As the Australian government readies to vaccinate against Covid-19, our state quarantine systems, contact tracing and testing also need to be addressed before we can reopen our borders to the world.By Karen Middleton.
Lifting standards in quarantine
As Victoria comes out of yet another lockdown and Western Australian restrictions ease, the residual stress from Covid-19 outbreaks linked to hotel quarantine is prompting a common question nationwide: How can we avoid shutting down the economy again and again?
The answer may not lie in building new quarantine facilities to keep incoming passengers out of the cities.
Increased compliance with daily testing, swifter contact tracing and more meticulously enforced infection control are essential, says Jane Halton, the chair of the global Coalition for Epidemic Preparedness Innovations.
Halton, who wrote last year’s national quarantine review, says these measures would ideally stop infection spreading at all, but if not, would certainly catch the leak before it takes hold in the community.
“If they [the government] know inside 24 hours whether someone’s become Covid positive, one, they know where they’ve been; two, they probably know who they’ve been with; and three, you can go find them and isolate them,” Halton says. “The daily testing regime, if it’s been implemented, means you should be able to catch it early.”
This, in turn, should give state and territory leaders the confidence to avoid locking down their jurisdictions every time there is an infection outbreak of one or two cases from hotel quarantine.
States and territories committed to daily testing of hotel quarantine workers in early January but some have been slow to implement it. Most do not test on workers’ days off. Some states’ contact tracing appears faster than others’, and stories keep emerging of some staff not wearing masks.
Victoria extended its daily testing of hotel quarantine workers to include their days off when its latest outbreak emerged from the Holiday Inn two weeks ago.
But the failure to identify the infection of a worker before they spread the virus to Terminal 4 of Melbourne Airport recently meant that about 7000 other people were potentially exposed – a preventable event that is understood to have angered officials in other jurisdictions.
Halton supports examining new options for expanding quarantine capacity.
The Northern Territory is planning an expansion of the existing 3000-bed facility at Howard Springs, outside Darwin, and the federal government is understood to be discussing joint funding.
Halton has long advocated expanding Howard Springs, a set-up she says is ideal because of its separated accommodation with access to fresh air and outdoor areas.
But she says avoiding future lockdowns depends on improving the existing system.
“We do know that obviously places like Howard Springs – where you do have access to the outside and there’s no shared airconditioning – those are ways to minimise risk,” Halton says. “But it’s not the only way. And it’s not that you have to have those arrangements in place to make this thing work.”
Halton argues that better end-to-end assurance of infection control – from when someone boards a plane overseas, through transportation and accommodation to when they leave hotel quarantine in Australia – is entirely possible.
National cabinet, under pressure to get more Australians home from overseas, has discussed various options for adapting quarantine arrangements.
A home-based quarantine option, which featured in Halton’s quarantine report, is one used for some returnees in the ACT, primarily diplomats and government officials.
But even ACT chief minister Andrew Barr acknowledges this will not be suitable everywhere.
“Home quarantine can be a more suitable model but it is more resource-intensive than having everyone together in a hotel because you’ve got to go to so many different sites in order to check on people,” Barr tells The Saturday Paper.
The ACT has only accepted occasional intakes of international quarantine passengers to help ease the national burden and is operating only one quarantine hotel, selected because it offers apartment-style accommodation with both a balcony – fresh-air access – and self-catering facilities in each room.
“Where the quarantine facility is more like a serviced apartment rather than a hotel room, then that is a lower risk [of aerosol transmission],” Barr says.
“It is a safer model and that’s also more comfortable and bearable for the person in quarantine ... But clearly there aren’t as many suitable and available properties. If you limited hotel quarantine to those sorts of facilities then your repatriation numbers would significantly reduce.”
Quarantine is a federal responsibility but has been outsourced during the pandemic to the states and territories, which run hospitals.
Calls to further restrict incoming numbers, as Victorian premier Daniel Andrews has proposed, could create potential legal problems for governments, as Australian citizens have a constitutional right to return to the country.
