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The Ins and Outs of Covid PCR Testing for Travel

"Do they have to stick a Q tip all the way to the back of my brain?" "Is it safe to go to a clinic?" "What if my results don't come back in time?" "Will my travel certificate be accepted?" These are just a few questions that come up as people are getting ready to fly abroad in the Covid era.


In the best of times, travel can be hectic and frustrating but travel during Covid adds another layer of complexity that can be anxiety producing. The non-uniform rules of travel between countries seem to be ever-changing adding to the confusion, but from the standpoint of a clinic in Japan that provides PCR testing for travel, let me demystify some of this confusion as it stands at the time of this writing.


The process is relatively simple. You book a reservation online, within a certain time frame before your flight, and for your appointment, make sure you are healthy and symptom free, bring your passport, and have had nothing to eat/drink for 30 minutes prior to your test. At our clinic we primarily treat cancer patients, so we keep appointments 30 minutes spaced apart and fully decontaminate the area where the testing occurs between patients. You come in, get your temperature checked by a nurse, show your passport, check over your details/paperwork, sign a consent form, talk to the doctor, pay the 22,000 yen fee for the test and certificate (not covered by insurance), and take the test. For the saliva test, you just collect your saliva (about 1 ml) by spitting into a special tube. Some people have trouble producing saliva on demand, in which case it's helpful to visualize sucking on a sour lemon or running your tongue around your gums to induce salivation. For the rare person needing a nasopharyngeal swab test (those who can't produce enough saliva such as the very young or very old or if required by certain countries) the doctor will insert a very skinny Q tip and swab each side of the inner portion of the posterior nasal cavity (not into the brain!) which takes just a few seconds of minor discomfort. Most people are in and out of the clinic in about 15 minutes, and if the test is done in the morning, we will have the results and certificate for you by late afternoon.


The confusion with travel certification starts where there is no one uniform format for travel and different countries require different information. Generally a travel certificate should have: your name, date of birth, passport number, nationality, sample date and time (of when you take the test - not when you receive the results), type of testing (saliva/nasopharyngeal swab and PCR/LAMP/antigen testing), some countries require what laboratory was used and what equipment was used, the all-important NEGATIVE (not "undetected" or "-" written on the paper), the clinic name, and the doctor's signature (and license number for some countries).


What is the difference between the PCR, LAMP and antigen tests? The PCR test is the most commonly used "gold standard" test, but also the most time consuming. It involves extracting the RNA from your saliva sample, and amplifying it through many cycles of heating and cooling and looking for strands of viral (in this case COVID) RNA. It detects even the smallest amount of virus and considered the most accurate. There are newer completely automated machines that can do this in about 90 minutes (at the airports for example), but in general this takes several hours. LAMP testing is similar in that it amplifies RNA, but it doesn't use the heating/cooling cycles so takes slightly less time, but is also slightly less accurate. The antigen test is the least accurate of the bunch, as it tests for proteins on the surface of the Covid virus, not the actual genetic material. This is similar to testing for the flu or strep throat and results are ready in about 15 minutes. Different countries have different requirements for which test you need, but PCR testing is universally accepted.


So what are the actual rules and exceptions by country? These are often changing, so please confirm with your airlines and embassy, but as of this writing (May 2021) this is the information sourced from government websites and by calling various embassies. For most countries, the time you take your PCR test should be within 72 hours before boarding your flight (known exceptions to follow) and most will accept a digital copy (scanned pdf format) of the certificate. This may vary, however, so definitely confirm before opting for the digital option. In my experience, most people request the hard copy, and if getting the emailed version make sure you print out a copy, just in case your phone battery dies or if you have any technical difficulties.


For the United States, Covid testing must take place within 3 days (rather than 72 hours, giving you more time) of boarding your flight. All travelers 2 years old and up must be tested. The state of Hawaii, however has its own rules and require testing through their "trusted travel partners" in order to avoid their 14 day quarantine.


For the United Kingdom, testing is within 3 days for travelers 11 years old and up. They require tests that "meet performance standards of ≥97% specificity, ≥80% sensitivity at viral loads above 100,000 copies/ml", which PCR testing by any TeCOT certified clinic (part of Japan's ministry) should qualify.


Australia requires PCR (not LAMP/antigen) testing 72 hours prior to the scheduled departure time of your flight. Ages 5 years and above need to be tested.


You would think that the rules of travel to all EU countries would be uniform, but it is not so. For France, a PCR test (not LAMP/antigen) must be taken for passengers 11 years and up, 72 hours before boarding. Germany is particularly strict, with a PCR test for ages 6 years and up that must be done within 48 hours prior to your landing (not boarding) time. And the most restrictive of all to date, for travel to the Netherlands, you must provide proof of negative PCR testing for ages 13 and up, 24 hours prior to boarding. This holds true even if you are only transiting through the Netherlands and your final destination is another country.


Saliva or swab test? Most countries now accept the saliva test as it is just as accurate as the nasopharyngeal swab. However, you might find vague wording on your country's webpage that they "prefer" the swab but will "accept" the saliva test. For example, Singapore and France initially stated that the swab was needed, but upon calling the embassies for clarification, stated the saliva test was fine. Malaysia as of this date still requires the nasopharyngeal swab and for Israel, while their website does not specify saliva vs swab I was told by a traveler that a swab was needed.


One point of clarification, often in the UK travel certification is called "fit to fly certificates" which indicates that the traveler has had a negative Covid-19 test within the last 72 hours and is thus "fit to fly", analogous to our travel certification. This should not be confused with a "fit to fly" medical certificate that it attests that the traveler is free of any major illnesses that would preclude them from flying. This is for someone for example with a critical illness, on a respirator, or in the 3rd term of pregnancy. Thailand requires such a "fit to fly certificate" which makes the doctor attest that the traveler has no major illnesses (not just Covid), so this should ideally be done through the traveler's regular doctor who is familiar with their medical history.


Again, rules are ever-changing, so please be sure to confirm with your airlines and embassy prior to travel. At the moment, there are no exemptions to testing and travelling based on vaccination status, but countries are working together to come up with a (hopefully) cohesive "vaccine passport" that will make travelling easier. In the meantime, my hope is that this allays some of the fear and confusion and that armed with knowledge, we can go about and safely resume travel again. For more information please visit https://tokyocancerclinic.jp/lang/en/inspection/covid-19-pcr-testing/.


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