Estimating the Failure Risk of Quarantine Systems for Preventing COVID-19 Outbreaks in Australia and New Zealand

Estimating the Failure Risk of Quarantine Systems for Preventing COVID-

19 Outbreaks in Australia and New Zealand

Leah Grout,

Ameera Katar,

Driss Ait Ouakrim,

Jennifer A. Summers,

Amanda

Kvalsvig,

Michael G. Baker,

Tony Blakely,

Nick Wilson

Department of Public Health, University of Otago Wellington, New Zealand

Melbourne School of Population and Global Health, University of Melbourne, Melbourne,

Australia

* Corresponding author: leah.grout@otago.ac.nz

Abstract

Objectives: To identify COVID-19 outbreaks and border control failures associated with

quarantine systems in Australia and New Zealand and to estimate the failure risks.

Design, setting, participants: Observational epidemiological study of travellers transiting

quarantine in Australia and New Zealand up to 31 March 2021.

Main outcome measures: The incidence of COVID-19 related failures arising from

quarantine, and the failure risk for those transiting quarantine, estimated both per 100,000

travellers and per 1000 SARS-CoV-2 positive cases.

Results: Australia and New Zealand had 24 COVID-19 related failures arising from

quarantine systems up to 31 March 2021 (14 and 10, respectively). One resultant outbreak

involved an estimated 800 deaths and quarantine failures instigated nine lockdowns. The

failure risk for those transiting quarantine was estimated at 6.3 failures per 100,000 travellers

and 5.8 failures (95%CI: 3.5 to 8.1) per 1000 SARS-CoV-2 positive cases. The latter risk was

three-fold higher in New Zealand compared with Australia. Approximately 55% of

quarantine system failures could likely have been prevented with the full vaccination of

frontline border workers, for 70% effectiveness at preventing transmission.

Conclusions: Quarantine system failures can be costly in terms of lives and economic

impacts such as lockdowns. Ongoing improvements or alternatives to hotel-based quarantine

are required.

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Introduction

New Zealand and Australian states have successfully eliminated community transmission of

the pandemic virus SARS-CoV-2,

albeit with occasional outbreaks from imported cases that

have typically been quickly brought under control. These two countries have primarily used

hotel-based quarantine for citizens returning to their countries during the pandemic period,

with 14 days of quarantine combined with PCR testing and mask use in any shared spaces

(eg, common exercise areas used in New Zealand, but not in most Australian states).

Converting hotels for quarantine purposes has the advantage of making use of a resource that

would otherwise be underused during a pandemic, given declines in international tourism.

However, the major disadvantage of hotel-based quarantine is that it is likely to be less

effective than purpose-built quarantine facilities owing to shared spaces and lack of safe

ventilation (as per WHO advice on air flow

). Moreover, the consequences of leakage of the

virus out of quarantine (eg, through facility workers) may be more severe given higher

population density in urban settings where the hotels are located. Given these issues, we

aimed to estimate the failure risk of quarantine systems in New Zealand and Australia in

terms of the spread of COVID-19 infection into the community.

As of 31 March 2021, the rolling 7-day average number of COVID-19 vaccine doses

administrated per 100 people was 0.18 in Australia and 0.08 in New Zealand

However, this

was counted as single vaccine doses and does not equal the total number of people vaccinated

(eg, the Pfizer/BioNTech vaccine which is currently used in New Zealand requires two

doses).

The majority of border workers in Australia and New Zealand have been vaccinated

(eg, over 56,000 doses had been administered to border workers as of 28 March,

and all

hotel quarantine workers in Victoria who have face-to-face contact with returned travellers

received their first dose of the vaccine by the first week in April

Methods

We defined a quarantine system failure as where a border/health worker or person in the

community with a link to the quarantine/isolation system, became infected with SARS-CoV-

2. This definition included people infected in hospital from cases who had been transferred

from a quarantine facility (as such cases were still in the 14-day quarantine process). But this

definition did not include pandemic virus transmission between returnees within the

quarantine facilities (as some other commentators have included in lists of failures in the

Australian context

We searched official websites in both countries, and for the eight states and territories in

Australia, to identify outbreaks and border control failures associated with quarantine systems

(searches conducted between 6 January and 29 April 2021). Where an outbreak source was

uncertain (eg, the Auckland, New Zealand, August 2020 outbreak) we used the best available

evidence to classify it as a quarantine failure or not. We used two denominators: a) the

estimated number of travellers who went through quarantine facilities during the 2020 year

up to 31 March 2021; and b) the number of SARS-CoV-2 positive people who went through

these facilities in this same time period. The unit of analyses were New Zealand, the eight

Australian states and territories, and both countries combined.

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For New Zealand, we used official data on both travellers going through the quarantine

system,

along with official (Ministry of Health) data on SARS-CoV-2 positive cases,

although there are some discrepancies in the information about when regular testing began in

Managed Isolation and Quarantine (MIQ) facilities. For Australia we used overseas arrival

data

and health data.

10 11

Results

The collated data for quarantine system failures is shown in Table 1, with specific details of

each event in the Appendix (Table A1). In Australia, 14 failures were identified, one causing

over 800 deaths (Victoria’s second wave) and eight out of the 14 resulting in lockdowns. In

New Zealand, there were ten failures, with one causing an outbreak with three deaths, and

also a lockdown.

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Table 1: Identified quarantine system failures in Australia and New Zealand during the COVID-19 pandemic, the relevant denominator populations

and estimated failure risks (with numerator and denominator data up to 31 March 2021)

Jurisdiction

Identified

quarantine

system failures

Travellers

experiencing

quarantine/

isolation

Active cases

of SARS-

CoV-2

infection

identified in

quarantine

Failure risk

per 100,000

travellers

going

through

quarantine

Failure risk

per 1000

positive cases

quarantine*

(95%CI) Comments

New Zealand 10 127,730 758 7.8 13.2

(5.0 to 21.4)

From 17 June 2020 (date of the first positive test in a

quarantine facility) until 31 March 2021, excluding 9 cases

with no history of overseas travel.

