Introduction: Leading Australian public health specialist Tarun Weeramanthri is urging Australia’s Infection Control Expert Group (ICEG) and the bodies it advises, including National Cabinet, to “stop dancing around the issue of airborne transmission” and its risks for hotel quarantine and Australia’s long-term management of the coronavirus pandemic.
Adjunct Professor Tarun Weeramanthri is President of the Public Health Association of Australia. Over the last year, he has worked with governments in WA, Victoria and South Australia as an advisor on the COVID-19 response, and with the Commonwealth Government as a panel member on the National Contact Tracing Review. In early 2021, he conducted an independent review of Hotel Quarantine Arrangements in WA.
Saying airborne transmission is now the single biggest residual risk to Australia’s hotel quarantine system, he is urging ICEG, the Australian Health Protection Principal Committee (AHPPC), and National Cabinet to show leadership and transparency on the issue which has caused much acrimony between academics and scientists in Australia and internationally.
Tarun Weeramanthri writes:
Since November 2020, there have been 14 outbreaks of COVID-19 from hotel quarantine (HQ) across five states in Australia.
The public has got used to the following: short, sharp lockdowns; official bemusement about how the outbreak happened; a statement about how infectious the new variants are; announcement of a review; a reflection on how many people have gone through HQ, how few people overall have been infected, and how well current arrangements have served us; a comment about the unsuitability of older city hotels for quarantine; praise for the Howard Springs facility in the NT; and a commitment to further improvements.
All this plays out first at a state level, but the problem is that there are serious discordant elements in the national conversation, and we are failing to learn from each other’s experiences, and move forward as a country.
The biggest problem is the failure to accept and simply state what is now obvious from the science and first-hand analysis of the cases – the significance of airborne transmission generally, and in the HQ environment specifically.
Recent editorials in The Lancet and the Medical Journal of Australia state the case for airborne transmission simply and clearly.
Over the last year, Australian states and territories have set up their HQ systems and dealt effectively with the risk of close-range droplet transmission and indirect transmission from environmental contamination.
Hundreds of thousands of people have gone through the HQ system successfully as a result, and thanks are due to the hard work of all HQ staff.
However, I believe that the single biggest residual risk is now from airborne transmission, made possible by poor ventilation in closed hotel environments.
I stated this in my recent independent review of HQ arrangements in WA. Indeed, if you read other published reviews from South Australia, Queensland and Victoria closely, you will find no convincing evidence to support any other form of transmission as the source of recent outbreaks.
The second discordant element is the finger-pointing between states and territories on the one hand, and the Commonwealth on the other, about responsibility for HQ.
Most recently, WA Premier Mark McGowan firmly reminded the Commonwealth that under section 51 of the Constitution, quarantine is a Commonwealth responsibility.
Prime Minister Scott Morrison stated after National Cabinet last week that the states had agreed a year ago to take responsibility for HQ, and that it was a matter for ‘state public health acts’.
Headlines have sharpened in the last few days (‘COVID Hotel Blame Game’, The Sunday Times, 25 April 2021), but the public could reasonably conclude it is a shared responsibility.
These discordant elements have prevented a thorough co-operative reset of quarantine arrangements as the global context has changed, vaccines have come into play, and the Australian public has come to expect and demand no community transmission, a basically unrestricted lifestyle and the prospect of a resumption of normal travel.
Vaccines are seen as the way out of the pandemic, and the vaccine rollout prioritised. National Cabinet is on a ‘war footing’ with respect to vaccines but has failed to maintain a similar level of urgency with respect to quarantine.
Since the national review of hotel quarantine was released in October 2020 (the Halton Review), states and territories have essentially been left to go it alone.
For many months, there has been an acrimonious divide between academics as to the position of the Infection Control Expert Group (ICEG), and their views on the relative contribution of droplet vs. aerosol transmission in the community.
Contrary views are expressed not just by respected academics, but also increasingly by national health professional groups and influential commentators each time an outbreak occurs.
In October 2020, ICEG released a statement on transmission of SARS-CoV-2, which acknowledged the potential for aerosol transmission in certain settings, particularly in poorly ventilated indoor environments.
Listening to the ICEG Chair, Lyn Gilbert, interviewed on radio in February 2021, I believe that there is substantial agreement between the opposing camps, and a consensus is possible as to appropriate risk mitigation in HQ sites.
Stop dancing around
But the ICEG needs to now update and state its position publicly with specific reference to HQ, given the number of academic articles supporting airborne transmission in recent months, and in light of the recent reviews and ventilation assessments.
Without such a statement, ICEG and the government authorities they advise, risk being left isolated in a minority position, outside the bulk of mainstream independent scientific advice, which has been convinced about the significance of airborne transmission in HQ for many months.
Our health advice and expert committee system has served us very well so far in Australia, and we do not want to see a split into different camps, as seen in the UK with the formation of an ‘independent SAGE’ group separate to the official Scientific Advisory Group for Emergencies (SAGE). Contestability and transparency of advice should form part of the expert committee process, not be separate from it.
