Improving Resilience and Recovery to the Travel and Tourism Industry in the Caribbean ()
1. Introduction
The Caribbean region, renowned for its inviting weather, captivating beaches, vibrant cuisine and rich diverse culture, is a well-known, favoured travel destination for many tourists, especially for those who live in regions with temperate climates. The Caribbean is significantly dependent on its travel and tourism industry, especially as it is the leading source of recruitment, employment and revenue for many of the Caribbean islands. According to the World Travel & Tourism Council [1], the travel and tourism sector supported more than 2.7 million jobs and accounted for an estimated 14% (US$61.5 billion) of the Caribbean’s gross domestic product (GDP) in 2019 with direct and indirect contributions ranging from 25% to 74% in most countries of the Region [2]. In 2017, in some countries of the region, the contribution to the GDP ranged from 50% to 90% [3].
Caribbean tourism, and by extension, its economic longevity and vitality, is susceptible to many external shocks. The Caribbean region remains vulnerable to outbreaks caused by Chikungunya, Zika, Dengue and Malaria due to its geographical position in a tropical climate. Travel, alongside the islands’ adjacency and interconnectedness, can enable highly transmissible communicable diseases, such as COVID-19, to surpass borders, disabling tourism and livelihoods. Between 2005 and 2019, cruise ship-related outbreaks increased by 44%, while from 2010 to 2019, over 300 gastroenteritis (GI) outbreaks were reported to the Caribbean Public Health Agency (CARPHA), one-third of which were travel-related. These outbreaks highlight the vulnerability of the travel and tourism sector and highlight the importance that the health of Caribbean economies is closely related to the health of its travel and tourism industry, especially as the Caribbean is the most tourism-dependent region in the world. Damaging publicity can discredit travel destinations, affecting the number of tourists visiting Caribbean countries. Without the region’s travel and tourism industry, the Caribbean can encounter disastrous effects as demonstrated by the COVID-19 pandemic.
Due to travel and the rising frequency of travel-related illnesses and outbreaks in the Caribbean, the initial instances of many diseases were imported cases. This is evidenced by the introduction and spread of H1NI, Chikungunya, and Zika by tourist populations and other newly emerging and re-emerging diseases. Most recently, with the advent of COVID-19, which was declared a pandemic on March 11, 2020, the Caribbean experienced first-hand, the detrimental effects COVID-19 had on its travel and tourism industry which led to economic instability and threatened regional health security in the Caribbean. Some of these shocks are still being endured presently, over two years since COVID-19 was announced a pandemic. During the period 2019-2020 international tourist arrivals to the Caribbean Community (CARICOM) region fell by 70% [4]. This precipitous fall highlights the notion that sustainable tourism must be at the forefront of future development, leading the resilience and recovery of the Caribbean’s travel and tourism industry, as we transition to the endemic phase of the COVID-19 disease.
Despite the devastating effects of COVID-19 in 2020-2021, the region is “recovering at a faster rate than any other region in the world [5].” The Regional Tourism and Health Program (THP), an innovative program that addresses the health, safety, and environmental sanitation (HSE) threats to tourism in the Caribbean, was envisioned and developed in 2014 to strengthen countries’ capacities to prepare and respond to public health threats, thereby promoting the resilience of Caribbean tourism and the sustainability of its economies. Through the provision of healthier and safer tourist destinations and the protection of both the transient and local populations, tourism and health stakeholders’ health and safety needs are met, granting the Caribbean a competitive advantage over the rest of the world.
The purpose of this paper is to illustrate how the THP supports the Caribbean’s preparedness and response to COVID-19 and other public health threats whilst strengthening alliances amongst Member States to improve the recovery and sustainability of Caribbean tourism.
2. Implications of COVID-19 on Tourism and the Economy in the Caribbean
2.1. Status of COVID-19
The coronavirus disease (COVID-19) is caused by the novel coronavirus, SARS-CoV-2, a new strain that has not been previously identified in humans [6]. The World Health Organization (WHO) knew of this virus in December 2019 [7], following cases reportedly causing severe acute respiratory illness in Wuhan, China [6].
The first case of COVID-19 in the English-speaking Caribbean was reported in Jamaica on March 10, 2020 [8] and to date, all countries in the Caribbean region have recorded cases of SARS-CoV-2. As at June 21, 2022, there were 537,591,764 confirmed cases and 6,319,395 deaths globally. Of this, 3,838,332 cases and 34,215 deaths have been recorded in the Caribbean, a region consisting of 35 countries/areas/territories [9]. Most Caribbean countries are documenting community spread, with the dominant variant of concern in the region as of June 2022 being Omicron [9]. Over the 2.25 years since the declaration of a pandemic, the response to COVID-19 has shifted from the initial national lockdowns, cessation of travel (air and sea) and closure of businesses and schools, followed by the phased lifting of public health restrictions, to the present state where some Caribbean countries have instituted full reopening with varying levels of relaxation and removal of COVID-19 prevention and control measures [9].
With the increased transmissibility of Omicron and its sub-variants in conjunction with decreased adherence to COVID-19 public health measures and the Caribbean’s low vaccination rates (2% - 65%), the risk of further COVID-19 cases occurring in the Caribbean remains Very High [9]. The Caribbean Public Health Agency (CARPHA), the single regional public health agency for the Caribbean, reiterates the significance of active surveillance, testing, application of COVID-19 prevention and control measures and vaccinations as countries continue to concentrate on disrupting spread and decreasing deaths [9].
2.2. Impact of COVID-19 on the Tourism Industry
Travel and tourism are fundamentally ingrained in the economies of many Caribbean countries as it drives revenue and employment. The Tourism Dependency Index is a scale that rates 166 countries (based on available data) on their economic dependence on the tourism sector, in terms of individual GDP, employment and exports [10]. According to the Inter-American Development Bank (IDB), in 2019, 13 Caribbean countries were ranked in the top 30 countries globally on the Tourism Dependency Index [10]. Based on this index, Aruba topped the list globally with 79.8% dependence on tourism, with Grenada (58.5%), Antigua and Barbuda (55.1%), The Bahamas (54.5%), St. Lucia (53.4%) and Dominica (42%) all within the top 10 of the Index [9]. Additionally, in 2019 and 2020, the World Travel & Tourism Council (WTTC) ranked Aruba, St. Lucia and the US Virgin Islands as the top three Caribbean economies that had the highest percentage of their country’s GDP being generated from the travel and tourism industry [11].