Australian States and Territories

Australian Capital

Territory (ACT)

0 765 25 0.0 0.0

Queensland 3 40,896 543 7.3 5.5 Two of the failures occurred at a hospital during the

quarantine process.

New South Wales 5 128,646 1,581 3.9 3.2

Northern Territory 0 9,180 88 0.0 0.0 Includes a non-hotel facility (a former workers’ camp)

South Australia 1 13,023 230 7.7 4.3

Tasmania 0 405 21 0.0 0.0

Victoria 4 33,300 462 12.0 8.7 Victoria suspended flights from 14 February to 25 March

2021 due to the Holiday Inn cluster, where an illegal

nebuliser allegedly caused a quarantine failure and resulted

in 14 cases.

Western Australia 1 29,383 450 3.4 2.2

All of Australia 14 255,598 3,400 5.5 4.1

(2.0 to 6.3)

These only included cases diagnosed between 1 April 2020

until 31 March 2021.

Relative risk (New Zealand : Australia)

3.2 (1.4 to

7.2)

P-value = 0.0081 (Mid-P exact, 2-tailed test)

New Zealand and Australia

Both countries

combined

24 383,328 4,158 6.3 5.8

(3.5 to 8.1)

* 95% confidence intervals are shown in parentheses for country-level risks only; state-level risks with zeros or low numbers are too sparse

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Given our estimates of the number of travellers processed via quarantine systems (Table 1),

the overall risks for both countries combined were one failure per 15,972 travellers, and one

failure per 173 SARS-CoV-2 positive cases in quarantine. The combined data can also be

interpreted as one outbreak leading to a lockdown response per 42,592 travellers; and

approximately one death from COVID-19 per 477 travellers (using the 800 deaths estimate

from Australia and the three deaths from New Zealand – although this figure is largely driven

by the second wave in Victoria and is unlikely generalizable forward in time).

At the country level, there were 13.2 failures per 1000 SARS-CoV-2 positive cases transiting

quarantine in New Zealand (95% confidence interval [CI]: 5.0 to 21.4), compared to 4.1 per

1000 SARS-CoV-2 positive cases in Australia (95%CI: 2.0 to 6.3) – a three-fold difference in

risk (relative risk: 3.2, 95%CI: 1.4 to 7.2). Approximately 55.4% of quarantine system

failures could have been preventable with the full vaccination of frontline border workers

(Table A1) due to the combined effects of vaccination lowering the risk of getting infected by

70% or more (as in the case of the Moderna vaccine

), and the lesser duration of infectivity

and lower peak infectivity for those infected.

Discussion

This analysis identified 24 failures of quarantine systems in Australia and New Zealand

combined (up to 31 March 2021). The significantly higher failure risk per 1000 SARS-CoV-2

positive cases transiting quarantine in New Zealand versus Australia could reflect a lower

quality approach in the former, with perhaps some of the difference due to greater detection

in New Zealand from more border worker testing over a longer period.

These estimates are subject to chance variations due to the low numbers of failures. These

estimates will also probably be an underestimate of all quarantine breaches, as not all of those

infected will transmit the virus and start a detectable chain of transmission. Genomes of the

first 649 viral isolates collected in New Zealand show that only 19% of virus introductions

resulted in ongoing transmission of more than one additional case.

Therefore, counts of

border failures are sensitive to how they are identified and defined. Indeed, with increased

testing (eg, testing of people after leaving quarantine on day 16 as is now common in

Australia), we may be detecting breaches that previously would have been undetected.

Looking forward, the failure risks per month in New Zealand and Australia may increase,

given that the proportion of travellers returning to these countries who are infected is

increasing due to global intensification of the pandemic and the increasing infectivity of new

SARS-CoV-2 variants.

Indeed, there have been several clearly documented cases of spread

within quarantine hotels (eg, two instances in Melbourne in February 2021, two instances in

Sydney in April 2021), highlighting the increased risk and evolving situation with more

highly infectious variants arriving from overseas.

However, offsetting this trend will be measures such as the vaccination of quarantine

workers. In New Zealand, the vaccination of border workers began in February 2021 with the

Pfizer/BioNTech vaccine. However, vaccination does not fully protect against SARS-CoV-2

transmission, although a moderate degree of protection is likely. For example, infection rates

were halved for the AstraZeneca vaccine,

17 18

and perhaps reduced by 70% for the Moderna

mRNA vaccine, as indicated by using swab results for asymptomatic infection plus

symptomatic cases.

For vaccinated people who are infected, primate study evidence

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suggests (consistent with expectation) that the infectivity is decreased in peak and duration,

further protecting the border.

Furthermore, the level of testing of quarantine workers has been increasing (eg,

; which will

find some failures before they have a chance to establish as an outbreak in the community).

There have been other improvements in the quarantine systems over time (eg, improved

security, introduction of mask wearing within quarantine settings, reduction in shared spaces,

improved PPE used by workers, and other procedures as detailed in both countries

20 21

Another risk reduction practice would be using better or purpose-built facilities in rural

locations as these have less risk from close contacts in central business district hotels and

within-building spread from poor ventilation systems. Limitations of our analysis include

residual uncertainty around the cause of some outbreaks (eg, the Auckland August 2020), and

imprecision with denominator data on traveller numbers for Australia (eg, some travellers

were moved between states on domestic flights which is not captured in the official data we

used). Additionally, case numbers are constantly changing, due to the number of

reclassifications caused by false positives and duplications.

