to asymptomatic patients for 14 days when a control test is done, and hospitalized if they fall seriously ill.

“Imported COVID-19 cases have significantly reduced because of the country’s surveillance system,” says Misbah Gashegu, the point person for Rwanda Biomedical Centre at the Kigali airport, where two to three cases are currently detected per week among arriving passengers, down from around 20 weekly shortly after the system was set up in August 2020. Weekly international arrivals range between 2500 and 3500.

Previously, a team of health workers would collect samples from arriving passengers in hotels, but the risks of losing samples were higher, delays in providing results stretched up to 72 hours and stationing vehicles, supplies and personnel on location taxing. “The logistics were hectic and tedious,” says Dr Gatare Swaibu, who heads the Biomedical Services Department at the Rwanda Biomedical Centre. “The biggest challenge was the turn-around time for test results.”

Dr Swaibu points out that in addition to deterring imported cases, the surveillance system has a crucial role in helping to detect and contain any COVID-19 variants of concern. A single case of the variant initially identified in South Africa was promptly detected, isolated and further spread averted.

“Being able to detect and contain variants of concern before they spread into the wider population enhances our overall response to COVID-19 in the country,” says Dr Swaibu. “By averting potentially more contagious variants, we can focus on curbing the pandemic without the added threat of imported, more transmissible types of the virus.”

“Once we detect a variant in an arriving passenger, they are either going to stay in the transit hotel until they are clear of the virus or we isolate them in [a residence] or placed under home-based care,” he says.

Working with the Ministry of Health, the World Health Organization (WHO) provided technical support in the development of the passenger tracking system at the airport and linking it with the main laboratory. With the support of donors, including the governments of Canada, China, Germany and Japan, the Organization has deployed a technical officer at the airport to support the system’s management.

“Rwanda’s points of entry surveillance system is playing a crucial role in COVID-19 response and can be replicated in other countries to help stem the spread of the virus and protect lives,” says Dr Mary Stephens, Technical Officer at the WHO Regional Office for Africa. “With travels expected to increase as the northern hemisphere summer sets in, the risk of COVID-19 spread is likely to rise, and only with effective surveillance systems can we detect and curb widespread infections.”

Challenges

Even if travellers are required to present a negative COVID-19 test, ascertaining authenticity or that a real one was fraudulently obtained is a challenge, and that is one of the major reasons for the test—the cost of which is borne by the traveller—on arrival at Kigali international airport, Gashegu explains.

Health authorities in Rwanda are exploring ways of standardizing the PCR test certificate for travel, working with regional and international health or air travel regulatory bodies on the possibilities of establishing a trusted international COVID-19 test certificate. Fake certificates on the departure side are relatively easy to detect and deter, says Gashegu, a few have been detected, but the practice is not widespread.

Looking ahead

Efforts are also being made to automate viral extraction at the airport testing laboratory to further cut down on result issuance time. WHO has supplied two PCR machines for the airport laboratory as well as deployed laboratory technicians and analysts.

Beyond the airport, Rwanda plans to expand the surveillance system to its major land borders. Last year the East African Community—of which Rwanda is a member—launched an app for issuing digital COVID-19 test certificates recognized by partner states to ease cross-border cargo movement.

“We are looking at replicating the same system to other points of entry especially the busiest borders of Rwanda with Tanzania, Uganda and the Congo [Democratic Republic of the Congo],” says Dr Swaibu.