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Long COVID inquiry recommends action on clean indoor air

Introduction by Croakey: The Australian Government has been urged to act quickly to lead development of national indoor air quality standards, as part of wide-ranging recommendations for addressing long COVID concerns.

The House of Representatives Standing Committee on Health, Aged Care and Sport this week released the report of its inquiry into long COVID and repeated COVID infections, titled ‘Sick and tired: Casting a long shadow’.

The report makes recommendations in four key areas of federal government responsibility relating to long COVID:

  • research and surveillance
  • vaccination
  • antiviral treatments
  • indoor air quality and ventilation.

In relation to indoor air, the report states that the Committee was convinced by the “compelling evidence” it received 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.

It recommended that the Government establish and fund a multidisciplinary advisory body on clean indoor air, including ventilation experts, architects, aerosol scientists, industry, building code regulators and public health experts.

As well as developing national indoor air quality standards, the Committee recommended that this group oversee an assessment of the impact of poor indoor air quality and ventilation on the economy, with particular consideration given to high-risk settings such as hospitals, aged care facilities, childcare and educational settings.

For this article, Croakey editor Jennifer Doggett spoke with five advocates who have been calling for action on this issue since the start of the pandemic about their responses to the report and its recommendations.

*This article has been edited to include comments from Associate Professor Robyn Schofield.


Jennifer Doggett writes:

Poor indoor air quality and ventilation are unnecessarily contributing to or exacerbating COVID-19 transmission in a variety of settings, including schools and workplaces, the inquiry was told by many witnesses.

A key message of the report was that the importance of safeguarding air quality and ventilation has been overlooked so far in Australia’s response to managing COVID-19.

One reason given for this was the delay in recognising SARS-CoV-2 as an airborne virus by the World Health Organization. This did not occur until April 2021 – more than one year into the pandemic.

“The Committee shares the frustrations of many submitters and witnesses that the WHO’s delay in recognising COVID-19 as an airborne virus ultimately weakened the initial global response to the pandemic,” states the report.

It goes on to urge the Australian Government “from this point on” to consider improving Australia’s approach to managing indoor air quality and ventilation to help mitigate the impacts of long COVID and repeated infections.

The report also notes that this would positively benefit the health of all Australians beyond the COVID-19 pandemic in readiness for subsequent airborne threats such as smoke and pathogens.

While the report does not address in detail Australia’s framework or standards around air quality and ventilation, it outlines how responsibility for monitoring and managing air quality in Australia is largely split between state, territory and local governments, with the Federal Government playing a role in the National Construction Code, which covers minimum ventilation requirements for new buildings, building work, new plumbing and drainage systems.

“Australia’s states and territories have, throughout the pandemic, developed guidance on ventilation and air quality to assist with reducing COVID-19 transmission,” the report says. “However, implementing this guidance is voluntary and different jurisdictions have taken different approaches, resulting in inconsistencies across Australia.”

The Committee urged the Australian Government to 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.

Croakey spoke to four advocates for action on clean air who participated in the Inquiry: Colin Kinner, Director Clean Air accelerator; Karen Armstrong, Acting President of COVID-safe Schools; Professor Geoff Hanmer, Adjunct Professor, University of Adelaide; Associate Professor Robyn Schofield, University of Melbourne, and Distinguished Professor Lidia Morawska, Director, International Laboratory for Air Quality and Health

Broad support

All five expressed their broad support for the Committee’s focus on the role of clean air in preventing transmission of COVID-19 and the recommendation on the development of indoor air quality standards.

Schofield described the recommendations as “a great step forward” and stressed the importance of ensuring implementation was accompanied by strong operational standards with real time transparent monitoring of public, educational, hospital and care settings.

Armstrong said the report signalled a “welcome shift” in Australia’s response to COVID and expressed her gratitude to the Committee for the work that went into it.

“The report contained a much needed acknowledgement of the importance of addressing indoor air quality to reduce transmission. We were also pleased to see that it identified schools and education settings as a priority context,” she said.

