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Despite numerous reviews by state and federal governments into hotel quarantine, the system continues to lead to Covid-19 transmission in Australia, with experts criticising the lack of a co-ordinated strategy around the country. By Rachel Withers.

Covid-19 leaks from hotel quarantine

The Victorian government’s Covid-19 testing chief, Jeroen Weimar.
Credit: Luis Ascui / Getty Images

A year into the Covid-19 pandemic, every mainland state in Australia has seen transmission of the virus from hotel quarantine. In recent months, the virus has breached quarantine in Adelaide, Sydney, Brisbane, Perth and Melbourne, with leaks becoming more frequent, not less. While none has so far resulted in an outbreak on the scale of Melbourne’s second wave, experts are worried it would take only a single guest with a high viral load to spark one. Which prompts the question: Why isn’t Australia most important line of defence against this pandemic working as it should?

Concern reached new heights this week, after more guest infections in Melbourne and Sydney. On Sunday, a former guest of Sydney’s Sofitel Wentworth tested positive two days after leaving quarantine. It is believed they were infected while staying at the hotel. In Melbourne, a cluster at a Holiday Inn near the city’s airport continues to grow. It is clear that the virus is circulating within hotels – with guests infecting workers, workers infecting guests, and guests infecting guests.

These latest cases are made all the more serious by the emergence of more-infectious strains of the virus, brought into the country by returned travellers. The risk of these variants undermining Australia’s ability to suppress the virus is leading some experts to ask whether quarantine hotels are fit for purpose.

On Tuesday, Australia’s chief medical officer, Paul Kelly, announced that hotel quarantine would be reviewed by the Australian health protection principal committee, the body made up of state and territory chief health officers. It follows a previous national hotel quarantine review, led by former Department of Health chief Jane Halton, which was published back in October. There have also been multiple state-based inquiries, including in Victoria, after that state’s disastrous hotel quarantine breaches last year. Yet things seem still to be going wrong.

A number of the latest cases are believed to be the result of aerosol transmission, something experts say hasn’t been taken seriously, or even addressed, until now. Quarantine protocols – such as hand hygiene and surgical masks – have focused mainly on preventing droplet and contact spread. But these have not been effective in preventing airborne particles travelling between rooms and through corridors, with inadequate attention paid to ventilation and airflow in hotels.

This is starting to change, with Victorian authorities commencing reviews of quarantine hotel ventilation systems, but experts are frustrated that it has taken this long and this many cases to spark any scrutiny. The Burnet Institute’s Michael Toole, a professor of international health, says there has been “stubborn resistance” to the theory of aerosol transmission within government advisory groups, despite “study after study after study”. He says the expert group advising national cabinet lacks representation from occupational hygienists, ventilation engineers and occupational physicians.

Victorian authorities are pinning the Holiday Inn outbreak on an infected guest’s use of a nebuliser, a medical device sometimes used by asthma sufferers to aid breathing. The device causes users to exhale up to 10,000 times more aerosol particles than usual. However, Toole says, the focus on the nebuliser is “a little bit of a furphy”. The device alone doesn’t explain how transmission was able to occur between hotel rooms, nor does it explain all the recent cases. He wants more focus placed on airconditioning ducts and “positive pressure” – the rush of air into the corridor when a door is opened – believed to be responsible for a number of cases of room-to-room transmission.

While this is getting a bit into the weeds of hotel architecture, it underscores an important point: these hotels are not hospitals; they weren’t designed to be. In hospital rooms, for example, positive pressure is reversed.

But the fact that concerns about ventilation and corridor traffic was already identified in a recent review into Brisbane’s Hotel Grand Chancellor outbreak points to another problem plaguing Australia’s Covid-19 quarantine system: a lack of overarching national strategy.

Last year, hotel quarantine was introduced quickly, following a March 27 meeting of national cabinet, during which it was agreed that all incoming travellers would be required to undertake a 14-day supervised quarantine in a designated facility. State and territory governments were left to arrange and manage the facilities, as well as how to enforce the requirements, resulting in a patchwork of rules and systems, and no consistent standard on masks, testing or staffing. Individual reviews have fixed individual flaws in different states’ systems, but upgrades and lessons haven’t been applied nationwide, with the various jurisdictions failing to learn from one another’s mistakes.

Different states still have different rules regarding testing of workers on their days off, as well as testing of guests after they leave quarantine. A number of states are still employing private security guards who can work second jobs, despite Victoria’s judicial inquiry showing this was a major contribution to the second wave. As of Thursday, all Victorian hotel quarantine workers will be provided with N95 masks, based on what’s been learnt from the Holiday Inn cluster, but this won’t be applied nationwide.

Many experts are calling for a nationally co-ordinated standard, implemented on a consistent basis and based upon best practices learnt from the different systems and reviews. Toole is one of the academics who have been calling for a national approach. He doesn’t want the federal government managing hotel quarantine directly – they don’t have the capacity for that, he says. Instead, they should be using their “considerable authority under the constitution” to insist on the best possible standards, fostering collaboration between the states, and making sure they have the best possible advice.

Labor is also pushing for a national approach, though there’s likely some political calculation to that: it has become clearer that the premiers, most of whom are Labor, have taken on all the responsibility and all the blame, while the federal government has got away scot-free simply because it didn’t step up. At a recent national cabinet meeting, some of the premiers called for more federal responsibility – but this push went nowhere. The Liberal premier of New South Wales, Gladys Berejiklian, stood apart from her counterparts, saying in an interview that she didn’t know what the other premiers were asking for. The interstate rivalry over “gold standards” is making states reluctant to implement each other’s advice.

Former World Health Organization epidemiologist Adrian Esterman, a professor at the University of South Australia, says it makes sense that the states took on quarantine at the start of the pandemic, when action was urgent and hotels vacant. But that time has long since passed.

“Quarantining people in hotels that aren’t fit for purpose in the middle of cities is just plain nonsense,” he says.

Esterman has been calling for hotel quarantine to be moved out of cities to reduce the risk of transmission into urban areas, pointing to the success of the Northern Territory’s Howard Springs facility. The government’s own review last October made similar recommendations, advising the establishment of “a national facility for quarantine to be used for emergency situations, emergency evacuations or urgent scalability”.

Others have raised concerns with building such facilities away from cities, with a high construction outlay, as well as the costs to move and accommodate the appropriately skilled staff. But Esterman insists it would be worth it, especially when compared with the billions of dollars it costs each time a major city is locked down because of a hotel quarantine breach.

“It’s peanuts,” he says of the relative cost. It would also be an investment – for the next pandemic.

For now, the federal government remains firm in its insistence that state-managed hotel quarantine is the best option. But Toole is deeply concerned that the next hotel quarantine breach may be the one that leads to a major wave. We are, he says, currently running on a “fine line of luck”.

This article was first published in the print edition of The Saturday Paper on Feb 13, 2021 as "Outbreak hotels".

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Rachel Withers is the contributing editor of The Monthly Today.