Hotel quarantine: Corridor swab ignited Holiday Inn outbreak, lockdown
The Holiday Inn outbreak that sparked Victoria’s third lockdown didn’t begin in the room of a man using a nebuliser as first claimed.
A secret report into the Holiday Inn COVID-19 outbreak that sparked Victoria’s third lockdown finds it first escaped into a corridor during the lengthy swabbing of an unmasked woman in an open doorway, not from the room of a man using a nebuliser, as originally claimed by health officials.
Identifying the “extended time” taken by a contracted health worker to swab the woman, the March report says the virus, “previously contained” in her room, was blown down the corridor by airconditioning before “pooling outside the door” of the room where the man with the nebuliser was staying with his partner and infant.
The COVID-19 Quarantine Victoria Infection Prevention and Control report, obtained by The Australian, says one of the adults became infected picking up meals from outside their room door or putting out rubbish.
Within days, the trio all had COVID-19, with the nebuliser aiding transmission of the virus in the room and pushing it back into the corridor, infecting food and beverage workers delivering meals to residents’ doors.
According to the review, the virus was blown further down the corridor, infecting a food and beverage worker quarantined in the room next to the family of three. An authorised officer who handled the family’s hotel entry and exit was also infected.
Referring to the man’s use of a nebuliser in his room, Victoria’s Chief Health Officer, Brett Sutton, said in February: “We think the exposures are all to that event, the use of the nebuliser, which then meant the virus was carried out into the corridor and exposed the authorised officer, the food and beverage service worker and also the other resident.”
But, after reviewing CCTV footage and conducting staff interviews, the report suggests the “proposed working hypothesis of the outbreak”, finding the virus first escaped into the corridor from room 317 where the woman was staying, not room 322/323 occupied by the family of three.
The man blamed by the Andrews Government and health chiefs for starting the Holiday Inn
cluster by using a nebuliser welcomed today’s revelations in The Australian that he
was, in fact, not responsible for the outbreak. “I am very glad this has come out,” he said in a statement to 3AW’s Neil Mitchell. “Though, it continues to show there’s systemic problems that need to be resolved.”
The report says the woman in room 317 was “presumed to be the sentinel case”, having picked up the virus in Sri Lanka prior to departing for Australia. It says while it was transmitted into the corridor when she was being swabbed on either January 25 or 26, she only returned a positive result on February 8, after she left quarantine and was in the community.
The family of three tested positive on February 4 while the officer involved in their transfer became symptomatic on February 7 before testing positive.
Highlighting the time taken to swab the woman in room 317, the report includes a photographic re-enactment of the swabbing technique used by a Healthcare Australia pathology collector, and how the door is open for an “extended time” while the resident is not wearing a mask.
Given the events leading up to the outbreak, and the emergence of more infectious variants of SARS-CoV-2 (B1.1.7 strain), the report calls for “a thorough review of procedures used by contracted health services to swab residents”.
A separate confidential “rapid review” into outbreaks at three quarantine hotels, obtained by The Australian, recommends an end to open doorway testing, and for residents to be tested inside their room with the door closed.
“IPC Steering Committee to reconsider the IPC risks associated with the current process for COVID-19 testing residents in the open doorway of their room,” the Safer Care Victoria report says, in its summary of recommendations. “We recommend this be done inside the resident’s room with the door closed.”
The CQV IPC report says the swabbing methods used by Healthcare Australia and Health Department pathology collectors needed to be reviewed and audited using CCTV to ensure best practice was maintained.
“This may account for the number of potential false negatives that occurred during this outbreak,” it says.
The report says the residents in rooms 317, 322/323 and 324 all arrived at the Holiday Inn on the same day, hours apart. “Airflow from the airconditioning unit, due to the strength and direction of the airflow, may have played a significant role in transmitting the virus, without being the primary source.”
It calls for clinical staff swabbing residents to use a definite “route” moving throughhotels, as this would help determine if transmission between rooms was a “result of airflow or poor IPC techniques among … staff”.
The government maintains nebuliser use remains the most likely source of transmission in the Holiday Inn outbreak.
It is understood CQV discussed the Safer Care Victoria recommendation for closed door room testing with Alfred Health and Healthcare Australia, but they both rejected the proposal, citing unacceptable risks to staff. However, CQV has made changes to the swabbing regimes of residents in terms of testing duration and scheduling to ensure adjacent rooms are not being tested at the same time.