Morawska told Croakey that she was “very pleased” with the recommendations on clean air as they reflect what she and her colleagues have been advocating for Australia throughout the pandemic.

Hanmer stressed the role that low ventilation had played in driving indoor infection during the pandemic, in particular in aged care settings, and said that the benefits of improved ventilation would “far outweigh the costs, including improvements in productivity, learning and general health, not to forget reducing COVID infections and mortality”.

Kinner agreed that the Report contained a “much-needed acknowledgement” that addressing indoor air quality will help to reduce COVID transmission but added that it “completely ignored” the fact that “Australia has widespread COVID transmission because the policy settings encourage and facilitate it”.

“Why is the Government still pursuing a pro-infection policy that exposes millions of Australians to repeat COVID infections, when one of the consequences is hundreds of thousands of Australians suffering from long COVID?”  he asked.

Kinner disagreed with the Committee’s call for a “summit” into Australia’s pandemic response, which he describes as a “public health disaster”, instead supporting a Royal Commission.

He also objected to the Committee’s call for “an assessment of the impact of poor indoor air quality and ventilation on the economy” [emphasis added], arguing that the primary consideration should be the impact on people’s health, with the economy as a secondary consideration (pointing out that these two are inextricably linked).

Advisory group membership

There was also broad support for the development of indoor air quality standards and the proposed advisory group, with some suggestions provided about its membership.

Kinner supported the proposed membership with the exception of industry representation, arguing that industry should be consulted on the standards but should not be part of the advisory body.

“It should go without saying that the appointments must be impartial and not in any way constrained from providing candid, public health-focused advice,” he said.

Armstrong said that COVID-Safe Schools supported the Committee’s recommendation on the creation of an advisory body and highlighted the need to involve people working on the ground in this process.

“Teachers know education settings intimately and can advise on priority areas for attention and potential problems with implementation,” she said.

Morawska agreed that the expertise listed in the recommendations is “pretty inclusive” and suggested that this group should first agree on the formulation of the questions necessary to gather the evidence, the process, how it will be done and the pathway to national standards.

Hanmer recommended that consultation with the Australian Building Codes Board will be important to ensure the standards are effective and Schofield highlighted the need for expertise in operational compliance and real time monitoring, as well as a role for the Group in education and communication.

Implementation issues

A common view among the advocates was that the Government should move quickly to develop and implement clean air strategies, based on a robust body of research on this issue.

“Speed matters,” said Kinner. “There is no reason we shouldn’t implement air quality standards very quickly, and refine them over time. Australia has some of the world’s leading experts. We can also look to countries such as Belgium and France which are already putting standards in place. I would be very concerned if we are still talking about air quality standards in the future tense in six months’ time.”

Armstrong also argued for swift action, saying that the case for clean indoor air has already been “extensively demonstrated” by the research.

Schofield highlighted some of the challenges the Government will face, given that currently no one regulates operational indoor air or reporting at the moment. She suggested looking to the CO2 standard non-compliance mechanisms used in Belgium and France to understand what works or doesn’t. She also stressed the need to address the gap between who pays and who benefits needs to be addressed by weighing the health benefits against the developers’ costs.

Hanmer suggested that the highest priority for the implementation of the proposed standards should be naturally ventilated buildings which contain a high density of people, such as schools and aged care facilities.

In evidence provided to the Committee, he explained that buildings in Australia are required to be either naturally or mechanically ventilated. It is in those deemed to be “naturally ventilated” that Hanmer said people are most at risk of COVID-19 infection.

“One problem is that natural ventilation relies on people opening windows and when the weather is too hot or cold – which is often – this does not occur.  When windows are closed, a heater or air conditioner simply moves contaminated air around which increases the spread of infection.

“Another problem is that the current building standards specify the ratio of window to floor space in a building without taking into consideration the number of people likely to be using it. This means that a school assembly hall with hundreds of students crowded in together has the same requirements for the area of windows as a private home,” he said.