To substantially reduce the risk of SARS-CoV-2 incursion out of quarantine (until such time

as enough of the population is vaccinated), the most obvious action is to reduce arrivals, or

even suspend arrivals, from high infection locations (as New Zealand temporarily did for

travel from India and other high risk countries in April 2021

). Beyond this, there are a range

of other potential improvements in ongoing arrangements and processes as detailed in Table

2. Furthermore, the start of quarantine-free travel between Australia and New Zealand (also

known as a "green zone") in April 2021 provides an opportunity to benchmark COVID-19

border control policies and practices, identify potential improvements in both countries, and

harmonise best practices across the region. The green zone further intertwines the biosecurity

status of both nations and it is therefore even more important to lower the risk of border

failures that could disrupt such travel. This shift from a one-size-fits-all strategy to a risk-

based approach to border management can be summarised as a 'traffic light' approach.

Table 2: List of potential policy and operational options for improved COVID-19 control

associated with quarantine systems in Australia and New Zealand, including measures to

reduce the numbers of infected people arriving into quarantine facilities

Policy option Description

Our priority

rankings

1. Cap travel from

high prevalence

countries and/or

suspend for a

period

Reduce the in-flow of travellers by reducing or suspending flights

to Australia and New Zealand (NZ) from very high incidence

countries where the pandemic is out of control. These governments

have the legal powers to put conditions on the existing rights of

their citizens to enter their country of citizenship (ie, on public

health grounds).

Top priority

2. Pre-departure

testing plus/minus

pre-departure

quarantine

Expand existing requirements for pre-departure testing to additional

traveller source countries. Pre-departure testing could be expanded

from not only a PCR test within 72 hours of departure to also add a

rapid test at the airport immediately before departure (given many

infected may have started shedding the virus in the previous 72

hours and most, but not all, of such cases will be detected by a rapid

test even though it has lower sensitivity). Of note is that such

arrangements are considered legally acceptable (see the above row).

Pre-departure quarantine (eg, for a week), would provide additional

Top priority

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Policy option Description

Our priority

rankings

assurance, but this would probably need to be in a transport hub (eg,

at an airport hotel at Singapore or Hawaii) where NZ and Australian

officials were permitted access to ensure quality processes. Even if

establishing a formal facility is shown to be impractical, all

incoming travellers could be asked to self-quarantine as strictly as

possible in the week before travel, eg, by a request through the

passenger booking system (see Policy Option 4).

3. Pre-departure

vaccination

Make travel contingent on completing a course of approved

vaccination. This measure assumes the vaccine is at least partially

effective at preventing transmission. This requirement needs further

investigation and development.

Uncertain

4. Use passenger

booking systems to

reduce infection

risk

Require passengers to declare pre-departure COVID-19 precautions

via the system that they use to book spaces in quarantine facilities

prior to travel. Such a system is operating in NZ and could be

adopted more widely in Australia.

High priority

5. Increase in-flight

precautions

Explore means to reduce the risk of in-flight infection as

documented on a flight to NZ.

This could be via more stringent

enforcement of mask wearing in airports and on flights, use of

higher-efficacy masks (and/or double masking), and minimizing

talking when masks are displaced during eating and drinking on

flights. Improved ventilation and spacing requirements on flights

might also be worthwhile.

High priority

6. Reduce infection

risk at airports and

transit hubs

Ensure measures are in place at departure airports and transit hubs

to minimize the risk of cross infection (eg, through physical

distancing and mask use).

Medium

priority

7. Improve local

transport

arrangements

Ensure sufficient physical distancing of travellers on arrival and in

transit to quarantine (eg, lowering density on buses). For such

arrangements, N95 masks could be required.

Medium

priority

8. Shift to discrete

quarantine units

Shift some or all quarantine facilities to rural military bases or

camps where discrete units (eg, mobile homes or caravans) could be

appropriately spatially separated. The success (to date – see Table

A1 in the Appendix) of the Howard Springs facility (a converted

workers’ camp

) should be considered. This approach allows for

natural ventilation and eliminates shared indoor spaces. If spaces

were limited, then these settings could be used for travellers from

the highest risk countries.

High priority

9. Restrict hotel

quarantine in large

cities to low-risk

travellers

Reserve hotel quarantine in large cities to the lowest risk category

of travellers, with hotels in more minor cities being used for the

highest risk category of travellers. However, the risk/benefit

analysis of such changes would need to consider airport access and

if the additional travelling to minor cities poses excessive additional

risk.

High priority

10. Expand use of

PCR testing of

saliva in facility

workers (and

travellers)

Expand the regular (daily) use of PCR testing of saliva of facility

workers to all facilities in both countries. This approach could also

be considered for all travellers, albeit potentially still combined

with existing testing regimens. In view of increased transmissibility

of new variants, consideration should be given to testing of all

workers in border-associated occupations (eg, providing airline

meals and laundry services) at least twice per week. Documented

negative tests at appropriate frequency should be an occupational

requirement for all border workers instead of the self-report systems

High priority

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Policy option Description

Our priority

rankings

(as currently used in NZ).

11. Accelerate or

mandate

vaccination for

quarantine staff

Vaccinate all quarantine workers against COVID-19 and redeploy

all unvaccinated workers. This measure will be particularly valuable

when vaccines are known to prevent transmission in addition to

protecting recipients from illness.

As of April

2021, this is

measure is

nearing

completion in

some

jurisdictions

12. Cohorting

complete flights of

travellers

Cohorting of flights means that all returnees arriving into a country

go to the same quarantine facility until that facility is full and then

the intake switches to another facility and so on. This approach is

designed to reduce cross-infection in such facilities. This system

was introduced in NZ on 16 May 2021.