The Economic Commission for Latin America and the Caribbean (ECLAC) reported that the tourism industry accounted for 11% of the Caribbean’s GDP in 2019. In certain countries, the share of the tourism sector’s contribution to the country’s GDP, was considerably greater, e.g. The Bahamas [12]. ECLAC noted that tourism’s input toward GDP is much broader as tourism does not operate in a silo, but is connected to other divisions, such as food and beverage, entertainment and creative industry, agriculture, etc. [12]. Based on this consideration, the Caribbean’s “tourism economy” is estimated to be about 2.5 times bigger than the sector itself, accounting for 26% of the region’s total GDP [12]. Tourism also remains an essential driver of foreign exchange within the region.
The COVID-19 pandemic devastated the Caribbean’s travel and tourism industry, crippling its economy. According to the Caribbean Tourism Organization (CTO), Caribbean destinations welcomed approximately 32 million international tourist arrivals in 2019, a 4.4% increase from the previous year [13]. The pandemic halted operations at ports and airports, dwindling visitor arrivals which dropped close to zero in 2020 [12]. Cuba’s incoming visitor arrivals declined to 20% in January, 13% in February and 33% in March 2020 [10] whilst The Bahamas, Barbados and Jamaica experienced significant reductions in their international visitor arrivals—76%, 67% and 69%, respectively [10].
The UN World Tourism Organization (UNWTO) communicated that international tourism and its closely related industries lost $2.4 trillion in 2020 due to the impacts of the massive reduction in international tourist arrivals [14]. Additionally, the WTTC explained that the Caribbean endured excessively more negative impacts relative to the global situation as its travel and tourism GDP dropped by 58% in 2020 [11]. St. Kitts and Nevis and St. Lucia were some of the islands that were hardest hit, experiencing a downturn of 72.3% and 71.3%, respectively in their GDP. Similarly, The Bahamas, British Virgin Islands and St. Vincent and the Grenadines all bore substantial deficits to their GDP [11].
It is important to note that the Caribbean region faced significant and far-reaching inadequacies in response to the COVID-19 pandemic, such as vaccine inequity, unavailability, delays and inaccessibility [14] [15]. This reality may have worsened the economic losses [14] as well as hindered the timely recovery and resilience of Caribbean tourism.
Caribbean tourism seems to have taken an upward trajectory in 2021 as the region documented the second-fastest comeback, surpassing UD$39 billion equaling 9.1% of the total economy. The region is projected to have an increase of 47.3% year-on-year, leading toward an upsurge of almost US$12 billion [1]. With these optimistic calculations, safeguarding the health and safety of locals and visitors whilst advancing the resilient, sustainable resurgence of Caribbean tourism and its economies are of paramount importance.
2.3. Impact of COVID-19 on the Airline Industry
The Caribbean region’s early response to control the spread of the virus by closing the borders to international travel, for the most part, had been a success with some island states managing to keep the infection rate at zero for weeks. However, since tourism and air travel are inextricably linked, these restrictions have put a considerable strain on the region’s tourism industry since a significant percentage of overseas visitors arrive in the Caribbean by air.
By early April 2020, COVID-19 had impacted airlines and air travel globally, with global flight numbers down 80% compared to the same period in 2019 [16]. The International Air Transport Association (IATA) reported a 60.2% reduction in the number of passengers that flew, dropping from 4.5 billion in 2019 to 1.8 billion in 2020 [17]. The demand for industry-wide air travel declined by 65.9%, with international and domestic passenger demand reducing by 75.6% and 48.8% respectively, from 2019 to 2020. The airline industry was severely affected with net losses accumulating to $126.4 billion, plummeting by almost 70% in 2020 [16]. At the depth of the crisis, 66% of the world’s commercial air transport fleet was prohibited from flying and this resulted in a worldwide loss of over US$370 billion [17]. This is largely due to strict travel restrictions enforced by several governments to combat the spread of the virus, as by the end of April 2020, travel restrictions were instituted by 100% of global destinations [11].
The regional air carriers were not immune to the negative impact of COVID-19. International and domestic flights within the Latin American and Caribbean area had reduced to almost zero, with many regional airlines, e.g., Caribbean Airlines, Avianca, Copa and LIAT, grounded almost entirely [11]. By mid-2021, Caribbean Airlines reported an operational loss of over $300 million, which resulted in almost 300 employees being retrenched while an estimated 100 employees were also temporarily laid off [18].
To stop, safeguard, and respond to the global spread of disease in the interest of public health, nations all over the world adopted strict international health regulations [19]. For all travellers, maintaining good personal hygiene, following the coughing/sneezing etiquette and maintaining a safe distance of at least six meters were pivotal. However, according to the UN World Tourism Organization, the road to recovery for the tourism industry has been “slow and uneven [20] ”. Despite the easing of initial restrictions and the introduction of COVID-19 public health measures, such as a negative PCR or antigen testing and documentation of either being fully vaccinated or at least receiving one dose of WHO recommended vaccine before boarding flights, the total number of inbound tourists to the Caribbean in 2021, failed to reach the level as that of 2019, as shown in Figure 1. Jamaica, The Bahamas, and Aruba had the highest number of tourists arriving by air in the top ten Caribbean countries. As of mid-June 2022, many of the territories within the region would have further relaxed the entry requirements for local and international travel.
The airline industry predicts 4 billion overall travellers in 2024, surpassing pre-COVID-19 levels [21]. Relative to March 2021, there was a 76% increase in total traffic, over 400 billion revenue passenger-kilometres, with domestic traffic rising from 11.7% in 2021. International traffic climbed 285.3% compared to March 2021, however still down 23% relative to pre-pandemic levels in 2019 [22]. Air travel passenger numbers in the Caribbean are projected to outperform 2019 figures in 2025 by 101% [21].
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Figure 1. Tourist (Air) arrivals in top 10 Caribbean countries by year (2000-2021). Source: Caribbean Tourism Organization, 2021.
