Another city, another lockdown as coronavirus escapes from hotel quarantine in Perth.

COVID-19 wrap: how can we improve quarantine safety?

Melissa Sweet
Wednesday, November 18, 2020

COVID-19, COVIDwrap, Public health

As South Australians enter a hard lockdown, for six days at this stage, public health researcher Alison Barrett provides a timely overview of recommendations for improving quarantine systems in the latest edition of the COVID-19 Wrap.

National review of hotel quarantine

Australian Government Department of Health, 23 October 2020

As international COVID-19 cases surge, especially in Europe and North America, and the capacity for international arrivals into Australia has increased, the need for quarantine systems to be tightly managed is vital. We need to minimise the risk of importation of COVID-19 cases into the community, and also protect the health and wellbeing of returned travellers.

The unsuccessful hotel quarantine program in Victoria and current outbreak in South Australia (SA), linked to hotel quarantine, highlight how easy it is for the virus to move in to the community from hotel quarantine.

To manage and control the current and any future outbreaks, and ensure Australia returns to minimal community transmission, it is imperative that an efficient contact tracing team complements a tightly-managed hotel quarantine program.

SA Premier Steven Marshall and Professor Nicola Spurrier, SA’s chief public health officer, highlighted in a press conference on November 18 that contact tracers have been working around the clock, and since Saturday, identified 22 confirmed cases linked to the same cluster. At the time of publication, SA had 35 active cases with two patients in hospital.

A review of hotel quarantine, one of the key components of Australia’s coronavirus management plan, was published in October 2020. The review examined hotel quarantine programs in all States and Territories except Victoria, which has a separate inquiry underway, and highlights some of the key features of, and recommendations for, the continuation of the program.

Key findings include:

Between March and October, 130,000 domestic and international travellers have been quarantined in Australia, usually at a designated facility in their arrival location.
Each State and Territory adopted their own approach to implementing their quarantine program that was consistent with its administrative, policy and health arrangements, all established at short notice and scaled up as the public health emergency increased. Most States/Territories operate their quarantine program out of hotels. NT quarantines returned travellers in a former mining camp, Howard Springs Accommodation Village, and in the ACT, most quarantine is undertaken in private homes with supervision.
Traveller feedback indicated it was a challenge to find information about the hotel quarantine program on government websites.
Depending on what airline they travel with or where they board, some travellers may have no knowledge of the hotel quarantine program until their arrival into Australia when Australian Border Force and/or Human Biosecurity Officers board the plane to deliver a briefing about the quarantine requirements. They are therefore often unprepared for quarantine.
As per Australian Health Protection Principle Committee guidelines, returned travellers are tested for COVID-19 on the second and eleventh day of their stay, and only allowed to be discharged if two negative results are returned.
A specialised workforce that includes security, clinical and welfare staff are necessary for the running of the program.
Support for mental and physical health needs to be well integrated within the quarantine programs, available to travellers and should not be reliant on them needing to reach out for assistance.
Regular access to fresh air is important for wellbeing, and hotel infrastructure should enable the guest to access this independently.
Variations exist between jurisdictions in the standard of health screening and care of the traveller, clinical oversight in the facilities, and access to fresh air and exercise.

In the review, “many people reported, while challenging, the experience of quarantine was acceptable. The care provided by health and hotel staff was widely acknowledged; however, a lack of fresh air, support for mental health and the quality of hotel food also featured in feedback.”

Under the Biosecurity Act 2015, the Commonwealth Chief Medical Officer can request quarantine of individuals to manage risks to human health, such as from COVID-19. The legal justification for quarantine, as with any restriction to human movement, needs to be communicated clearly to returned travellers and open to review, as discussed in this COVID-19 Wrap.

In the period up to 28 August, 90 complaints about aspects of the quarantine program had been made to the Human Rights Commission and 218 to the Ombudsmen, including complaints about lack of access to fresh air, food, the cost and access to medical support.

The review says that: “Hotel quarantine is difficult to endure, particularly for vulnerable people,” such as those with disability, addictions, mental ill-health, the elderly and those travelling with children. Quarantine programs need to ensure adequate health and psychosocial screening is completed upon arrival into Australia to enable appropriate support throughout their quarantine.

Six key recommendations were made in the review, of which two have already been acted upon (recommendations 5 and 6):

States and Territories should aim to continuously review and improve their hotel quarantine program and ensure it is delivered following good practice.
Information about the quarantine requirements and program, including clear lines of accountability and risk ownership should be easily accessible to travellers so they can gain a clear understanding of the requirements and they can better prepare themselves for the experience.
Information about decision making, review processes and pathways for escalation should also be easily accessible to people in quarantine.
Options for new forms of quarantine should be developed for consideration by National Consideration, that include a risk assessment of the options and analysis of suitability for the traveller.
Travellers from low risk areas, such as New Zealand, should be considered for exemption of mandatory quarantine. As of 16 October, New Zealanders are allowed to travel into some jurisdictions in Australia without quarantining.
A national facility should be considered by the Australian Government that can be used in case of urgent scalability, and/or emergency situations. As of 15 October, the Howard Springs accommodation facility in Northern Territory was set up to help stranded Australians return back home.

To date, hotel quarantine programs have proven mostly effective in preventing importation of COVID-19 into the community. However, with the increase of returned travellers, current quarantine programs are likely to be pushed to their maximum limits.

Overall, the review found that most of the hotel quarantine programs in Australia were high standard. However, with the need for quarantine programs to remain in place until a vaccine is available, aspects of the program should be improved to ensure the health and wellbeing of returned travellers and to minimise breaches.

The full report, including details on who governs the program in each jurisdiction, can be viewed online.

The science of superspreading

Enserink, M, Kupferschmidt, K, Desai, N, Science Mag, 30 October 2020

Superspreading events have been reported throughout the pandemic, occurring in all kinds of places and events, such as bars, nightclubs, cruise ships, the White House, and conferences.

Studies in India and China have found that while most people don’t infect many, if any, other people, a small percentage of infected people cause the majority of secondary cases. For example, in the Chinese study, they estimated that ten percent of patients caused eighty percent of secondary cases.

It is not fully known why some people spread the virus more than others; however, it is possible it may be from asymptomatic patients or those that may have such mild symptoms they don’t realise they have COVID-19 and fail to self-isolate or seek medical care.

Events and conditions that favour superspreading include shouting, singing, and heavy breathing within close proximity of other people, especially when in a location with poor ventilation.

To help control the pandemic, it is important to stop superspreading events from occurring by getting tested even with the mildest symptoms, avoiding events and conditions that don’t enable physical distancing from others, wearing masks and following other hygiene etiquette.

Contact tracing is also important; however, as the authors point out, when tracing contacts of an infected person, it is likely that person did not infect anyone and no other infected people will be found.

It then becomes important to do what is called ‘backward contact tracing’ to determine where someone was infected and find other people infected from the same cluster. This is also one of the 22 recommendations the National Cabinet accepted made by the national contact tracing review.

“Backward contact tracing also helps scientists better understand where superspreading events happen,” the authors conclude. “That may help prevent more such events in the future.”

The national contact tracing review can be viewed online here.

Alison Barrett is a Masters by Research candidate and research assistant at University of South Australia, with interests in public health, rural health and health inequities. Follow on Twitter: @AlisonSBarrett. Croakey thanks her for providing this column as a probono service to our readers.

See previous editions of the COVID wrap.