Medium

priority

13. Upgrade

processes at

quarantine facilities

Upgrade processes at quarantine facilities in terms of eliminating

shared spaces (eg, no shared exercise areas and shared smoking

areas), in particular ensuring that day cohorts do not mix under any

circumstances. Ventilation improvements could also be considered

with limiting the use of rooms to those with external windows.

Medium

priority

14. Prosecute rule

breaking in

quarantine facilities

Enforce quarantine facility rules more rigorously. Rule breaking,

which is relatively common in NZ facilities,

could start to be

prosecuted (given no prosecutions during 2020).

Medium

priority

15. Improve

conditions for

quarantine staff

Improve working conditions for the staff in quarantine facilities to

minimize the risk of overwork (which may increase the risk of PPE

failures) or of workers taking on other part-time jobs in other

settings. For example, in February 2021 there were still concerns by

NZ health workers about staffing inadequacies in these facilities.

High priority

16. Improve

management of

travellers who

smoke

Introduce specific measures for travellers who are nicotine

dependent to reduce their need to smoke in designated areas during

their travel and while in managed quarantine (eg, nicotine

replacement treatment as a requirement for travel).

Medium

priority

17. Add post-

quarantine control

measures

Introduce a post-quarantine period of home-quarantine to reduce the

risk of local transmission arising from undetected infections in

people leaving hotel quarantine facilities (which may arise from

either exceptionally long incubation periods or cross infection

during quarantine stays). Post-quarantine testing could also be used

to detect such infections.

Medium

priority

18. Mandate the

use of digital

contact tracing

tools

Mandate quarantine workers to use digital technologies (eg, the

Bluetooth function on the NZ COVID Tracer smartphone app) to

facilitate contact tracing in the event of a border failure. Travellers

could be required to use such technologies for two weeks after

completing their time in quarantine. There is also a case for

travellers using these tools within quarantine as (at least in NZ)

quarantine facilities are sometimes evacuated for fire alarms and

burst water pipes.

Medium

priority

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Conclusions

In summary, Australia and New Zealand have had 24 COVID-19 identified failures arising

from quarantine systems up to 31 March 2021. Quarantine system failures can be costly in

terms of lives and economic impacts such as lockdowns. Ongoing improvements or

alternatives to hotel-based quarantine are required.

Competing interests: Nil.

Funding: Prof Baker and Dr Kvalsvig received funding support from the Health Research

Council of New Zealand (20/1066). Dr Grout, Ms Katar, Dr Ait Ouakrim, Dr Summers, Prof

Blakely, and Prof Wilson did not have external funding support.

Appendix

Appendix Table A1: List of COVID-19 border control failures associated with quarantine

systems in Australia and New Zealand during 2020 and up to 31 March 2021

Event

Extent of

known

spread

Details

Event preventable

with full

vaccination of

frontline border

workers

(assuming 100%

effectiveness)?

Australia

Rydges Hotel –

Victoria "second

wave" outbreak

(late May to late

October 2020)

Over

19,800

cases,

26 27

and over

800

deaths

Genomic testing indicated that 99% of Victoria's

second wave of community COVID-19 cases were

linked to transmission events related to returned

travellers infecting workers at the Rydges Hotel in

Carlton and the Stamford Plaza Hotel (see row

below) in Melbourne's central business district

(CBD), which were used as facilities for quarantine.

Specifically, around 90% of cases can be traced

back to a single family of four that returned to

Australia in mid-May and were quarantined at the

Rydges Hotel.

The virus then spread from the

infected workers to the community, with high rates of

local transmission.

The outbreak led to a stringent

lockdown for 112 days in the state, with particularly

strict measures in the major city of Melbourne.

least nine people employed in Melbourne's hotel

quarantine program tested positive between late July

and early October 2020, although the cases may

have been a reflection of substantial community

transmission in Melbourne at the time rather than

additional hotel quarantine failures.

Two of those

cases worked while infectious.

Likely

Stamford Plaza

Hotel - Victoria

"second wave"

outbreak (late

May to late

See row

above

Almost 10% of cases in Victoria's "second wave"

outbreak were attributable to an outbreak at the

Stamford Hotel in mid-June.

The outbreak was

traced back to international travellers who returned

to Australia in early June,

and then was spread by

Likely

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Event

Extent of

known

spread

Details

Event preventable

with full

vaccination of

frontline border

workers

(assuming 100%

effectiveness)?

October 2020)

security guards who worked at the facility

Marriot Hotel at

Circular Quay in

Sydney, New

South Wales

[NSW] (August

2020)

2 security

guards

A security guard at the Marriot Hotel at Circular

Quay in Sydney tested positive for COVID-19 on 15

August.

Genomic sequencing linked the infection

to a returned overseas traveller at the facility.

second security guard subsequently tested

positive.

Likely

Parafield outbreak

in South Australia

(December 2020)

cases

Genomic testing indicated that Adelaide's Parafield

cluster was linked to transmission events related to a

returned traveller in a quarantine hotel infecting

workers in the facility, possibly due to poor

ventilation at the facility.

The virus spread from the

workers to the community, resulting in a strict

lockdown.

Likely

Quarantine hotel

facility cleaner

infected in

Sydney, NSW

(December 2020)

A single

worker

A quarantine hotel worker (a cleaner) who

completed shifts at two quarantine hotels, the Ibis

Hotel and the Novotel in Darling Harbour in Sydney,

tested positive in early December.

There was also

spread in a facility with 5 returned travellers being

infected.

Likely

Avalon outbreak

in NSW (January

2021)

151 cases

(as of 11

January

2021)

It has been reported that genomic sequencing

suggests that the strain is of US origin and entered

Australia via an infectious returned traveller who

entered hotel quarantine upon arrival.