2.4. Impact of COVID-19 on the Cruise Ship Industry
The cruise industry plays an essential part in the world economy and to many regional Caribbean economies [23]. Cruise tourism is one of the components of the travel and tourism industry that has grown tremendously in recent years, especially within the Caribbean. According to the Cruise Lines International Association (CLIA), prior to the pandemic, in 2019, cruise demand across the world grew to 29.7 million passengers with the largest percentage of passengers (52%) from North America [24]. In 2020, the cruise industry had been projected to reach a peak of 32 million passengers [25]. Over a 10-year span, from 2009-2019, CLIA documented an average annual growth rate of 5.4%, which is more than that average annual growth rate of 4.9% for land-based tourism from 1980-2017 [23]. As a result of its continuous growth, more cruise ships are dispatched yearly with increased on-board capacity. Recently, cruise lines have been gravitating toward warming climates with the Caribbean accounting for almost 40% of total itineraries [23]. Prior to the COVID-19 pandemic, there was a significant expansion in the number of cruise passengers visiting the Caribbean, rising from 6.2 to 11.3 million from 2010-2018, demonstrating an average growth rate of 7.8% growth for this period [24]. Cruise ship tourism allowed for economic growth both directly and indirectly in Caribbean countries, including employment, visitor expenditure, purchases and contributions to other sectors, e.g., entertainment [23].
COVID-19 affected sea-based tourism as well land-based tourism, as large congregations of persons/passengers in a confined space support the increased risk of transmission for COVID-19 and other communicable diseases onboard a ship as well as to other countries when infected travellers disembark [26]. This leads to the introduction of new diseases into the local populations of these Caribbean islands. With the onset of COVID-19, there were many COVID-19 clusters, outbreaks and deaths associated with cruise ship travel in early 2020 [23] [26]. The Centers for Diseases Control and Prevention (CDC) documented 3689 confirmed cases of COVID-19 or COVID-like cases on cruise ships and 41 deaths from March to September 2020 [25]. Thousands of passengers were unable to disembark as they were retained in quarantine onboard the ships or denied porting [27]. CDC issued the first No Sail Order in March 2020 thereafter, halting cruise ship travel [26]. In October 2020, CDC issued its Conditional Sail Order (CSO) and later, opted for a voluntary COVID-19 Program for Cruise Ships following the expiration of the CSO in January 2022 [28].
The cruise industry suffered due to the pandemic with global disruptions and cancellations impacting millions of travellers and employees [27]. In 2020, there was a loss of 76% of the industry’s revenues with the operating income dropping from 7.1 billion to −17.9 billion. CLIA noted 5.8 million cruise traveller embarkations (81% reduction) in 2020 with the industry’s total economic contribution declining by 63.4 billion (−59%) and experiencing a loss of 51% in cruise-supported jobs, compared to 2019 [29]. Within January to June 2020, cruise ship arrivals declined by approximately 49% to the Caribbean, compared to the same period of the subsequent year, equating to only 8.5 million travellers arriving by cruise ship in the Caribbean [30]. In 2020, Bermuda, St. Maarten and Belize had the largest contraction rates compared to 2019, with −95.8%, −56.2% and −50.8% respectively [31].
With the resumption of cruise ship travel in 2021, the future of this industry looks encouraging. CLIA reports that currently over 75% of cruising capacity has returned with almost 100% predicted to be restored by August 2022 [29]. Additionally, the number of passengers is predicted to exceed figures from 2019 by 2023, further increasing to 12% more than pre-pandemic levels by 2026 [29].
2.5. Impact of COVID-19 on the Hospitality Industry
The hospitality sector, which includes the sub-sectors of accommodations, food & beverage, transportation, and entertainment for visitors (both local and foreign), is inextricably linked to the tourism industry and as highlighted in section 2.2 was tremendously affected due to measures implemented to combat the COVID-19 pandemic. Many governments of the Caribbean utilized strategies such as border closure which directly impacted visitor arrivals, restrictions on in-house dining which significantly inhibited the restaurant industry and no mass gatherings which affected all operations of these sub-sectors [32]. These public health measures, whilst needed at the time to stymie the effects of the pandemic, amplified the level of devastation that can be brought about by a health event on the lives and livelihoods of persons living in the Caribbean region.
During the peak of COVID-19 in 2020, when most governments instituted these public health measures, the accommodations sector saw a precipitous decline in stay-over arrivals (see Figure 2) with a decline of over 14 million visitors from the previous year. A similar decline was also observed in 2017, however, this was associated with a higher-than-average hurricane season that year. According to the Caribbean Hotel and Tourism Association (CHTA), the occupancy rate across the region was at its lowest point in June 2020 at 13.5% [33] with the average annual rate for the period recorded at 30.1% [34]. These unprecedented low arrivals resulted in both temporary and permanent closures of accommodation-based facilities with 14% of these businesses being viewed as highly likely or likely to remain closed [35] precipitating the large decrease in GDP and employment as articulated above. As intimated in previous sections, 2021 has seen a moderate resurgence in the tourism industry and that upturn has been also reflected in increased occupancy rates regionally with June 2021 recording a 48.2% occupancy [33]. Specifically, the highest Occupancy Rates in the region were found in Aruba (82.6 percent), Turks & Caicos (79.6 percent), and Curaçao (71.7 percent) [33].
The impact of the lower arrivals stemming from the COVID-19 restrictions flowed down to the Ground Transportation Companies, Tour Operators, Food
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Figure 2. Stay over arrivals in the Caribbean (2000-2021). Source: Caribbean Tourism Organization, 2021.
& Beverage as well as the Entertainment & Events industries, illustrating how intrinsically linked all these industries are to one another. As an example, the restrictions on mass gatherings resulted in the cancellation of many large events in the entertainment and events industry that influences large tourist arrivals to these island economies, such as Carnival and various music festivals. In addition to international visitors, local tourism was also severely affected by these public health regulations, particularly in the food and beverage and entertainment sectors, presenting a “double blow” for people in the hospitality sector. The World Travel & Tourism Council’s annual Economic Impact Report highlighted a $33.9 billion loss in revenue to the Caribbean’s travel and tourism sector in 2020, of which the sectors in the hospitality industry would have felt the largest burden [2]. Increased arrivals and relaxation of public health restrictions such as vaccination zones, mass gatherings and in-house dinning have begun to improve the outlook for these sectors with restoration to pre-pandemic levels expected in the short to medium term.