“You don’t have a constitutional right to make other people sick,” Andrew Barr qualifies. “So there has to be proportionality in this … I wouldn’t want to see cases taken to the High Court to demand to be let into the country. I’d much prefer that the nation build some additional quarantine facilities and meet repatriation demand that way.”
Halton says the issue is not whether regional facilities are owned and run privately, but whether whoever runs them has the skills and systems to do so.
“It’s quite a complex job to run quarantine,” she says. “It’s not simple at all … This is complicated. It needs to be run really properly, and you would want to be absolutely assured that the mechanisms you put in place are safe.”
Daniel Andrews confirmed this week that his government is in discussions with the operators of Avalon Airport, the Linfox Group, about opening a purpose-built facility in Victoria, modelled on Howard Springs.
“People would be in the same location but would not be sharing the same spaces, so they’re not under the same roofline,” Andrews said on Tuesday. “It would be a cabin-style, village-style environment, where there would be fresh air, where there would be not zero risk, but lower risk.”
A separate proposal by the Wagner Corporation is before the Queensland government to create a similar facility near Toowoomba Airport.
Accommodation Association of Australia chief executive Dean Long defends the existing hotel quarantine system.
“The program has worked extremely effectively in keeping Australians safe,” Long told the ABC. “It’s only in a very small number of situations, so there’s no need to overhaul the entire system, but we need to continue to refine it.”
As Australia’s vaccination program begins on Monday, leaders face tough decisions. When will it be safe enough to dispense with state border closures and when can Australia reopen to the world?
The formula for freedom is a complex one, involving a web of measures that all affect each other: vaccination, quarantine, testing and tracing and permanent hygiene measures. Vaccination will prevent recipients becoming very ill and dying but will not necessarily prevent the spread of the disease. As new strains develop, vaccines will need to change and be readministered, probably yearly.
Having consistently said they have acted solely on the medical advice, decision-makers now need to give increasing weight to other factors as they move towards a permanent reopening.
“This is ultimately a combination of epidemiology, modelling and judgement and risk appetite,” Halton says. “So, essentially, how much risk are you prepared to take?”
Government decision-makers have started designing a more permanent management system for Covid-19. After a national cabinet meeting earlier this month, Prime Minister Scott Morrison announced that his departmental secretary Phil Gaetjens would lead a new taskforce of the heads of central agencies from all Australian jurisdictions, examining the pathway to a reopened economy once the vaccination program is under way.
That program will be based on the expectation that as the virus mutates into new and possibly more virulent strains, the vaccines will also need to be adjusted to protect against the most dominant ones and be readministered, as is the case for influenza.
“At some point, we say, ‘Can we now manage this?,’ ” Halton says. “So the majority of the people who actually are really at risk of severe disease and death can be vaccinated. And that means we know we can keep the pressure off our intensive care units and our medical staff. But, yes, some people every year will probably die from this, just as they do from flu.”
But how to shift into that more permanent phase, reopen international borders and eventually dispense with the need for quarantine is the challenge.
Andrew Barr says vaccination will dramatically change the equation for managing the virus in the community in the future.
“The issue will be that the vaccines prevent the most vulnerable from ending up in ICU and dying,” he says. “And if the vaccines prevent the most vulnerable from ending up in hospital, then you know you can manage a level of illness in the community. We’re used to that with the annual flu season.
“Once the vaccination program reaches a certain point I think where we’re going to shift is to a new metric of number of hospitalisations. Are people with the virus getting that sick that they’re in hospital?”
Complicating that process further is the emerging concern that some existing vaccines – especially the AstraZeneca vaccine, which most Australians will receive – may not prevent severe illness or death from the new South African Covid-19 variant and other strains.
However, Halton says people should be vaccinated with what is currently available.
“People should take whichever vaccine they are first offered because we know it will protect against a good number of the variants of the virus that are prevalent in the world.”
Prime Minister Scott Morrison insists the vaccination program – designed in five phases with the most vulnerable given priority – is on track for completion by October.
But at this stage, not even the vaccination program can guarantee the freedom to travel like before. When that will return, nobody really knows.
This article was first published in the print edition of The Saturday Paper on Feb 20, 2021 as "Plugging the leaks".
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