Experts have their say on how we should fix quarantine program

Following the third breach in hotel quarantine in less than a week, epidemiologists are warning the system is not equipped to stop super strains escaping.

Epidemiologists say Victoria’s current quarantine system is not fit to contain super-strains of coronavirus, after two workers and a traveller were infected in the hotels in a fortnight.

Three experts — the University of South Australia’s Adrian Esterman, Deakin University chair of epidemiology Catherine Bennett, and Melbourne University public health expert Tony Blakely — detailed the quarantine issues and how to fix them.

Are Victoria’s quarantine hotels fit for purpose, particularly in containing variants of the coronavirus?

AE: No – they were not designed for this, and were only chosen because of the need to act fast.

CB: We are still identifying areas of transmission risk and need to thoroughly investigate to understand these, and then design them out. Would this have happened in other types of quarantine facilities? This is not yet clear. If we cannot mitigate these risks in hotel settings, then we will need to look at alternatives.

TB: Yes and no. Yes, in that as a rapid solution to a global pandemic in 2020, they were an obvious resource to utilize. During 2020, we had roughly one breach of the virus out of hotel quarantine per month somewhere in Australia. And this was (other than, and after, the Melbourne second wave) able to be managed with contact tracing and stamping it out.

But things have change. We are now seeing an increased frequency of breaches from hotel quarantine. Some of this may be random variation, but some of it is at least due to a higher rate of SARS-CoV-2 infection in people arriving at our borders (due to worsening situation in other countries) and more infectious variants.

Standing guard outside the Grand Hyatt hotel as tennis players and officials arrive for a two-week quarantine period ahead of the Australian Open. Picture: AFP

What are the key issues?

AE: Location in the middle of a city is not a good idea. Traditionally, quarantine stations have been located in remote areas for a very good reason. With a virus that can be transmitted by aerosol, the ventilation systems are a major problem.

CB: Ventilation, especially in corridors, PPE use by workers and testing between shifts have all been identified as areas still needing work this week here and in other states. Lack of access to fresh air remains an issue in many hotels also.

TB: We need to improve. We need to keep up, and even ahead, of the virus. Three actions are paramount:
1. As much as we can, expanding capacity in purpose built or ‘better’ facilities such as Howard Springs – and preferentially sending higher risk people to these facilities (where there is better natural ventilation, and lesser opportunity for aerosol transmission in dead spaces like corridors, and to separate out of CBD with staff also located outside of CBD).

2. We will still need to use CBD HQ as well. So we just keep on learning, and keep on improving. For example: set up an independent agency that visits and inspects quarantine on a regular basis, reporting openly and publicly, and making recommendations to improve; improve ventilation; cohorting – people on one corridor should all have arrived on same day, for example; and further improvements in facility such as mask wearing, staggered opening of doors.

3. Vaccinate the border as priority. This is already the plan – good. With Pfizer, we would expect 70% to 80% (indicative only) reduction in the chance a quarantine worker is infected and able to carry the virus out of hotel. We hope this vaccination will occur in first week of March, with benefit occurring by end of March.

Should the quarantine programs be moved to regional or remote areas?

AE: Yes – better ventilation, less risk to the general population.

CB: We need to create a checklist of all the design and operation requirements for safe hotel quarantine — purpose built or adapted. The actual location is a secondary consideration if the transmission risk is very low and the movement of workers back to the community is managed, minimised and monitored. There may not be a need to move the facility to a remote setting if workers stay on site between shifts and are regularly tested. Remote settings comes with their own problems – access to medical and other care, not just COVID-19 related and organising safe transport to and from airports and other ports.

TB: As above.

The Melbourne Airport Holiday Inn is the latest hotel to have been linked to a quarantine breach.

Should CCTV cameras replace guards in hallways to monitor travellers in hotel quarantine?

AE: Guards will still be needed for other reasons.

CB: We should look at any alternatives that remove the need for someone to be near guests doors that are opened multiple times. CCTV will be part of that and should be on all floors and all hotels. But these support staff aren’t just providing monitoring so it may not be as simple as just having CCTV.

TB: Yes – where the balance of risks and benefits supports it. Each situation will require its own assessment, but the starting position has shifted from “have security guard on corridor” to “use CCTV”.

Should all workers in hotel quarantine be wearing the N95 masks and goggles?

AE: For normal quarantine hotels, a standard surgical mask should be okay, unless they are working on a floor with positive cases.

CB: Or face shields, ideally yes whenever near guests – and not just when with guests who are known to be positive. New cases that emerge will be infectious between the last negative test and the positive one, and will not be symptomatic for that critical time when they are at their most infectious.

TB: Yes, if within 1.5 metres of travellers, or in deadspaces where aerosol likely such as poorly ventilated corridors.

Why is air flow so important in hotel quarantine? How many air flow changes should happen every hour?

AE: It is important because we know that the virus can be transmitted by aerosol. The chance of transmission drops with good airflow. The CDC recommends 12 air changes per hour for isolation rooms in hospitals. Most hotels have more like 1-4 air changes per hour.

CB: Even with good ventilation systems, the virus particles can build up in the air when people are shedding a lot of virus as they do in those first few days as they develop symptoms. Planes have had surprisingly low transmission rates reported because they have High Efficiency Particulate Air (HEPA) filters and turnover about once every three minutes. The Victorian hotels were selected on the basis of their ventilation and aircon systems were boosted as well with more fresh air intakes etc, but more could be done.

TB: To disperse the virus that is in aerosol. As much as possible.

Should international flights into Australia be temporarily stopped until a review of hotel quarantine across the country can take place?

AE: Yes – I think this would be sensible.

CB: We are constantly reviewing and adapting. Every infection is a worry, but it is also possible these have been occurring at low rates all along, and we are seeing more transmission cases as we are testing more frequently and looking so much harder since the variant strains emerged. We cannot stop reviewing and refining, but we do not need to shut down international flights to do this.

TB: That is hard. I suspect not, we just need to keep improving and learning and adapting as best as possible.