2.6. Impact of COVID-19 on Employment
Prior to COVID-19, the travel and tourism sector supplied numerous job opportunities and remains a versatile environment for job creation. Globally, the sector was responsible for 334 million jobs (10.6% of all jobs) and was able to generate 1 in 4 of all net new jobs between the last 4 years before the pandemic, over 2014-2019 [3]. During this time, women were able to secure 54% of travel and tourism employment globally with this sector assembling almost double the number of female employers relative to other sectors [3]. Youth were also able to take advantage of the job opportunities available as the travel and tourism sector hired a greater proportion of youth than the overall economy. In 2019, WTTC reported that 2.76 million persons were employed within the travel and tourism sector [36]. The sector considerably contributed to a “higher than average multiplier effect [2] ” on other industries connected to tourism, e.g., construction and agriculture, as well as provided opportunities for vulnerable workers and those with restricted qualifications and skillsets [2].
In 2020, as result of the COVID-19 pandemic, 19% (62 million) jobs were lost whilst 272 million persons remained employed in the travel and tourism sector globally, with Small and Medium Enterprises (SMEs), women, youth and minorities being notably and inordinately impacted [3]. Moreover, out of the current global working population of 3.3 billion, an estimated 81% were impacted by the full or partial closures of their place of work, caused by the pandemic [37]. The Caribbean experienced approximately a 25% decline in the number of persons employed in the travel and tourism sector, moving from 2.76 million to 2.08 million from 2019-2020 [36]. Subsequently, there has been an average 5.5% surge in unemployment of unskilled labor across the world, with this number varying between the range of 0% - 15% based on the dependence of tourism for the economy [13].
WTTC envisages that 1.34 million more jobs can become available in the span of 10 years, employing an estimated 3.8 million persons in the travel and tourism sector, once there is collaboration among key players [1]. Private and public partnerships, including those with public health agencies, is critical importance and must be strengthened on the local, regional and international levels to drive the safe and healthy recovery as well as the reestablishment of job opportunities in the tourism sector.
3. Countermeasures for Building Caribbean Tourism Resilience, Recovery and Sustainability
3.1. Regional Tourism and Health Program
The Regional Tourism and Health Program (THP) was developed due to the necessity of addressing health and safety among visitors in the Caribbean, noting that the region 1) depends on visitor arrivals more than any other region in the world, 2) the first cases of many illnesses were imported cases, by virtue of travel, e.g., COVID-19 and 3) the increasing incidence of travel-related illnesses and outbreak in the Caribbean. Prior to the THP, health monitoring surveillance systems were focused on the local, resident population and there was no ongoing visitor tourism-based surveillance and response system to rapidly detect public health threats and trigger measures to reduce or stop the spread of disease across and within borders. Insufficient food and environmental sanitation training, absent integrative health, safety and environmental sanitation (HSE) standards and certifying system alongside the notable segmentation between tourism and health stakeholders compound the gaps to contributing to the food safety and environmental sanitation issues and disease outbreaks in the region. These public health concerns can transform into catastrophic tourism crises. These risks, in conjunction with the economic importance of the Caribbean tourism industry, reiterate the need for a system to monitor both travellers’ and residents’ health, and provide rapid response to prevent and control outbreaks. It is within this context that CARPHA established its Regional Tourism and Health Program in 2014.
The Regional Tourism and Health Program is an innovative, versatile program that addresses the HSE threats to tourism, aiming to strengthen countries’ capacity to prepare and respond to public health threats and enhance the health and safety of visitors and locals. The THP, therefore, seeks to improve regional health security and the quality, competitiveness, reputation, sustainability and resilience of Caribbean tourism (https://www.carpha.org/THP).
The program is being executed by CARPHA, the Caribbean’s sole public health agency responsible for preventing disease, promoting and protecting health, in collaboration with the two regional tourism agencies, Caribbean Hotel and Tourism Association (CHTA), CTO, as well as countries. The program is being primarily funded by the IDB. CARPHA is leading the regional health response to COVID-19, in keeping with its Intergovernmental Agreement (IGA) mandate from CARICOM and recommendations from the Council of Health Ministers (COHSOD) Working Group on regional coordination for COVID-19 management. The THP has been a critical component of CARPHA’s COVID-19 response.
The THP is addressing HSE threats in a comprehensive, all-inclusive manner adopting a multi-faceted, multisectoral approach for implementation through real-time surveillance, response, guidelines, capacity building, standards, policy, advocacy and partnerships, and a travellers health award for proactive healthier safer measures and app. With the advent of COVID-19, the THP quickly expanded and realigned its tools for a more rapid and relevant response to the pandemic. Implementing countries have enhanced capacity to mitigate against COVID-19 and other HSE threats, lending toward sustainable tourism.
The THP is building countries’ capacities, to prepare for and respond to COVID-19 and other public health threats, toward sustainable tourism through the following regional public health goods (see Figure 3):
● Tourism and Health Information System (surveillance for land-based tourism)
● Caribbean Vessel Surveillance System (surveillance for sea-based tourism)
● Regional Guidelines for Managing Illness in Accommodations and Ship Settings
● Capacity Building in COVID-19 Health Guidance, Food Safety and Sanitation
● Caribbean Travellers Health Assurance Stamp for Healthier, Safer Tourism
● Caribbean Travellers Health Mobile App
● Hospitality Health, Safety and Environmental Standards
● Partnerships, Mandates and Policy
With the advent of COVID-19, the THP quickly expanded its tools for a more rapid and relevant response to the pandemic. The THP is elevating Caribbean tourism by building traveller’s confidence and reinstating healthier travel to the Caribbean, especially during COVID-19. This timely, relevant, multi-pronged program, a regional and international trailblazer, is the first global effort of its kind. There is no better time than now, as new threats to health and travelling the region emerge and in this era of real-time, instant information flow, for implementing mechanisms for monitoring and responding to tourism health and safety threats. Each of these THP components is discussed below and linked to possible COVID-19 preparedness and response actions.
