AUSTRALIAN hotel quarantine has failed about once for every 200 returning travellers infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Twenty-two failures – defined by us as when a border or health worker or person in the community with a link to the quarantine system became infected with SARS-CoV-2 – occurred between April 2020 and June 2021. More effective quarantine systems would reduce the damage caused by the associated outbreaks and the responses required to control them, along with the suffering of those unable to return to Australia due to increasingly severe travel caps.
By analysing Hong Kong’s quarantine process, we used diverse perspectives from business and critical care risk control as well as occupational medicine principles to look at how Australia can reduce the risks associated with hotel quarantine.
Reviews of quarantine in Australia
Several government reviews have made similar observations. Analysing the Victorian review reminds us that hazard controls will have durable success in eliminating catastrophic risk only when there is strong governance, a safety culture, and continuous quality monitoring. A national review in 2020 supported similar principles including risk stratification. There remains opportunity for improvement; for example, vaccinating frontline border workers with a 70% transmission-reduction vaccine could have prevented 55% of the quarantine failures. The Weeramanthri review in Western Australia acknowledged for the first time the lack of control of airborne spread in hotels and recommended better ventilation, governance and welfare improvements.
Airborne spread of SARS-CoV-2
The recent overdue consensus that airborne transmission of SARS-CoV-2 is an important mode of spread has resulted in changes to infection and prevention control guidance from the World Health Organization, the United States Centers for Disease Control and Prevention, the Australian Commission for Quality and Safety in Healthcare, the National COVID Evidence Taskforce, and the Infection Control Experts Group.
This fundamental acknowledgement of an important mode of transmission mandates updating all levels of the hierarchy of controls pyramid, which are elimination, substitution, engineering, administration and personal protective equipment.
Aspects of particular interest in the Hong Kong quarantine process
Dynamic global risk assessment with country risk segmentation
Hong Kong assesses global risk through analysis of a range of data points, including the rolling average number of cases in the past 14 days, and consideration of variants of concern.
The data in the global risk assessment are then used to place countries in five classifications. These categories then affect management of critical hazard control points.
|Group A1 specified places
(extremely high risk)
|Brazil, India, Nepal, Pakistan, the Philippines and South Africa
With effect from 25 June 2021: Indonesia
With effect from 1 July 2021: the United Kingdom
|Persons applicable||Hong Kong residents who have stayed in Group A1 specified place(s) during the relevant period (the day of boarding for/arrival at Hong Kong or during the 21 days before that day)|
Australia does not yet have a similar public systematic process for analysing the international landscape of SARS-CoV-2 risk that translates into risk controls. Some bilateral travel bubble arrangements, for example with New Zealand, have been implemented and adjusted. A ban on international flight arrivals from India in April 2021 to assist in maintaining manageable levels of SARS-CoV-2 in hotel quarantine had not been applied to other places with high risk levels, resulting in public criticism.
In the domestic context, Australian governments do stratify other Australian states and geographical areas in order to inform travel restrictions and government support, mainly on the basis of community spread of SARS-CoV-2.
Hong Kong uses a “Place Specific Flight Suspension Mechanism”. If more than five passengers among all airline flights from the same place in one week are confirmed as positive for SARS-CoV-2, then all arrivals from that place are prohibited for 14 days, as the country is designated “extremely high risk”. The mechanism operates dynamically with no ad hoc decisions required by the government. Detailed notices are published immediately.
This provides an incentive for COVID-19 safety management by airlines. Flight suspension risks reputation and commercial performance. Pre-arrival safety could also be improved with information about the vaccination of flight crew and the use of airborne level personal protective equipment. Transfer arrangements have been a weak link in Australia and prevention of airborne spread to ground staff should be a priority.
Screening of arrivals
Since August 2020, in addition to the pre-departure PCR test for SARS-CoV-2, all passengers arriving in Hong Kong are allocated a QR code and undergo another PCR test at the airport to determine their quarantine process. Passengers then wait from 4 to 6 hours for these results before they can proceed. The QR code persists throughout their stay.
