Maintaining Cross-Border Cargo Movements Between Jordan and Saudi Arabia During the COVID-19 Pandemic

Introduction

Jordan reported its first case of COVID-19 on March 2, 2020. ¹ The virus quickly spread, predominantly in the northern region of the country. In response, on March 15, 2020, Jordan closed all 12 points of entry (POE): 3 airports and 9 ground border crossings. ² Under its National Defense Law, the country introduced a range of nonpharmaceutical interventions including mask-wearing mandates, social distancing, gathering restrictions, risk communication, nonessential travel bans, a series of curfews, and a complete lockdown between March and June 2020 of almost all nonhealthcare-related services including the closure of all schools and universities. ³ The mitigation strategy also involved quarantine and isolation measures at the household, building, area, and governorate levels to inhibit escalation of SARS-CoV-2 transmission originating from imported cases.

One of Jordan's most essential ground border crossings is the Al-Omari crossing between Jordan and Saudi Arabia, 1 of 3 ground crossings between the 2 countries, located 160 km west of the capital Amman. ⁴ The Al-Omari crossing is a primary route for transportation of food supplies and is considered a major route for exporting the majority of Jordanian goods. Under normal circumstances, between 300 and 500 loaded trucks pass through the Al-Omari crossing daily, accounting for around 6-fold the number of any other Jordan POE. ⁵

When Jordan decided to close all POE, the Al-Omari crossing received special attention given its paramount role in food supply. Several evidence-based actions were taken to suppress potential cross-border transmission of SARS-CoV-2.

Data and Information for Risk Assessment

The epidemiological situation in Saudi Arabia played a critical role in informing decisions around COVID-19 control measures for the Al-Omari POE. Despite several restrictive measures implemented during the first 2 months of the pandemic, the number of active COVID-19 cases in Saudi Arabia increased exponentially until May 8, 2020, when a temporary stabilization was observed, followed by a resurgence in the middle of May (2,000 to 3,000 case per day). ⁶ In June, Jordan reported fewer than 20 cases per day, and on June 4, 2020, most of the sectors were reopened, allowing the movement of people. ⁷

Data on the epidemiological situation at the Al-Omari crossing was compiled based on multiple sources, including Saudi Arabian national authorities, websites, and platforms, ⁸ and World Health Organization situational reports.^9,10 Evaluation of the Saudi epidemiological situation included an assessment of the risk (likelihood and impact) of importation of COVID-19 cases based on transmission trends in terms of case rates, fatality rates, and geographical distribution of new cases. In addition, mitigation measures were adopted by Saudi authorities, especially in the context of POE.

Frontline personnel delivered data on the number of new COVID-19 cases and new clusters to central decisionmakers at the Ministry of Health (MOH) and the National Center for Security and Crisis Management. Both verbal and written reporting methods were used to transfer messages between central and peripheral lines. Situational reports and data on the number of positive cases, secondary infections, and people in isolation and quarantine were sent to central teams and decisionmakers. In response, decisions and actions were informed by expert judgments, either from local authorities or in consultation with international partner organizations.

Public Health Decisions Based on Risk Assessment

Based on findings from the risk assessment, the Al-Omari ground crossing remained open for cargo truck drivers, but drivers were required to undergo mandatory body temperature screening. If they had a fever of 37.5°C or higher, the drivers were tested for COVID-19 and their samples were sent to a PCR laboratory in Al-Haddain, a few kilometers from the crossing. Until mid-April 2020, between 10 and 15 drivers daily were detected to be febrile. Of these, 2 tested positive for COVID-19. ¹¹ The drivers likely waited for many hours to get their PCR test results. Positive cases were referred for isolation in caravans at an isolation area near the Dead Sea. ¹² These measures appeared insufficient as 2 drivers developed symptoms and tested positive after they sought medical care in local hospitals. The Al-Omari ground crossing remained open for truck drivers only. Other POE were completely closed from March to June 2020.

In response to these breakthrough cases, on March 25, 2020, national authorities decided to establish a border laboratory in Jordan to test truck drivers at the Al-Omari crossing^13,14 and required truck drivers to sign a pledge for a home quarantine of 14 days. Drivers were then subjected to quarantine in their homes. ¹⁵ All drivers were local and lived within Jordan; however, the government guaranteed institutional quarantine for any person not living within Jordan.