3.2. Components of the Regional Tourism and Health Program
3.2.1. Tourism and Health Information System
The Tourism and Health Information System (THiS) is a web-based application for syndromic surveillance of populations in tourist accommodations and services (https://this.carpha.org). This early warning, monitoring and response system is designed to confidentially capture traveller’s illnesses in real time. Its built-in alert system, accessible to national authorities, triggers a rapid and coordinated response that aims to reduce illness spread, economic and reputational negative impact. The system, despite being developed less than 5 years ago, has already resulted in improved disease detection by providing alerts to small outbreaks of respiratory illness—which includes COVID-19—and gastroenteritis, stopping the spread and curtailing economic damage. These public health events were identified early and investigated, which could have resulted in severe reputational and economic devastation to the tourism establishment and country. Figure 4 shows a schematic of how the THiS web application integrates into the existing national and regional public health surveillance mechanisms.
Data collection through the THiS web application is performed by staff from the registered tourist facility using an online questionnaire administered to an unwell guest or staff member. Tourist facilities are also required to confirm the absence of cases by epidemiological week, using a “zero case” submission on the web application page, when applicable. Additionally, the self-reporting page allows visitors and staff to independently report their illness using the same online questionnaire located on the THiS web page: http://this.carpha.org.
The online questionnaire includes short questions that capture key demographic information such as age and gender, potential exposure information, such as recent travel and home country, and which symptoms they are experiencing. These include diarrhoea (≥3 loose or watery Vomiting and/or nausea stools in past 24 hours), Fever (>38.0˚C or 100.4˚C), Cough or sore throat, Bleeding (gums, nose, blood pooling under skin, when coughing, in stool), Headache, Joint or muscle pains, Eye or facial pain/headache/facial, Rash, Blurred vision or convulsions or altered consciousness. Responses to these symptoms are analysed by the system’s unique algorithm to generate the 6 internationally recognised potential syndromes (Figure 5):
● Gastroenteritis
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Figure 4. Primary surveillance pathways for THiS.
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Figure 5. The logic used to generate syndromes from reported symptoms.
● Undifferentiated fever
● Fever and haemorrhagic fever
● Fever and neurologic symptoms
● Fever and respiratory symptoms
● Fever and rash
Data analytics are executed on the data inputs from each facility on the THiS web application. The dashboard provides interactive data visualizations through the facility manager’s login. This feature gives the ability to disaggregate the information to view cases among guests vs. staff, by facility (for national users only), and by country (for regional users only). Additionally, information can be sliced by gender, age, and time; Ministry of Health (MOH) users, by facility and time (case counts by day, week, month, or year). This access is limited to hotel management, e.g., hotel manager, health and safety manager, who would be the persons engaging with public health staff at the MOH in the event of a potential public health issue, such as an outbreak. At the MOH, access is given to users determined by the country’s health focal point and typically includes an epidemiologist, surveillance officer, and/or Chief Medical Officer (CMO) or Environmental Health Officer. At CARPHA, access is limited to the THP epidemiologist and head, who looks at the surveillance picture from the perspective of the Caribbean region.
To safeguard and improve the health of the population, surveillance is essential. During a pandemic such as COVID-19, public health officials must be able to rely on a surveillance system that produces real-time and accurate data on the outbreak, collected and monitored over time, directly from the communities, so that they can rapidly identify and implement the most effective interventions. THiS fulfils this requirement by monitoring illnesses among visitors and staff in tourist accommodations and services in real time. From January 2017 to June 2022, there have been 789 businesses registered on THiS across 21 CMS. During the pandemic, THiS expanded to a wider range of users, now including hotels, guesthouses, health centres, transportation, yachts, airlines, restaurants, tour operators, events and also, includes self-reporting capabilities.
THiS has been able to capture COVID-19 positive cases in many hotels that would have gone unnoticed. Through the implementation of the alert notification feature, investigations into cases breaching the system’s thresholds commence within 24 hours, with most being addressed 1 - 2 days subsequent to this communication. Since the activation of this feature in March 2022, 17 syndromic alerts have been recorded involving 43 cases with over 90% being resolved within 48 hours. These alerts have also precipitated follow-up training and awareness building sessions among staff as well as sustained health and safety initiatives. The strength of the platform is also that the visitors themselves are considered part of the surveillance system. Being able to collect these data in the context of the COVID-19 pandemic cannot be overstated.
3.2.2. Caribbean Vessel Surveillance System
THP’s Caribbean Vessel Surveillance System (CVSS) is part of CARPHA’s regional surveillance mandate to public health emergencies. It is a novel electronic system created to enhance the monitoring and response to illnesses and outbreaks in passengers and crew onboard vessels. It is designed to capture symptoms for each of the six (6) syndromes under surveillance (same as THiS), inclusive of suspect COVID-19 and other public health illnesses. Real-time alerts are sent to countries if illness thresholds are reached/passed before the ship arrives, so as to trigger a rapid response from countries (denying entry/entry with only well persons disembarking, inspection before entry) so as to reduce disease spread across borders and enhance regional health security.
Cruise Ships continue to be a major public health concern since the resumption of sailings in August 2021 because of the increased risk of transmission of COVID-19 and other diseases, due to large numbers of persons in a confined space who are likely to be in close contact for a long duration of the journey (3-7 days or more). The cruise ship acts as a means for infected persons travelling to different geographical locations thereby perpetuating the spread to “virgin” territories. CARPHA’s THP developed the Regional Guidelines for Managing Issues of Public Health Significance on Passenger Ships Coming to the Caribbean. Following consultations with CMOs, VSP, and research we updated the “CARPHA’s Interim Guidelines for Cruise Ships travelling to Caribbean Countries during the COVID-19 pandemic.” The key recommendations are (see Figure 6 below):
Following a partnership formed with CDC Vessel Sanitation Program (VSP), the CVSS sends out alerts based on CDC Color Status that depict varying levels
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Figure 6. Key recommendations for cruise ships travelling to the Caribbean.
of COVID-19 illness on ships [38]. The illnesses are matched with Caribbean itineraries and if a threshold level is reached, real-time alerts are sent to relevant authorities (CMOs, Port Health Officers, National Surveillance Focal Points) of ships arriving to their shores with COVID-19 or COVID-19 Like Illness (CLI) on board, to allow CMS to investigate and make decisions on pratique. This platform allows for the capture of symptoms for each of the six (6) syndromes under surveillance (like THiS). It will alert stakeholders when outbreak levels surpass threshold values on the vessel. The CVSS is supported by Regional Guidelines, outbreak databases, contact/coordination lists and communication protocols for outbreaks. See Figure 7 for operation details of CVSS.
