Introduction by Croakey: This is no time for complacency on COVID-19, public health leaders have warned in Europe, urging governments there to do more to protect vulnerable people.
This includes urgently investing in improving ventilation and indoor air quality in healthcare and other settings, and revisiting surveillance and monitoring systems, they write in The Lancet.
Excess mortality, although not only attributable to COVID-19, remains unacceptably high. As well, persisting absenteeism from work linked to COVID-19 and to other circulating respiratory viruses since the lifting of public health measures has had negative effects on European economies, they say.
Meanwhile, as coronavirus transmission continues to be an issue in healthcare and aged care in Australia, all levels of government are being urged to implement a national approach to clean air in indoor settings.
This is the final article in a series investigating safety in health and aged care in the era of COVID-19. Read the first article here.
Jennifer Doggett writes:
Australia does not have a nationally consistent approach to healthcare-associated infection surveillance so data on the transmission of COVID – or any other infection – in healthcare settings is patchy. State and territory governments have also taken different approaches to the ways they disseminate data on the spread of COVID in public hospitals.
This report from the Victorian State Government from the first year of the pandemic identified 277 patients as having COVID-19 infections acquired in hospital between 25 January and 15 November 2020. During the same period, 2,492 cases were hospitalised with COVID-19 in Victoria, equating to around one hospital-acquired infection for every nine patients hospitalised with COVID-19.
This data has not been updated since 2020 but according to information obtained by NSW lawyer Peter Vogel under FOI, COVID-19 transmission is still an issue within Victorian hospitals. Vogel is a NSW solicitor with The People’s Solicitors and father of school-aged children. He advises Covid Safe Schools Inc and assists parents and teachers with concerns about poor COVID safety at schools. He is also acting for Covid Safe Schools in cases before the NSW Administrative and Equal Opportunity tribunal involving disability discrimination and access to government information.
The data Vogel obtained shows that during 2022, 4,477 people caught COVID-19 in a Victorian hospital, of whom 466 people died. This equates to more than one death each day and a case fatality rate of 10 percent.
He has attempted to obtain the same information from NSW and Commonwealth Department of Health but has been told that they do not have that information.
Data on COVID transmission in aged care facilities is more systematically collected and has repeatedly demonstrated a high level of transmission. Australia had one of the highest global total percentage rates of death from COVID-19 within residential aged care facilities during 2020 at 75 percent.
High level of transmission and the impact of COVID on aged care residents has continued throughout the pandemic. Aged care residents account for nearly 30 percent of the 11,000 deaths from COVID in Australia to date in 2022.
The latest data from the Department of Health shows that at 1 June 2023 there are 3,782 active COVID-19 cases in 476 active outbreaks in residential aged care facilities across Australia.
Evidence for clean air
Improving indoor air quality and ventilation helps reduce the transmission of COVID and other airborne viruses and threats that are transmitted via smaller aerosol particles. While larger respiratory droplets tend to fall to the ground or surfaces relatively quickly, aerosols can accumulate, particularly in enclosed spaces.
Studies have shown that the risk of infection and disease severity is influenced by the viral load (the amount of virus present in the body at the time of exposure). Clean air and improved ventilation can lower the overall viral load in a given environment. By reducing the concentration of viral particles in the air, the exposure and subsequent infection risk may be decreased.
At the recent Clean Air Forum held at Parliament House, experts discussed Australian and international research on the benefit of clean indoor air for health, academic performance and business productivity.
The aerosol transmission of COVID-19 and the role of clean air in preventing transmission is widely accepted by the scientific community and is being acted on by governments and regulatory agencies worldwide, including the US Centers for Disease Control and Prevention. They extensively updated its ventilation guidance on helping prevent indoor transmission of the virus that causes COVID-19.
The agency had advised people to ventilate indoor air before, but this is the first time a federal agency has set a target – five air changes per hour – for how much rooms and buildings should be ventilated.
Information on the importance of ventilation to prevent COVID-19 transmission has also been conveyed to governments in Australia, for example, through advice from the Victorian Chief Health Office to Premier Daniel Andrews in August 2022, which highlighted the increased risk of COVID-19 transmission in crowded, enclosed, poorly ventilated spaces and cited evidence supporting the role of ventilation in reducing the risk of transmission.