It is currently

unknown how the virus spread to the community and

source investigations were still underway (as per

January 2021). Case numbers include those from

the linked Croydon and Wollongong clusters, but not

the linked Black Rock cluster in Victoria (27 cases as

of 5 January 2021) due to separate reporting by

states.

Unclear

Berala outbreak in

NSW (January

2021)

26 cases

(as of 11

January

2021)

It has been reported that genomic sequencing linked

the outbreak back to infectious international

travellers.

A patient transport worker transferred

infectious travellers from Sydney Airport to a

hospital.

37 38

Another patient transport worker who

was a close contact of the first then also tested

positive

37 38

The virus then spread from the second

infected worker into the community, seeding the

Berala outbreak.

Likely

Hotel Grand

Chancellor

outbreak in

Brisbane,

Queensland

(January 2021)

6 cases

(as of 13

January

2021)

A hotel quarantine worker in Brisbane tested positive

in early January 2021 for the UK variant of COVID-

19 (ie, B.1.1.7).

This case led to a three-day

lockdown in the greater Brisbane area, while contact

tracers worked to ensure there was no community

transmission of the strain.

It was later revealed that

there were six genomically linked cases within the

quarantine facility, including the hotel quarantine

worker and five returned travellers.

Likely

Four Points by A single A Perth quarantine hotel security guard, who worked

Likely

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Event

Extent of

known

spread

Details

Event preventable

with full

vaccination of

frontline border

workers

(assuming 100%

effectiveness)?

Sheraton

hotel,

Western Australia

(January 2021)

worker

a second job as a ride share driver, tested positive to

the UK strain of SARS-CoV-2, sparking a five-day

lockdown for 80 per cent of the state's population, in

an attempt to stop any further transmission.

It’s

believed he was exposed to the virus on the 26

January when he worked at Four Points by

Sheraton, on the same floor where a quarantined

returned traveller with a confirmed case of the UK

variant was staying. After feeling sick on 28 January,

the case visited a GP, and tested positive on 30

January. The exact cause is unknown, but it’s

believed poor ventilation could be a factor.

This

comes a week after Western Australia committed to

daily testing of the hotel quarantine staff, instead of

weekly.

Quarantine hotel staff, including cleaners,

security guards and catering staff, are no longer

allowed to have second jobs but will receive a pay

increase of about 40 per cent as compensation.

has been announced an inquiry will be held.

Grand Hyatt

Hotel, Victoria

(February 2021)

A single

worker

One 26-year-old staff member at the Grand Hyatt

Hotel (an isolation facility) tested positive for the

highly transmissible UK variant of COVID-19 (ie, the

B.1.1.7 variant) in February 2021, leading to

heightened restrictions.

The close contacts of the

case all tested negative, and the outbreak did not

spread into the wider community.

Likely

Holiday Inn Hotel

Cluster, Victoria

(February 2021)

22 cases

Twenty-two cases have been linked to the Holiday

Inn cluster in Melbourne, where an infected returned

traveller used a nebuliser, causing an outbreak and

a 5-day lockdown.

There were no further cases

detected in the community during the lockdown as

all confirmed cases had already been informed of

their status as close contacts and were in isolation

for the duration of their infectious period. Cases

included returned travellers, hotel quarantine staff

and their families, as well as a Melbourne Airport

worker.

Likely

Princess

Alexandra

Hospital Doctor

outbreak,

Brisbane (March

2021)

6 cases

A doctor and a nurse (see row below) who worked at

the Princess Alexandra Hospital while unvaccinated

were linked to two separate COVID-19 outbreaks.

While both outbreaks were the highly transmissible

UK variant of the disease and originated at the same

hospital, they were from two different sources.

The

doctor tested positive on 12 March 2021, with

subsequent infections in 5 other persons.

These

outbreaks resulted in a 3-day lockdown just before

the Easter holiday.

Likely (we

considered health

workers at the

Princess Alexandra

to be “border

workers” given that

the hospital

patients were still

part of the

quarantine system)

Princess

Alexandra

Hospital Nurse

outbreak,

cases

A nurse (see row above) who worked on a COVID-

19 ward at the Princess Alexandra Hospital while

unvaccinated tested positive in late March.

Genome sequencing links the case to an overseas

Likely (we

considered health

workers at the

Princess Alexandra

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Event

Extent of

known

spread

Details

Event preventable

with full

vaccination of

frontline border

workers

(assuming 100%

effectiveness)?

Brisbane (March

2021)

traveller from India who was being cared for at the

hospital.

The nurse's sister, a number of attendees

at a “hen's party”, and several other contacts were

subsequently infected.

to be “border

workers” given that

the hospital

patients were still

part of the

quarantine system)

Sofitel Wentworth

Hotel in Sydney,

NSW (March

2021)

A single

security

guard

A security guard at the Sofitel Wentworth in Sydney

tested positive for COVID-19 on 13 March through

routine surveillance testing.

Genomic sequencing

linked the case to a returned traveller and

subsequent testing revealed that another returned

traveller was also infected within the facility.

Likely

New Zealand

Auckland August

2020 outbreak

A total of

179

cases,

with 3

deaths

The cause of this outbreak remains unknown, but

genomic work probably provides the best evidence

to this being a border facility (isolation or quarantine

facility) failure: “There are a large number of similar

genomes which are from the UK, which would seem

to suggest the UK is the most likely source of any

unknown importation”.

This was at a time when

40% of cases in NZ quarantine/isolation facilities did

not have genomic work on the virus infecting them

(ie, there was not enough complete virus in the

samples). It was also estimated

that there was only

a very tiny risk of this outbreak being a continuation

of the March/April spread of the pandemic in NZ:

“Our Bayesian phylogenetic analysis … estimates

that there is a 0.4% probability that case 20VR2563

is in the “sister clade”' of the Auckland cluster.”