Due to these factors, Hanmer identified naturally ventilated buildings where large numbers of people congregate as high risk for COVID transmission.

“These are the buildings that I am most worried about as from measurement in the field, they have the worst air quality. Along with schools, aged care facilities should also be a priority given the high vulnerability of residents to COVID-19 and other respiratory viruses,” he said.

Focus on schools

Armstrong also suggested schools should be a focus for the implementation of clean air standards and welcomed the inclusion of schools in the report as an important context for action on clean indoor air.

However, Armstrong expressed concern that the recommendations did not provide sufficient detail on the strategies required to improve air quality in schools.

“I would have liked to see the Committee respond to this research with a clear recommendation on a major infrastructure project to deliver HVAC [heating, ventilation and air conditioning] in every school and learning space or, at the very least, recommend CO2 monitors and HEPA filters in classrooms.

“We could do this straightaway for an estimated cost of only around $23 per student per year. Given the impact that COVID and long COVID are causing [for the] teaching workforce – teachers leaving or missing classes because they or a family member is are unwell – this seems like a small price to pay,” she said.

“Also missing in the report is a recommendation on the need for education and training for school staff to ensure they know how to use clean air equipment and for a public health campaign on the health benefits of clean indoor air.”

In addition she stressed the collateral benefits of improving air quality in schools.

“HVAC will provide thermal comfort and help reduce the health impacts of air pollution due to external causes, such as bushfire smoke,” she said.

Kinner welcomed the report’s acknowledgement that children may be at greater risk from repeated COVID infections, but said he would have liked to see the Committee recommend the development of a national plan for schools to reduce COVID transmission, along with an education campaign and funding to implement ventilation assessments, widespread use of air purifiers and free access to N95 masks.

“Given the mounting evidence of COVID’s long-term impacts on kids, there is a very real risk that the current ‘let-it-rip’ policy could compromise the long-term health of an entire generation of children,” he said.

“Schools are the one place where ‘personal responsibility’ doesn’t exist. Kids have no choice but to spend many hours a week in classrooms, breathing shared air. In most schools, few if any students or teachers are wearing masks, and the level of knowledge about ventilation or use of HEPA filters to reduce transmission is, on average, extremely low,” he said.

Gaps identified

Kinner identified some gaps in the report, including a lack of recommendations on misinformation, mask-wearing and public health information campaigns.

He was disappointed the report failed to acknowledge the effect of misinformation on the spread of COVID, such as “statements from public health officials and politicians to the effect that COVID is ‘not exceptional’ and can be treated ‘like any other respiratory illness.’”

“These statements are demonstrably false, and have contributed to the widely held (but incorrect) perception that COVID is a mild illness that people don’t need to be concerned about,” he said.

In relation to mask-wearing, Kinner said it was a “huge mistake” the Committee did not make a recommendation on this issue, including on the reinstatement of mask mandates in healthcare settings, which he said is “inexcusable” and a clear breach of the Australian Charter of Healthcare Rights which states that all people have a right to access care that meets their needs and is safe.

“High-quality N95 masks have an important role in reducing COVID transmission, and people’s reluctance to wear them is in large part due to the poor public health messaging and an unwillingness to mandate them in high-risk settings. The report passes the buck to the states on this, noting that mask mandates are largely at the discretion of the states and a matter of ‘individual responsibility’,” he said.

Kinner also expressed support for a broad public information campaign which informs people about the real risks of COVID, the seriousness of long COVID, and how they can avoid infection.

Government response

The Government has not formally responded to the Committee’s recommendations but after the report was released, the Minister for Health, Mark Butler, announced an additional $50 million for research into long COVID and noted that his Department had been tasked with developing a national plan to respond to Long COVID, taking into consideration the committee’s findings.


See here for previous Croakey coverage of long COVID
Also see this recent story:
Landmark event highlights indoor air quality as important health concern

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