The need for a national approach
Because Australia lacks a national approach to clean air in indoor settings there is no single source of data on air quality in health and aged care settings. But experts in the area agree that poor air quality is a major factor in the spread of COVID-19.
Professor Lidia Morawska, who recently won the 2023 L’Oréal-UNESCO for Women in Science Laureate for Asia, provided evidence to the House of Representatives Standing Committee on Health, Aged Care and Sport Inquiry into Long COVID and Repeated COVID Infections highlighting the growing body of research supporting the importance of ventilation and filtration in indoor spaces to reduce COVID transmission:
Scientific understanding of the role and mechanism of airborne infection transmission was well advanced before the pandemic. During the pandemic and since the start of the pandemic, there has been an explosion of science on this virus. The whole field has significantly advanced.”
Professor Geoff Hanmer, Director at OzSAGE and Adjunct Professor within the School of Architecture at the University of Adelaide, told the Inquiry that poor ventilation in aged care facilities is playing a part in the “unacceptable” numbers of deaths among residents:
During the second winter wave in Victoria, about 700 residents died in residential aged care facilities. In the cold Melbourne winter, windows were shut, ventilation was minimal and COVID was able to accumulate in the air, a bit like smoke. When an infected person entered a facility it proved impossible to stop the infection spreading.“
In its final report, the Committee acknowledged the “compelling evidence” from submissions and witnesses that poor indoor air quality and ventilation leads to increased risk of COVID-19 infection. From this, it was convinced of the role that good air quality and ventilation play in preventing the transmission of COVID-19, and therefore in preventing long COVID and repeated COVID infections.
The Committee urged the Australian Government from this point on to consider improving Australia’s approach to managing indoor air quality and ventilation which it said would help mitigate the impacts of long COVID and repeated infections, and positively benefit the health of all Australians beyond the COVID-19 pandemic in readiness for subsequent airborne threats such as smoke and pathogens.
In particular, it recommended that the Australian Government act quickly to establish consistent indoor air quality regulation, working with the states and territories, while taking advice from ventilation and multidisciplinary experts and following international best practice. The report also stated that the Committee believes that national Indoor Air Quality Standards would be beneficial.
The Department of Health told Croakey that the Government is considering the report recommendations and will respond in due course including through a National Plan to respond to long COVID.
A regulatory “no-man’s land”
Part of the complexity of this issue is that in Australia, the responsibility for indoor air quality is shared among various entities, including governments, building owners and employers. Even among a single level of government, responsibility is split across different portfolio areas, statutory authorities and regulatory bodies.
This current approach to indoor air quality has been described as a regulatory “no man’s land” by Morawska, who for years has argued for a nationally consistent approach to clean air policies and programs.
Relevant standards and guidelines in this area include:
- the National Construction Code (NCC), developed by the Australian Building Codes Board, which includes specific standards for ventilation, including air exchange rates, air flow and air filtration systems, temperature, and ambient humidity
- the Australian Health Facility Guidelines (AHFG), developed by the Australian Health Ministers’ Advisory Council which includes specific requirements and recommendations related to ventilation, air quality, and infection control to maintain a clean indoor environment, and
- the National Safety and Quality Health Service (NSQHS) Standards developed by the Australian Commission for Safety and Quality in Health Care (ACSQHC) which states that health services must comply with Action 3.08 of the Preventing and Controlling Infections Standard, requiring environmental control measures, such as effective ventilation systems, to be in place to reduce the risk of infection transmission.
Sitting behind these are nationally accepted standards for ventilation developed by Standards Australia, including Australian Standard AS/NZS 1668.2:2012. This standard provides guidance on ventilation system design in various buildings, including healthcare facilities and covers aspects such as air change rates, filtration, and control measures to maintain clean indoor air quality. This and other Australian Standards are referenced by NCC, AHFG and NSQHS Standards.
Initiatives within health portfolio
Additional initiatives focussed on the issue of clean air and COVID transmission within the health portfolio include a statement developed by the Australian Health Protection Principal Committee (AHPPC) on the role of ventilation in reducing the risk of transmission of COVID-19.
The Department of Health told Croakey that the AHPPC has also tasked its Environmental Health Standing Committee to look at indoor air quality and this is expected to consider a number of different environmental hazards and settings.