Finally, the chance of the outbreak being from

contaminated imported food was also considered

very unlikely: “Our Bayesian phylogenetic analysis

… shows that the estimated mutation rate on the

branch leading to the cluster is not a lot smaller than

elsewhere in the tree, lending little weight to the

possibility that the virus lay dormant on packing

material for a long period of time.”

Unclear

Border facility

maintenance

worker infected

(August 2020)

A single

worker

A shared lift environment in a quarantine hotel (the

Rydges Hotel in Central Auckland was the source

suspected by officials,

with the sharing being only

minutes apart.

The genomic sequencing indicated

the same virus infecting the worker as per a recent

traveller in the same facility.

Likely

Border facility

health worker

infected

(September 2020)

A single

worker

This was a work-related infection associated with a

hotel facility used for isolating infected cases (the Jet

Park Hotel, Auckland), given that the case was

linked via genomic sequencing to 3 cases within the

facility.

Some details of the full investigation report

were provided to the media and these suggested

that while the nurse wore personal protective

equipment (PPE), there was a period where the

Likely

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Event

Extent of

known

spread

Details

Event preventable

with full

vaccination of

frontline border

workers

(assuming 100%

effectiveness)?

associated patient did not have a mask on during

treatment.

This situation could have contributed to

a failure of the PPE worn by the nurse.

Traveller-related

outbreak /

Christchurch

border facility

(September 2020)

The

traveller

and 2

others

(total of 3

cases)

This person was thought to have been infected

within a hotel quarantine facility before then moving

into the community, according to the Ministry of

Health.

This infected traveller appears to have then

infected another person (the Ministry suggest this

may have occurred on a charter flight after leaving

the facility).

A household contact was also reported

as becoming infected.

Border facility

health worker

(Case A) in

Christchurch (Nov

ember 2020)

A single

worker

This was a work-related infection associated with a

facility used for isolating infected cases. Both this

case (and “Case B” below) had the virus genome

sequencing linked to infection in a group of

international mariners in the same hotel facility but

with different virus subtypes in each case.

“The

finding supports the current theory that there were

two separate events infecting both workers at the

facility.” These cases of infected health workers

appear to have contributed to border control nurses

threatening strike action if they were not supplied

with improved PPE.

One estimate was that 12 of

the mariners were infected on arrival in NZ, but with

subsequent spread within the facility a total of 31

mariners were ultimately infected.

Likely

Another border

facility health

worker (Case B)

(see above)

A single

worker

This was a separate work-related infection

associated with a border control facility – see in the

row above.

Likely

Defence Force

worker outbreak

(November 2020)

The

worker, a

co-worker

and 4

others

(total of 6

cases)

This was a work-related infection in a Defence Force

worker associated with a hotel border facility in

Auckland (used for isolating known infected cases).

“The genome sequencing we have conducted on

Case A’s test result shows a direct link to two

travellers who are part of a family group in the

quarantine facility”.

The route of transmission to

one of the community cases remains a mystery

(albeit they worked in the same locality within

Auckland City). Associated with these cases, the

Prime Minister made statements around the need for

further risk reduction.

Likely

Traveller

infectious after

leaving a

quarantine facility

(January 2021)

1 traveller

A traveller was identified as being infectious in the

community after leaving a quarantine facility

(Pullman, Auckland). The traveller reportedly had the

South African variant (lineage B.1.351) of the

pandemic virus.

Genome sequencing has linked

this case to another traveller who was in the same

facility.

The transmission mechanism has not been

precisely identified with investigations still

proceeding as of mid-February 2021. However,

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Event

Extent of

known

spread

Details

Event preventable

with full

vaccination of

frontline border

workers

(assuming 100%

effectiveness)?

officials consider it likely to have been a separate

transmission event to the one in the following row.

Travelers

infectious after

leaving a

quarantine facility

(January 2021)

travellers

and a

contact

Two travellers (a parent and child) were identified as

infectious in the community after being infected with

the South African variant (lineage B.1.351), of the

pandemic virus with a link to a quarantine facility

(Pullman, Auckland).

A close contact (the mother

of the child) also became infected.

The

transmission mechanism has not been precisely

identified with investigations still proceeding as of

mid-February 2021.

MIQ workers

(March 2021)

3 workers

A cleaner at the Grand Millennium Hotel MIQ facility

in Auckland (Case A) tested positive during routine

surveillance testing on 22 March 2021.

While a

household contact returned a weak positive the next

day,

subsequent tests were negative.

The MIQ

worker had recently been vaccinated (with the

Pfizer/BioNTech vaccine) on 23 February, with a

second dose on 16 March,

although they tested

positive before full protection from the vaccine could

be expected. Their family had not yet been

vaccinated.

Genome sequencing revealed that

Case A was infected with the highly transmissible

variant first identified in the UK (B.1.1.7) and was

linked to a traveller in the facility who had arrived on

13 March.

In early April, two unvaccinated security

guards at the same facility tested positive (Cases B

and C) and genome sequencing linked the two

cases to Case A.

69 70

Likely

Approaches to managing quarantine in Australia and New Zealand

Table A2 details the various approaches to quarantine used in both countries. Key features of

which are summarised below:

• The length of quarantine in all jurisdictions is 14 days.

• Almost all jurisdictions require at least two separate PCR tests for travellers: one

shortly after arrival and another closer to the end of the quarantine period.

• Many jurisdictions have introduced or are considering additional tests for travellers,

either earlier in (eg, Day 0/1 in New Zealand) or after (eg, Day 16 in New South

Wales) the quarantine period. This is in response to concerns about new highly

infectious variants in early 2021.