The THP CVSS started sending alerts to CMS effective October 2021. During the period of October 2021 to June 2022, 1190 alerts have been issued. There was a marked increase in the number of Yellow Level Alerts (number of on-board cases exceeds CDC’s 0.1% threshold, warranting an investigation) from December 2021 to January 2022, likely due to the more transmissible Omicron, highlighting the increasing cases and risks posed by ships sailing during COVID-19. Several ships frequently recur on the listing for Yellow/Orange level alerts, and Member States have been advised to investigate re-embarkation/embarkation testing criteria, screening processes, adherence to Public Health Guidelines on the ship and vaccination status. To date, these alerts have triggered the following responses from countries and agencies:
● Denied pratique/entrance to cruise ships as a result of these updates
● Conducted investigations and risk-based assessments before letting ships in
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Figure 7. Process flow for reporting on cruise ships alerts from CARPHA to CMS.
● Solely allowed well persons to disembark while ill persons stay on board
● Requested rapid COVID-19 test before disembarking
● Designated special areas/island for cruise ship passengers
● Special meetings with CLIA, CDC and CMOs to discuss minimum requirements
As a proactive tool, the CVSS provides timely alerts to CMS before ships arrived which triggers a range of rapid responses from countries and allows CMS to make better informed public health decisions on granting pratique before a ship arrived. These actions reduce disease spread across borders and enhance regional health security. The decision to grant pratique or not can also severely impact countries’ economies, tourism and health systems, namely, the spread of illness and related morbidity and mortality, availability of hospital beds and services, health care costs, reduction of human capacity, reputational damage and depletion of other resources.
3.2.3. Regional Guidelines
To support the THiS and CVSS visitor-based surveillance and response system, two sets of regional surveillance guidelines were developed:
● Regional guidelines for managing issues of public health significance on passenger ships coming to the Caribbean (Caribbean Vessel Surveillance System (CVSS))
● Regional guidelines for managing issues of public health significance in stay-over arrivals (Tourist Accommodation-based Surveillance) in the Caribbean
These guidelines, collectively called the “Regional guidelines,” are instructive guidelines for harmonised scientific response to travel-related public health issues that support countries in managing issues of public health importance in a timely and coordinated fashion and thus, protecting the health and security of visitors and locals (see Figure 8). These guidelines are widely used by countries for norovirus and recently COVID-19 response.
Within the Caribbean, there is a marked variation and lack of standardization in the surveillance and response to travel-related public health issues occurring among visitors arriving by sea and those in stay-over arrivals. Core competencies and protocols regarding the investigation and reporting of public health emergencies on passenger ships are described in the 2005 International Health Regulations (IHR), however, its implementation differs by country as each country is sovereign. The commonality of tourism-based illnesses, close proximity and frequent travel (both intra-regional and international) in the Caribbean necessitate
the need for uniform and harmonised surveillance and response guidelines to travel-related public health events.
CARPHA, as the Caribbean authority for public health surveillance, developed the Guidelines for coordinated surveillance and response to travel-related public health illnesses to prevent and mitigate public health events on passenger ships and in stay-over arrivals. It will support countries in carrying out public health action to manage issues of public health importance in a timely and coordinated fashion and thus, protect the health and security of visitors and locals within the region. It will also allow for the collection of surveillance data to establish baselines for outbreak detection and strengthen national surveillance. The Guidelines are based on the IHR (2005), the WHO management of public health events onboard ships (2016) and other documents developed over a 3-year period involving country and agency consultations; and in close collaboration with CLIA and CDC VSP. It was presented to the 33rd COHSOD, endorsed at the 2018 CARICOM CMOs meeting, and supported at the 2018 Regional Tourism and Health Stakeholder Workshop by 13 agencies and 14 countries.
The Guidelines were published in May 2018; presented to CMOs in June 2018 and distributed to countries. In 2020/2021 the Guidelines were updated to include response to COVID-19 and other public health emergencies and will be published in 2022. Since the onset of the COVID-19, the Regional Guidelines, in particular the Guidelines for Managing Issues of Public Health Significance on Passenger Ships, are being used by many countries. The latter was the foundation for the development of a CARICOM Heads of Government mandated Regional Coordination for the Management of COVID-19 and other Infectious Diseases in Passenger Ships. In addition, with the announcement of cruise resumption in June 2021 in the Caribbean during COVID-19, THP updated the guidelines and produced Interim Guidelines for Cruise Ships travelling to Caribbean during the COVID-19 Pandemic and Minimum Harmonised Guidelines for the Resumption of Cruise Ship Sailings in April 2022. This was approved by CARICOM via Savingram #582 [36]. Virtual sessions on the response protocols were held with CMOs and some chief environmental health officers, to enhance ports of entry screening for suspected COVID-19 cases and thus, ensure consistent implementation of pandemic responses.
On 25 August 2021, CARICOM approved minimum guidelines for safe cruising which were circulated [39]. In summary, these are:
● Proof of a negative PCR testing 72 hours before boarding ship (at start of voyage)
● Recommend Vaccination of crew (100%) and passengers over 12 years
● Daily accurate reporting of all symptoms through the Maritime Declaration of Health form
● Immediate reporting of any COVID-19 positive case or COVID-like illness (CLI) cases
● Demonstrated capacity on Ship to isolate, quarantine and test for COVID-19
● Ship capacity to range between 60% - 70% maximum to promote social distancing
● Repeat viral testing on ships after 4 days on board ship (Antigen/PCR)
● Implement public health measures on ship: hand sanitisation, mask wearing, social distancing
● Provide detailed shore and homeporting protocols
3.2.4. Capacity Building
1) Advanced Food Safety Training and Certification
Food safety impacts the health, wealth, and reputation of countries. Diarrhoeal illness, resulting from contaminated food or water and foodborne disease (FBD), is the most common health problem faced by visitors to the Caribbean. In the last 15 years, the Caribbean has experienced an increase in the number of large and costly visitor-based outbreaks of illness leaving the tourism and travel sector negatively affected. The non-enforcement of existing food and environmental safety standards, inadequately trained staff and the absence of an effective monitoring and reporting system have contributed to these FBD outbreaks. Whilst decreasing the incidence of FBD remains a challenge, effective tools for preventing foodborne and other illness, such as, science-driven food safety management, education and training, must be utilised.