They also said that in response to Recommendation 45 of the Royal Commission into Aged Care Quality and Safety, the Government is consulting with older people, the aged care sector and design experts to improve the design of residential aged care accommodation.
This includes developing a new Residential Aged Care Accommodation Framework and National Aged Care Design Principles and Guidelines to guide the design of the most appropriate aged care accommodation to help improve quality of life for older people. Clinical supports and safety features, including infection prevention and control measures and good ventilation will be considered as part of this process.
A spokesperson from the DOH said:
The National COVID-19 Health Management Plan and National Statement of Expectations on COVID-19 Management in Aged Care Settings was released in December 2022. It provides nationally consistent principles and best practice guidance to the aged care sector on their responsibilities for preparing for and responding to COVID-19 outbreaks.
It also sets out and reinforces the Commonwealth’s expectation of the actions aged care providers should take when preparing for and responding to COVID-19 outbreak situations.”
Safety in healthcare
ACSQHC has also undertaken additional work to support health service organisations improve indoor air quality and effective ventilation to help reduce circulating infectious particles in the air.
This includes developing guidance to explain the importance of effective ventilation systems for preventing and controlling infections and how ventilation risks can be mitigated to improve patient and workforce safety, along with a range of other resources to support implementation of systems and practices that reduce the risk of transmission of COVID-19 in healthcare settings.
While this will all help improve indoor air quality, it is insufficient to provide consistently clean air across all health and aged care facilities.
This is partly because of the standards themselves, which have gaps in their content and application – for example, the NCC only applies to new buildings and ventilation standards do not apply to naturally ventilated buildings (most aged care facilities and general practices). Additionally, there is insufficient monitoring and enforcement of their implementation across health and aged care settings.
Also part of this landscape are occupational health and safety (OHS) regulators, including Safe Work Australia and state-based authorities. Safe Work Australia has published a National guide for safe workplaces – COVID-19 which includes information on ventilation and heating, ventilation and air-conditioning (HVAC), and more detailed stand-alone guidance on ventilation and HVAC.
Legal implications
For Vogel and others advocating for action on clean air, OHS legislation and regulations provide the most promising mechanisms for making progress, in the absence of a comprehensive national policy.
Vogel says that the legal obligations of those running health services is clear.
According to occupational health and safety law, a person conducting a business or undertaking has to do everything reasonably practicable to reduce the risk of injury in the workplace. In the case of a hospital this applies to staff, patients, visitors, and anyone else would walks through the front door. From a safe work point of view, simply complying with whatever health orders or advice may have been issued by health authorities is not sufficient to discharge the duty.”
According to the healthcare workers contacting Vogel, hospitals and healthcare settings around Australia are currently taking a very inconsistent approach to COVID mitigations.
Because they are subject to gag orders, they can’t speak up, Vogel told Croakey. However, they have contacted him “at their wits end” due to the unsafe conditions for staff and patients, sometimes caring for patients in beds next to patients with COVID, “separated only a curtain”.
Vogel also told Croakey that state health departments often don’t appear to know what is happening in their public hospitals in relation to clean air.
He said he sought information about the number of HEPA filters in public hospitals from NSW Health under the Government Information Public Access (GIPA) Act. He was told they didn’t know this information as it was handled by local health districts (LHDs).
He then tried to obtain information from the LHD’s under the GIPA and “got an extremely varied response – some have made piecemeal efforts to improve air quality in their facilities but there has been no coordinated effort across the state and direct instructions from the state government”.
Vogel warns of the potential for hospital and healthcare operators to be sued by people infected by COVID in these settings.
“I’m just waiting for the lawsuits to roll in,” he said, arguing that we shouldn’t have to wait until this occurs to take action. Vogel suggested that Safe Work Australia could step in now and order hospitals to measure and improve air quality.
“If asbestos were discovered in a hospital tomorrow, no-one would argue about the cost or inconvenience of taking action. The hospital would be ordered to remediate it even if no-one could demonstrate that anyone had contracted mesothelioma from exposure or if only one person was expected to get it in 50 year’s time. This is the approach we should be taking to prevent COVID transmission,” Vogel said.
Differing views
Another challenge facing governments are the differing views among experts and key health stakeholder groups about the urgency of this issue and the best strategies for improving air quality in health and aged care settings.