The implementation of laboratory testing at POE and home quarantine measures resulted in a decrease in the number of imported and secondary cases from truck drivers entering the country, as self-quarantine reduced contact between truck drivers and individuals in the community.

The Jordanian government covered testing costs, and drivers waited for test results in their trucks for 4 to 8 hours. Drivers who tested negative were allowed to enter the country, with home quarantine for 14 days after delivering the cargo. Drivers who tested positive were transferred via the civil defense ambulances to designated COVID-19 hospitals for isolation and medical treatment if needed.

This process was a multisectoral response led by different bodies and ministries of Jordan, including the National Center for Security and Crisis Management, MOH, Ministry of Interior, Ministry of Transportation, Ministry of Finance, Ministry of Water and Irrigation, and Zarqa Governorate.

After testing negative, Jordanian truck drivers were allowed to cross the borders into Jordan and deliver cargo within 12 hours before sharing their GPS location with MOH officers to confirm arrival at home. Drivers signed a pledge to remain quarantined at home for the following 14 days, with an option of expense-free, institutional quarantine at Dead Sea caravans if they could not guarantee a quarantine-appropriate household. During the quarantine period, dedicated MOH teams followed up with the drivers through phone calls, and the epidemiologic investigation teams performed PCR testing on days 7 and 14.

Government schools were converted into quarantine centers for Jordanian drivers with a bed capacity of 200, and a strategy to test drivers on days 0, 7, and 14 before discharge was implemented. On May 17, 2020, repurposed schools were replaced by 200 fully equipped caravans to host drivers for the 2-week quarantine period.

Although no scientific literature offered specific thresholds, national authorities aimed for the lowest number of cases in order to minimize the risk of community transmission of the virus.

During the study period, authorities in Jordan worked in collaboration with the Jordanian military forces in detecting possible hot spot epidemiological areas and applying measures, such as contact tracing, movement restrictions, and scheduled testing of suspected cases and contacts.

Cross-Country Collaboration

Cross-border risk communication complemented international contact tracing. Since the early phase of the COVID-19 pandemic, communication channels were built and orchestrated between Jordanian and Saudi International Health Regulations (2005) ¹⁶ national focal points by sharing information and signals via direct hotlines and official written letters for bidirectional updates and feedback. Additional communication and cooperation took place among border managers. Collaboration was established through auditing the epidemiological data of cases that had crossed the border to prevent duplication of case counts, and therefore ensure more accurate epidemiologic data. Jordan focal points were also responsible for reporting positive COVID-19 cases among non-Jordanian drivers and facilitating the transportation of drivers to the Saudi side of borders. For Jordanian drivers who tested positive or became sick after entering Saudi Arabia, they were admitted entry, upon prior agreement between the 2 countries' ministries of health, and received medical treatment in Saudi hospitals that maintained standard reporting.

Lessons Learned and Implications

This case study highlights critical recommendations to address in order to prepare for future public health emergencies. First, continuous and consistent information flow at POE can help tailor measures to mitigate the impact of emergencies at the regional level and can enhance national security. Second, implementation of joint cross-border activities, including risk assessments, drills, and simulation exercises, can further improve a coordinated, multicountry response to common threats.

Establishing onsite testing centers was an immediate move to address the shortcomings of sending samples to local laboratories. However, some issues did occur, such as delays in delivering samples and obtaining the results afterward, which in turn caused delays in the delivery of cargo at borders and placed a substantial physical and mental burden on drivers.

As pointed out by Parker et al, ¹⁷ although serious attempts were in place to minimize contact between drivers, these early mitigation measures were likely undermined by overcrowding at border crossings and delays in construction of the quarantine site at the Al-Omari border with Saudi Arabia. As a consequence, early cases and superspreading events associated with truck drivers occurred.

It is also worth mentioning that due to COVID-19 disease dynamics, POE screening will never be sufficient to prevent all cases from entering because travelers can be presymptomatic or asymptomatic when arriving at the POE or could be exposed while at the POE. Thus, mitigating the international spread of COVID-19, and any communicable disease, benefits from a layered approach of screening and community and healthcare facility collaborations.

Evidence, which Jordan has heavily considered throughout the pandemic,^18-20 and sustainable strengthening of surveillance and diagnostic capacities remain the standard baseline recommendation to substantiate public health decisionmaking, especially at POE where different sectors play important roles.