• Australia does not currently have a national strategy for quarantine.

• Detailed information on quarantine programs for each Australian state/territory is

limited and in many cases we had to rely on news articles for additional details in

compiling Table A2. Descriptions of PPE required for quarantine staff in different

jurisdictions were particularly difficult to identify and information often was not

available by staff role (eg, security guards vs cleaners).

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Appendix Table A2: Description of key infection control processes and surveillance at quarantine facilities in Australia and New Zealand as of 31

March 2021 (with the length of quarantine being 14 days in all jurisdictions)

Jurisdiction

PCR testing regimen for

travellers

PCR testing

regimen for staff

Mask

requirements for

travellers

(outside of

rooms)

Mask

requirements

for staff

Shared space

restrictions

Comments and historical

changes of note

New Zealand

(NZ)

NZ requires evidence (with

some exemptions) before

boarding of an aircraft to

NZ from most international

locations of a COVID-19

pre-test of either a PCR

(including RT-PCR), LAMP

or antigen test taken 72

hours before scheduled

departure (introduced

between 15 and 25

January 2021).

requires tests on days: 0/1

(most), 3 and 12.

Weekly

(nasopharyngeal

swab) for some

staff,

but with

selected

voluntary use of

daily saliva

(PCR) testing in

selected

locations. Staff

transporting

travellers to

hotels are also

subject to

testing.

It is

possible that the

required testing

has not been fully

undertaken in

some

instances.

Single-use face

masks are

provided to

travellers and are

to be used when

outside of room.

They are required

to be worn if

someone enters a

hotel room, such

as during testing.

Surgical or

procedure

masks to be

worn by staff if

nearby

travellers.

N95/P2 masks

to be worn by

staff when 2

meters

physical

distancing

cannot been

maintained by

staff when

nearby

confirmed or

probable

cases of

COVID-19

(effective 26

November

2020).

There are some

restrictions, with

travellers in some

facilities required

to book allocated

times to access

shared spaces –

but there remain

shared

recreational,

exercise, and

smoking areas in

most facilities.

The testing process has changed

over time with a day 0/1 test

introduced in January 2021 for

travellers from most countries

(excluding those from some low-

risk countries). On some occasions

the infection control processes in

the facilities were found to be

suboptimal (eg, 19 mariners

infected while in one facility

Some facilities run daily bus trips to

take travellers to outdoor exercise

areas, a practice which has raised

concerns from epidemiologists.

Vaccination of staff was initially not

required, however, if staff are not

vaccinated, they will be redeployed

to a non-frontline role.

76 77

Australian States and Territories

Australia requires evidence (with some exemptions) for boarding aircraft to Australia from most international locations of a negative COVID-19 PCR test taken 72

hours or less before scheduled departure (introduced on 22 January 2021).

Australian

Capital

Territory

ACT requires tests

between days 0-2 and

between days 12-13.

Asymptomatic

staff to be tested

every 7 days.

79 80

Masks must be

worn when

opening hotel

Possible

surgical mask

use (as

Travelers are

required to remain

within their hotel

To date, ACT has only accepted

repatriation flights.

All front-line quarantine workers are

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Jurisdiction

PCR testing regimen for

travellers

PCR testing

regimen for staff

Mask

requirements for

travellers

(outside of

rooms)

Mask

requirements

for staff

Shared space

restrictions

Comments and historical

changes of note

(ACT)

doors

If sharing

a hotel room and

COVID-19

symptoms

develop, a face

mask must be

worn inside the

hotel room.

suggested by

photographic

evidence).

room

required to be vaccinated for

COVID-19 as a condition of

employment (policy announced in

late March 2021).

Queensland

Tests required on days 2

and 11.

Staff are required

to have throat &

nasal swabs or a

saliva test within

7 days after

commencing

work at a facility,

and then daily

saliva testing,

with rolling throat

& nasal swabs

every 7 days.

Travelers are

required to wear a

face mask when

traveling to a

quarantine hotel

until reaching the

hotel room.

Travelers are also

requested to wear

marks where

appropriate.

Staff are

required to

wear PPE

(including a

surgical

mask

) when

entering a

traveller’s

room to

conduct

COVID-19

tests.

Travelers have no

access to shared

facilities and are

required to remain

within their

allocated room.

Testing clinicians ‘may’ ask

travellers to wear ‘appropriate PPE’

when being tested for COVID-19.

Testing clinicians are advised not to

enter a traveller’s room unless

there is no other way to collect

specimen.

Staff who working

within direct or indirect contact are

required to be vaccinated.

New South

Wales

(NSW)

Tests required on days 2

and 12.

PCR or saliva

collection: Hotel

staff in

quarantine facility

(effective 14

December 2020)

and persons

providing security

services to

quarantine facility

(effective 11

January 2021);

Travelers are

typically not

allowed outside of

rooms.

Additional

information was

not available on

mask requirements

for travellers.

PPE (including

a surgical

mask) when

conducting

COVID-19

test,

cleaning

rooms,

transferring

travellers and

their

luggage.

No smoking, e-

cigarette use, or

outside exercise

allowed while in

hotel

quarantine.

89 92

In February 2021, NSW introduced

a test for travellers on day 16.

Saliva swabs are also required from

the following designated quarantine

facility workers once per shift, taken

during shift: NSW Police Officers

(effective 20 January 2021), and

Healthcare staff providing medical

treatment or care to a person

(effective 18 January 2021).

Quarantine transport workers

(effective 21 January 2021)

and

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Jurisdiction

PCR testing regimen for

travellers

PCR testing

regimen for staff

Mask

requirements for

travellers

(outside of

rooms)

Mask

requirements

for staff

Shared space

restrictions

Comments and historical

changes of note

testing taken

once per shift,

during shift.