Croakey spoke to two experts who agreed that preventing airborne transmission of COVID was important but had contrasting positions about the actions that should be taken by healthcare providers.
Professor Brendan Crabb is an infectious disease researcher, CEO of the Burnet Institute and a member of OzSAGE, a multi-disciplinary network of Australian experts from a broad range of sectors relevant to the wellbeing of the Australian population during and after the COVID-19 pandemic.
He told Croakey that until indoor air quality is prioritised and regulated, “COVID-19, and other airborne pathogen transmission, such as influenza, will remain an ongoing challenge in health and aged care settings, resulting in preventable illness and death.”
Crabb described the current situation in healthcare as a paring back of many protective measures – such as testing, isolating, reporting and in some cases, masks – without leveraging other crucial tools, such as ventilation and air purification.
He believes that we have the means to reduce this risk – an approach he described as focussing on reducing transmission of COVID and airborne pathogens (breathing clean air through enhanced ventilation, air purification and high-quality masks) and interventions to reduce illness and severity (vaccination, testing and treatment).
Crabb strongly supports the need for increased action prioritising settings where there is risk of higher transmission and/or people at greater risk of worse outcomes, including hospitals, residential and disability care, schools and education, corrections and justice, and public transport.
“Hospitals should be safe. Prior to the pandemic, any nosocomial infection was taken seriously, and steps immediately taken to prevent recurrence. The approach to COVID-19 infections in health settings should be no different.”
He strongly supports the long Covid inquiry’s recommendation on national air quality standards and would like to see this as an immediate action for governments, led by the commonwealth and supported by the states.
Along with other experts in this area, Crabb supports a multi-step approach to the development of these standards, involving high level political commitment, a multidisciplinary working group, standards that can be monitored and regulated, support for implementation, public communication and ongoing research and evaluation, including supporting new technology and Australian innovation.
He references the national response for hand hygiene to combat bacterial infections of IV lines in hospitals as a framework which could be leveraged to comprehensively address COVID transmission in healthcare.
Longer term, Crabb would also like to see a focus on hospital building design and engineering controls, as well as newer technology, such as germicidal ultraviolet light (GUV).
He stressed the importance of using multiple risk mitigation strategies to protect health and aged care residents, including combinations of engineering and non-engineering controls (visitor restrictions, masks, screening, testing, vaccination) in order to optimise effectiveness, cost, and energy use.
“The COVID-19 pandemic has heralded a paradigm shift in our understanding of the importance of airborne transmission of respiratory viruses, and the role of key mitigation measures such as ventilation and filtration. The potential impact of these design and management elements has been previously underestimated but the burgeoning research and scientific literature is significantly strengthening the evidence base.
“This will become increasingly relevant into the future, with growing societal and industry awareness of existing and emerging airborne pathogens beyond SARS-CoV-2 and the broader benefits of healthy indoor air including mitigating allergy and pollutants and improving performance and cognition,” Crabb said.
RACGP position
Crabb’s position on the urgent need for action on clean air in health and aged care settings contrasts with that of Professor Mark Morgan, a GP with a senior leadership role in Royal Australian College of General Practitioners as the chair of the Expert Committee for Quality Care. He is also the Associate Dean for External Engagement at Bond University and teaches within the Medical Program.
Morgan described how he and others working in healthcare during the earlier stages of the COVID-19 pandemic noticed that there was a reduction in influenza and colds among patients due to the COVID-19 prevention measures in place.
“There’s no doubt that these measures reduced the spread of COVID-19 and other respiratory infections but they came at a significant cost to people’s personal freedoms. As we move into a different pandemic environment, we need to remember these lessons but also recognise that COVID-19 is not the threat it previously was, given there are vaccines and treatments available.”
Morgan told Croakey there is a role for evidence-based guidance in this area, just as there is with other infection control measures, and he references information developed by the RACGP for GPs and practice owners.