The THP provides an Advanced Food Safety and Certification Train-the-Trainer course for health and hospitality stakeholders. This training is done by certified regional experts, using the globally recognised ServSafe food safety material uniquely infused with the Caribbean experience based on CARPHA’s illnesses investigations of public health threats. ServSafe is the internationally recommended comprehensive capacity-building proficiency course, using practical science-based knowledge and skills. It builds countries’ capacities in the areas of advanced food safety, illness causation and prevention, outbreak response and environmental sanitation (see Figure 9). It will also allow for globally recognised certification through the internationally recognised USA National Restaurant Association Educational Foundation (ServSafe). To date, the THP has trained and certified 562 persons from 10 countries. During 2021, 88 persons successfully completed the Advanced Food Safety and Environmental Sanitation training.
2) COVID-19 Training
The COVID-19 pandemic has quickly evolved into one of the greatest threats to human society and the second worse pandemic of all time in terms of virulence. The global spread of COVID-19, propelled by travel, continues to threaten the health security of the CARICOM Region, whilst concurrently, disrupting tourism and reducing revenues in CARICOM economies.
With the subsequent reopening of country borders, phased lifting of in-country restrictions, resumption of travel and roll out of vaccinations, a careful balance between reducing restrictive measures and ensuring adequate measures must be implemented to reduce importation and the spread of new cases. As a result, CARPHA, partnering with CTO and CHTA, initiated COVID-19 health guidance training to strengthen countries’ capacities to fight the effects of COVID-19
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Figure 9. Topics covered in the advanced food safety and environmental training.
with a focus on the relevant health and safety guidance, such as COVID-19 aetiology, transmission and prevention, proper cleaning and disinfection techniques and detailed interventions recommended in tourist facilities. Training on THiS is also incorporated as part of the COVID-19 training. At the end of the training, participants receive a certificate of participation, which is needed in the issuance of another THP tool, the Caribbean Travellers Health Assurance Stamp for Healthier, Safer Tourism. To date, 7836 persons from 51 countries (25 CMS and 26 non-CMS) have been trained in the COVID-19 health guidance and THiS sensitization session.
3.2.5. Caribbean Travellers Health Assurance Stamp for Healthier, Safer Tourism
The Caribbean Travellers Health Assurance Stamp for Healthier, Safer Tourism (HST Stamp) is a measurable and verifiable travellers health assurance and recognition award for tourism entities that are implementing the recommended proactive COVID-19 health monitoring and safety measures. CARPHA, with CTO and CHTA, continues to elevate Caribbean tourism by building traveller’s confidence and reinstating healthy and safer travel to the Caribbean. The HST Stamp has been approved by the Global Tourism Resilience and Crisis Management Centre (GTRCMC) and endorsed by WTTC. Caribbean travellers now have the added assurance of a healthier, safer option for accommodations and services awarded the WTTC recognised, regional CARPHA-CTO-CHTA HST stamp. The award adds assurance, gives a comparative, marketing advantage and provides value to the quality of service provided by the tourist facilities, protecting its image, investment and people whilst adhering to the recommended COVID-19 health and safety measures and actively reporting on THiS. HST Stamp awardees are listed as preferred healthier safer options on Caribbean Traveller’s Health Mobile App and listed on CARPHA websites. To be awarded the HST Stamp, tourist businesses must (see Figure 10):
● Register on the Tourism and Health Information System (THiS) and actively report for at least 1 month to be eligible for the HST Stamp. Reporting includes confirming zero cases for each week.
● Ten percent (10%) of all staff, including senior management, must attend and be certified in the COVID-19 Essential Guidelines for the Hospitality Sector training.
CARPHA will verify the use of THiS and participation in the certified training, in order to award the HST Stamp. After analysis and approval, an email will be shared with the business confirming the award, along with the listing on the Caribbean Travellers Health App. The digital logo of the HST Stamp will be shared for marketing purposes. It is important to note that if a tourism entity fails to consistently report on the THiS platform as a means of proactive monitoring, CARPHA reserves the right to remove this entity from the list of qualifying Healthier, Safer Tourism awardees.
The attainment of the HST Stamp fosters active collection and reporting of data, not only related to COVID-19, but to other illnesses and syndromes that
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Figure 10. Steps to acquire the CARPHA-CTO-CHTA Stamp.
can negatively affect the reputation and marketability of a tourist destination. As of June 2022, 108 tourist establishments and facilities in 14 CMS have been awarded the HST Stamp—82 facilities, 20 tour operators, 5 ground transportation and 1 yacht. The THP continues to work closely with various tourism stakeholders in multiple Caribbean countries to acquire the HST Stamp and to re-establish healthier, safer tourism in the Caribbean region.
3.2.6. Caribbean Traveller’s Health Mobile App
The Caribbean Traveller’s Health Mobile App is a multifaceted, Caribbean health information depository, designed for travellers and health and tourism stakeholders. It was designed to fill the gap in the provision of useful, relevant and timely information to prospective travellers to the region. It provides the self-reporting form for THiS, travel health and safety information by each Caribbean destination, inclusive of vaccinations, COVID-19 proactive/prevention measures and unique travel requirements. More importantly, the mobile app also identifies, by name, accommodations and other hospitality services, within a destination, that have been awarded the HST Stamp. This free app is available on both Google Play and Apple Store.
The Caribbean Health Mobile App users can access expert advice and regional health and travel information easily and freely. The provision of reliable health, safety and tourism-related information can increase public awareness and curb the spread of COVID-19. The ability to self-report on the mobile app can boost national health surveillance systems and enhance the collection of data and the appropriate, integrated response, if needed.
As of June 2022, there have been 836 downloads of the app, 301 from Google Play and 535 from the App store. The THP continues to collaborate with countries, tourism establishments and services to ensure accurate and timely dissemination of information circulated on the mobile app weekly.
3.2.7. Hospitality Health, Safety and Environmental Standards
The implementation of the Caribbean-wide Health, Safety and Environmental “clean and green” Standards will further contribute to preventing the transmission of communicable diseases, including the COVID-19 pandemic. In particular, the HSE standards encompass different components that are relevant to mitigate the spread of the virus, e.g., within the Food Safety and Sanitation component, frequent and proper hand hygiene is one of the key measures to prevent contamination and transmission, and disinfection will facilitate faster die-off of the virus. These HSE standards constitute a critical component of a set of preventive interventions to enhance not only the region’s capacity to respond to the public health threats, but also to support the region’s drive toward achieving quality and sustainability and to remain competitive in this rapidly growing global tourism trade.