90 91

designated airport workers also

receive daily saliva testing.

Vaccination is not currently

compulsory for staff.

Northern

Territory

At the Howards Springs

quarantine facility travellers

are tested upon arrival.

remains unclear how many

other COVID-19 tests are

required and when.

Daily testing

(nasal swab) of

staff at Howards

Springs

quarantine

facility.

99 100

Masks provided to

travellers, and

must be worn

when on veranda

of allocated room,

and when opening

door of room, or

going outside of

room.

101

Staff are

required to

wear PPE

(including a

surgical mask)

when

interacting with

travellers, and

are also

required to be

photographed

in their PPE

before starting

a shift.

There are

balconies

attached to each

traveller’s cabin

for individual use,

and also used

during COVID-19

testing at the

Howard Springs

quarantine

facility.

100

However, it is

unclear whether

reports of use of a

swimming pool

are correct.

Managed quarantine is not

undertaken in hotels and is closer

to ideal in terms of ventilation and

reduced shared space: ‘In Darwin,

rooms are single accommodation,

with no internal connecting doors

between the rooms. In Alice

Springs families are accommodated

in shared rooms, based on room

availability at the time.

101

' In some

managed supervised quarantine

locations, they do not allow for

delivery services.

101

Movement of

staff within the Howards Springs

quarantine facility is restricted.

Staff buddy systems are in place,

and careful monitoring of PPE use

with photographs of PPE taken

before each shift at Howards

Springs quarantine facility.

100

Vaccination of staff began in late

February 2021.

102

South

Australia

Tests are required on days

0, 5, and 13.

103

Staff are required

to have nose and

throat swabs

once every 8

days.

104 105

Masks must be

worn when

opening hotel

doors.

103

Returned

travellers are only

allowed to leave

their rooms in an

‘Hotel staff

must wear

appropriate

PPE and

maintain at

least 1.5

meters

Travelers must

remain within their

hotel room.

103

A requirement for a day 16 test for

travellers after leaving hotel

quarantine may be introduced in

February 2021.

107

Additionally, as

of 8 February 2021, hotel

quarantine workers were required

to have daily saliva tests.

107

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Jurisdiction

PCR testing regimen for

travellers

PCR testing

regimen for staff

Mask

requirements for

travellers

(outside of

rooms)

Mask

requirements

for staff

Shared space

restrictions

Comments and historical

changes of note

emergency

situation.

distance from

guests at all

times’.

106

Vaccination of staff is not

compulsory (current as of February

2021).

108

Tasmania

Tests are required within

48 hours of entering

quarantine and after day

10 of the quarantine

period.

109

Staff must get

tested every 5 to

8 days after their

first shift, then

tested every 5 to

8 days, until 14

days after their

last shift.

110

Required to wear a

facemask when

travelling to

quarantine hotel

and if leaving the

hotel room for an

approved purpose

(such as seeking

medical care) a

face mask must be

worn at all times

(unless an

exemption

applies).

109

Transport,

security, and

health officials

involved in

hotel

quarantine will

have

'appropriate

PPE'.

111

Travelers must

remain within their

hotel room.

109

Hotel quarantine workers given

wage supplements to prevent them

taking second jobs in effort to

reduce risk of COVID-19

transmission – December 2020.

112

Workers at government-designated

quarantine sites must undertake

saliva screening once per shift.

110

Vaccination of staff is prioritized in

Tasmania, and currently not

compulsory.

113

Victoria

Tests are required within

24 hours of arrival in

Victoria, as well as on (or

about) days 4, 12 and

14.

114

Daily testing is

required for staff

(even on days

off).

21 115

Travelers are not

allowed to leave

their rooms unless

there is an

emergency.

Travelers must

wear masks when

opening the doors

to collect their

food.

Full PPE is

required for

staff while on

shift.

There are no

shared spaces;

returned travellers

must remain in

their rooms.

After the significant failure that led

to over 19,800 cases, and over 800

deaths, Victoria began welcoming

returned travellers in December

with a revamped hotel quarantine

system which included a number of

improvements, such as daily testing

of staff, voluntary regular testing of

family members of staff, advanced

contact tracing, a ban on secondary

face-to-face employment for key

staff, strengthened PPE protocols,

and dedicated 'health hotels' for

positive and suspected cases and

their close contacts.

All front-line

staff were to be vaccinated with first

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Jurisdiction

PCR testing regimen for

travellers

PCR testing

regimen for staff

Mask

requirements for

travellers

(outside of

rooms)

Mask

requirements

for staff

Shared space

restrictions

Comments and historical

changes of note

dose by early April

116

Western

Australia

Tests are required within

24 hours of arrival and

again on day 12.

117

Staff must

undergo a nose &

throat PCR test

every 7 days

along with a daily

self-collected

mouth swab PCR

test, effective

from 31 January

2021.

118

Travellers are

required to wear

masks when

opening hotel room

door (must be put

on 2 minutes

before opening

door).

119

Travelers

must remain in

their rooms.

Hotel

quarantine

security staff in

Perth were not

required to

wear masks

up to early

February

2021,

120

however

masks and

eye protection

are now

required (from

late February

2021).

121

Individuals in

quarantine are

required to remain

in their hotel

room; any

exercise must be

done inside the

hotel room and no

smoking is

allowed in

hotels.

117

Previous PCR testing from 8

January 2021 for staff only required

testing every 7 days and no daily

mouth swab.

118

Certain hotel

quarantine workers, including

security guards, cleaners, and

catering staff, have been given a

40% wage increase and are no

longer allowed to hold a second

job.

There are possible plans to

make vaccination compulsory for

staff.

122

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References

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