This includes COVID-19 infection control principles (focused on testing and treating a suspected positive COVID patient) and a COVID Safety Plan template which has the following advice on ventilation:
enhance air flow by opening windows and doors in shared spaces (where and when appropriate) and optimising fresh air flow in air conditioning systems (by maximising the intake of outside air and reducing or avoiding recirculation of air)”
The RACGP has also produced general guidance on infection control for practices, including Infection prevention and control guidelines which advise that “Common sources of cross-infection in general practices and other office-based practices include poor ventilation or poor respiratory hygiene/cough etiquette by patients or staff” and a Winter Planning Toolkit which suggests practices aim for “ventilation that delivers 6-8 fresh air changes per hour and using High-Efficiency Particulate Air (HEPA) filters”.
Morgan believes that this sort of evidence-based guidance is better than a strict rules-based approach to air quality standards which might result in unintended consequences, such as increased costs, and end up as a net negative.
“There’s a lot we don’t know about what works and doesn’t work – from the basic science of how infectious agents survive in the air and how to clear them and how to reorganise practices to how to implement mitigations at scale. The research isn’t clear on how to effect change across the whole country and we are in danger of jumping the gun if we go straight to policies and procedures without understanding the consequences and real benefits we are achieving,” Morgan said.
He argued that from a patient perspective, it’s important to minimise exposure without creating additional problems and pointed out that people experience many potential COVID-19 exposures in everyday life from going to supermarket, using public transport or in other settings such as the gym or church.
“It’s reasonable to expect people with symptoms working in a health setting to stay home or mask up to reduce spread to patients. It’s reasonable for practices to make clear to patients what they are doing to minimise the spread of COVID-19 and other airborne infections. But we have to be careful about mandatory requirements unless they are evidence-based. Sometimes things that seem like a good idea can make no difference at all or even have unintended adverse impacts,” he warned.
Underlying policy approach
Also important to consider is the broader COVID policy context in which the issue of clean air is being debated.
This policy has shifted since the earlier stages of the pandemic when there was a clear goal to reduce or eliminate transmission. Colin Kinner, Director of Clean Air Accelerator, described the current policy as a “pro-infection” public health policy.
“Australia’s current pandemic response hinges on facilitating COVID infection on a massive scale in an attempt to achieve population-level ‘hybrid immunity’.”
Kinner told Croakey that hybrid immunity is based on a hypothesis that “getting most people vaccinated and then having them infected repeatedly will lead to a lower disease burden and eventually an end to the pandemic”.
“We need to be clear that this is a net harm policy, and one that experts have been describing as “not scientifically sound” and “a dangerous fallacy unsupported by scientific evidence“. Yes, people get some degree of immunity from infections, but that immunity is short-lived, doesn’t translate well to new variants, and comes with devastating consequences. Sadly last year this included more than 10,000 people dying from COVID,” he said.
Kinner also argued that the current national strategy fails to recognise that high-risk people are part of society, and that all parts of society are rife with infection due to a lack of mitigations. “Australians with chronic health conditions need to access healthcare, but doing this exposes them to unacceptable risk.”
This view was also discussed in a recent episode of the Democracy Sausage podcast, featuring Crabb in conversation with political journalist Mark Kenny and journalist and academic Professor Chris Wallace.
The panel discussed this policy shift, quoting Chief Medical Officer Paul Kelly’s comments late last year about moving away from “COVID exceptionalism” when discussing the government’s National COVID-19 Health Management Plan for 2023.
Crabb described the current policy as “quite dystopian” having been developed without an “honest conversation” about the cost of this strategy on the Australian community.
He also described how this policy informs other failures of our current COVID strategy, such as the lack of a public information campaign about COVID transmission, asking: “Why would you promote public health information when your strategy is to promote infection?”
Kinner also sees this policy as the key underlying reason why evidence-based actions to reduce transmission, such as mask mandates and better ventilation, are not being implemented. He also nominates a lack of knowledge among health professionals about the route of transmission of COVID as another factor, suggesting a role for education for them and the general community.
“Many in the community, including healthcare professionals, don’t understand the risks of COVID (including long COVID) or that COVID spreads mainly via aerosols and not by touching contaminated surfaces. We’re in the fourth year of an airborne pandemic, and it is just unbelievable that hospitals are still full of signs asking you to wash your hands.”
In response to the differences between stakeholders about the need for action on clean air, Kinner argues that the science is clear and should not be a matter for debate. “There is no rational basis for arguing against filtered indoor air in an airborne pandemic,” he said.
Also read: Why more needs to be done to reduce COVID-19 transmission in health and aged care settings.
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