The Australian Health Protection Principal Committee (AHPPC) needs to seek such advice from ICEG and come to a clear position on airborne transmission in HQ, and minimum criteria or standards for ventilation and PPE.
In the AHPPC statement of 14 April on Continuous Learning in Managed Quarantine for International Arrivals, there is no mention of ventilation and the specifics of personal protective equipment (PPE) are not addressed. It is time to stop dancing around the issue of airborne transmission.
National Cabinet must seek consensus
In public policy terms, all major crises are a test for the Federation. National Cabinet is an interesting innovation, not foreseen in the Constitution.
Its initial promise in March 2020 was of a ‘strong spirit of unity and cooperation.’ It has engendered public support and trust from its ability to negotiate the interests of all jurisdictions, to deliver pragmatic public safety and wellbeing outcomes in the national interest, and to consider both lives and livelihoods.
At the moment, its relative silence on HQ is telling, and it risks a quiet default to a lowest common denominator position, with each jurisdiction having an effective veto on national policy.
That is understandable from a state or Commonwealth sovereignty perspective, but the public can and should demand more effort to achieve consensus on key public health issues that require national action, coordination and planning.
Border controls and quarantine of international arrivals are inseparable in practice, and will be needed for years to come, with or without complete and effective vaccine coverage.
Completion of the global vaccine rollout will take till at least 2023, and as long as the virus is replicating and transmitting anywhere in the world, there is a chance of new vaccine-resistant variants emerging.
Key questions for key bodies
So, what can be done to end this circular and unproductive conversation, and allow us to move ahead as a country?
What is needed are straight answers to three simple yes/no questions from the three most important committees tasked with national quarantine policy in Australia.
The three committees are ICEG, AHPPC and National Cabinet. Remember, ICEG reports to AHPPC, which is a subcommittee of National Cabinet. All of them have been debating these matters for over a year.
The hierarchy of committees makes it crystal clear that National Cabinet is ultimately accountable. It is next due to meet on Friday 30 April 2021, a watershed day for national quarantine policy.
To ICEG: do you believe that airborne transmission is now the most likely form of transmission of COVID-19 in HQ in Australia, given the risks from droplet and environmental contamination are largely now eliminated with standard protocols and good practice?
If so, what updated guidance can you provide to reduce the risk of airborne transmission further in the HQ environment?
To AHPPC: do you agree that minimum national ventilation criteria or standards would be helpful for all HQ sites across Australia?
If so, will each state and territory release the ventilation audits from your HQ sites, so as to inform the development of such criteria or standards?
To National Cabinet: can you agree and state publicly that quarantine is effectively a shared responsibility between the Commonwealth, states and territories, and that you will work cooperatively to plan a fit-for-purpose quarantine system in Australia?
If so, will you, as a group, endorse an assessment of possible new quarantine sites, both Commonwealth and state-owned, in each state and territory against agreed criteria (e.g. proximity to health facilities, guest capacity, ventilation adequacy, capital and maintenance costs etc.)?
Such an assessment could cover both existing facilities and greenfield sites and include previously flagged initiatives in Toowoomba (Queensland) and Avalon Airport (Victoria). A comprehensive, transparent and independent assessment could take weeks to months to complete, which provides even more reason to start this process now.
The ultimate goal should be to expand high quality quarantine systems in Australia, not to completely replace HQ.
We will likely always need, in my view, a balance of HQ with other dedicated quarantine facilities, but they all should meet agreed national criteria or standards.
If National Cabinet truly believes that vaccines are the answer and we will not need quarantine long-term, or that we will ultimately move to home quarantine arrangements, they should state that position clearly and table the supporting expert advice and plans for transition.
Goals for the future
Australia will need to deal with the challenge of COVID-19 variants of concern as they emerge. However infectious a variant is, strict borders and high-quality HQ provide our best means of defence against community transmission.
But if quarantine is suboptimal, especially with respect to ventilation, a more infectious variant will find its way through. The preferred long-term answer, for both lives and livelihoods, is to provide expanded and sustained high quality quarantine in Australia, not restrict incoming numbers and impose recurrent lockdowns.
In the meantime, existing HQ systems need to be continuously improved based on risk assessments contained in the multiple state reviews and following the ‘Hierarchy of Controls’ framework endorsed by AHPPC.
Vaccination is obviously a key control measure as is suitable PPE, which I have not discussed in detail here, as the choice of PPE follows acceptance, or not, of the importance of airborne transmission.
In the longer term, we need to redesign and expand the quarantine system for international travellers in Australia, so it can achieve two distinct goals.
Firstly, to reduce the risk of transmission of COVID-19 into the community, and the avoidance of lockdowns. Secondly, to provide an opportunity to support the return of Australians living abroad, seasonal workers, international students, and business visitors, who are prepared to undergo and pay for quarantine. The costs of repeated lockdowns, and the damage to community confidence, are almost certainly greater than the costs of an optimal quarantine system.
Well said Tarum