A positive test results in immediate transfer of the passenger by ambulance to an isolation ward in a hospital where they are monitored in a controlled environment for 21 days. After this, a further short observation period is undertaken in hotel quarantine.
Passengers who test negative on arrival in Hong Kong proceed to their pre-booked quarantine hotel to watch and wait. The period of quarantine and testing frequency is varied, from a maximum of 21 days for extremely high risk countries to 7 days for passengers from low risk countries who have proof of full vaccination and serum antibodies to SARS-CoV-2. If they return a positive PCR test at any point, they are then transferred to hospital.
In Australia, all passengers proceed to government-allocated quarantine hotels without being tested and are held for 14 days. Some states subsequently remove PCR-positive passengers to separate facilities, but not directly from the airport.
In Hong Kong the testing frequency and the quarantine location and duration are all adapted according to:
- PCR result on arrival;
- country of origin risk classification;
- vaccination status
Australia does not test passengers on arrival but does so in hotel quarantine (in WA for example) on day 2, 5 and 13. A quarantine longer than 14 days is unlikely to be implemented in Australia, and given the small risks of long incubation and of acquiring SARS-CoV-2 in the hotel, post-quarantine community testing from around day 16 to day 21 probably remains preferable.
Hospital-like supervision of SARS-CoV-2-positive cases
In Hong Kong, all SARS-CoV-2-positive cases are hospitalised, irrespective of symptoms. Facilities, training and personal protective equipment are more appropriate for known infectious patients there than in hotels.
This sort of separation of known positive cases should occur in Australia. Mandatory vaccination, and daily salivary testing, with a PCR test at least weekly should be required for all hotel quarantine staff in Australia and any maintenance or service staff.
Occupational medicine principles should underpin the review of staff circumstances and control for close contact high risk crossover into other worksites and community.
Better ventilated facilities, strengthened psychological support, and improved medical treatment capacity would decrease the need to transfer patients for non-COVID-19-related health care.
Purpose built quarantine should be coordinated nationally
Air gapped facilities such as Howard Springs in the Northern Territory hold an obvious advantage for an airborne disease. Given the mooted expansion of these type of installations in various states, a national panel should be set up to oversee protocol and accreditation development, intake processes, quarantine, transfer processes, follow-up, complaints and systematic improvements. The panel should include occupational physicians and hygienists, ventilation engineers, public health and infectious disease physicians, infection prevention and control experts, quarantine managers, consumer representatives, pandemic biosecurity expert, and border force operatives.
Sundry issues of interest in Hong Kong public health and communication
- A one-stop-shop thematic website for the community about all aspects of management of the SARS-CoV-2 pandemic from travel to vaccination.
- Compulsory testing is required not only for international arrivals but those more likely to have been exposed through household contact, high risk occupation or location. Positive community cases are also transferred to medical quarantine facilities.
- A real-time case management dashboard provides the community with real time transparency of all cases both current and historical and updates with comprehensive contact information.
- Centralised booking for COVID-19 vaccinations
Australian quarantine and health protection would improve with unified governance by the Commonwealth within a closed control loop and a sophisticated, dynamic and streamlined approach, considering examples of international models including but not limited to Hong Kong. Detailed global risk analysis, airborne spread mitigation, ideally with air gapped quarantine, and removing all SARS-CoV-2-positive patients to medically supervised facilities are likely to be the most effective changes suggested by this comparison. Reducing quarantine time for vaccinated travellers would increase capacity with little added risk.
Acknowledgements: the authors thank Mr Nigel Oakey, MD and CEO of Dome Coffees Australia for his personal insights into Hong Kong quarantine process as well as business risk controls.
Dr Andrew Miller is Vice President of the Australian Society of Anaesthetists, Immediate Past President of the AMA (WA), and professional company director. Dual qualified in law and anaesthesia, he spends his time between clinical work, governance and advocacy for workplace safety for healthcare workers.
Dr Karina Powers is a consultant occupational physician for government departments and private practice, holds a Master of Public Health and Diploma of Occupational Health and Safety. She provided evidence for the National COVID-19 Clinical Evidence Taskforce IPC Healthcare Worker consultation.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.