Seven (7) Caribbean-wide health, safety and environmental (HSE) “clean and green” hospitality standards (see Figure 11) have been developed to improve
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Figure 11. Hospitality health, safety and environmental standards.
health, safety and environmental quality in the hospitality sector. These standards were developed under the authority of the CARICOM Regional Organization for Standards and Quality (CROSQ) through CARPHA THP and were approved at the CARICOM Council for Trade and Economic Development (COTED) in November 2021.
The seven HSE Standards include:
1) Energy Management and Efficiency
2) Food Safety and Sanitation for the Tourism Industry
3) Environmental Management Systems for the Tourism Industry-Guidelines
4) Integrated Pest Management for the Tourism Industry
5) Sewage Treatment and Management for the Tourism Industry
6) Solid Waste Management for the Tourism Industry
7) Water Treatment, Management and Efficiency for the Tourism Industry
The implementation of these standards by the Caribbean tourism industry will significantly reduce the adverse impact of HSE issues, which in turn would increase the economic well-being of the region. Implementing these standards would protect the region’s fragile environment and lead to a safer and better-quality environmental product and a standards-based certified destination, which in turn increases the comparative advantage of Caribbean tourism. Substantial benefits are possible if these standards are adopted and referenced in legislation/regulation that can be made sufficiently similar across the Caribbean Region. One such benefit is a substantial improvement in health food safety and environmental sanitary conditions in the hospitality sector throughout the region. The implementation of the standards would be recognised by the Association of British Travellers (ABTA) and other tour operators. Certified facilities would also be published on CTO, CHTA, and CARPHA websites.
3.2.8. Partnerships, Mandates and Policy
Tourism is currently one of the sectors that has been hardest hit by the COVID-19 crisis. Guiding the tourism sector’s response requires strong public-private intersectoral partnerships at national and regional levels between tourism, health, and environment stakeholders. This is the only way to support a rapid and well-coordinated approach to managing the pandemic—and this is what the Tourism and Health Program has executed since its inception.
The THP involves the implementation of new non-traditional health information and monitoring systems (i.e., tourism/visitor-based illnesses), new clients/data users (private sector hotels, cruise ships, visitors) and new partners (Ministry of Tourism, tourism authorities, tourism agencies). In this regard, a critical factor for the successful implementation and sustainability of the program is global and regional recognition, partnership development and endorsement from international public and private health and tourism agencies. The THP, starting with a Memorandum of Understanding between CTO and CHTA, is building multi-sectoral, multi-agency partnerships with regional and international health and tourism stakeholders to address travel-related public health threats in a rapid and well-coordinated manner for seamless information flow and response to traveler’s illness across regional and international borders. Additionally, Letters of Agreement have been signed with the CDC VSP in 2019, the Organization of Eastern Caribbean States (OECS) Commission in 2021 and CROSQ in March 2022. Other key partners to date include CDC, Public Health Agency Canada, UK Health Security Agency, CLIA, ABTA, Sandals, Cricket West Indies and Caribbean Airlines.
To boost the coordination and collaboration toward the Caribbean’s COVID-19 response, the COVID-19 Task Force was created, consisting of CARPHA, CHTA, CTO and GTRCMC, for a united, harmonised approach to these COVID-19 measures. This task force supplements CARICOM’s efforts to extend core health safety protocols throughout the region aimed at decreasing the risk of COVID-19 to residents and visitors and continues to recommend proactive COVID-19 Health Measures to build travellers’ assurance, tourism resilience and regional health security. It also lends technical input to CARICOM’s tourism reopening guidelines and discusses COVID-19 measures for safe reopening. It convened joint training and disseminated joint press releases.
Approved by Caribbean Ministerial bodies, COHSOD (2021) and COTED (2020), the Regional Policy mandates reporting of travel related illness to national authorities. It provides a framework for countries to amend their national policy to promote heathier safer tourism. Implementation creates an urgency among hospitality partners and travellers to reduce the risk posed to people in the Caribbean Region by communicable disease outbreaks and public health emergencies, through early detection and a strengthened rapid response.
The THP developed a Regional Travellers Health Policy Framework to mandate the reporting of tourism/visitor illnesses to national authorities from the hospitality sector for the successful implementation and sustainability of the THP. The Regional Travellers Health Policy Framework aims at ensuring an enabling environment for optimal implementation of the THP and its components. This framework is a critical tool in the drive to secure the Caribbean Region’s health security. Implementation of the Policy provides a basis for creating a sense of urgency among hospitality sector partners and travellers to reduce the risk posed to people in the Caribbean by communicable disease outbreaks and public health emergencies, through early detection and a strengthened rapid response.
● In 2017, the 33rd COHSOD mandated CARPHA, through the THP, to prepare a tourism/traveller’s health policy for improving regional health security.
● During 2018-2019, through a consultative process, the Regional Travellers Health Policy Framework was developed.
● On September 29, 2019, the Regional Travellers Health Policy Framework was approved at the 37th COHSOD, and then by COTED in 2020.
4. Conclusions
Travel and tourism remain a cardinal feature for the Caribbean, responsible for revenue, foreign exchange and employment of many of our resident populations. The COVID-19 pandemic and its tragic implications have reiterated the need to propel and promote sustainable tourism, contributing to improved economic stability and resilience of the travel and tourism industry, committing to a Caribbean that is better prepared to respond to future pandemics and other public health concerns, including health, safety and environmental sanitation threats.
To achieve sustainable tourism, with the inclusion of health in tourism, necessitates a well-coordinated, multi-faceted response. The dynamic Regional Tourism and Health Program continue to enhance the health and safety of Caribbean people and its visitors and strengthen regional health security, through its multi-pronged components and multi-sectoral partnerships. The THP remains pivotal in advancing the recovery and resilience of Caribbean tourism and the sustainability of its economies as a result of the COVID-19 pandemic, and in preparation for any future public health threats, as we continue to build travellers’ confidence and reinstate healthier, safer travel to the Caribbean. Also, we encourage the need to strengthen alliances among key stakeholders, such as the ministry of health and tourism to guarantee implementation and in turn sustained recovery.