AHPPC statement on national principles for end-to-end best practice managed quarantine arrangements for international travellers
A statement from the Australian Health Protection Principal Committee (AHPPC) on managed quarantine arrangements for international travellers.
Quarantine for international arrivals to Australia – including hotel quarantine and other highly controlled settings – has been Australia’s first line of defence against COVID-19. It continues to play a vital role in Australia’s public health response. The Australian Health Protection Principal Committee (AHPPC) is committed to continuously improving managed quarantine arrangements, in line with the AHPPC Framework for Continuous Improvement. This includes considering and implementing the recommendations of previous reviews into managed quarantine.
The National Principles for End-to-End Best Practice Managed Quarantine Arrangements for International Travellers (the Principles) are intended to bring together existing AHPPC guidance to set nationally agreed benchmarks for managed quarantine programs across Australia.
The AHPPC will periodically review the Principles to ensure they reflect emerging evidence and the latest expert medical advice.
End-to-end best practice arrangements
- The priority for managed quarantine is to minimise the risk of COVID-19 transmission and protect the Australian community. This is consistent with Australia’s current strategy to manage COVID-19 consistent with public health management of other infectious diseases in line with the Post-Vaccination Phase of the National Plan to transition Australia’s National COVID-19 Response.
- Managed quarantine programs should apply a Framework for Continuous Quality Improvement. This should:
- encourage an environment of constant vigilance
- apply assurance processes with regular audits against standards for quarantine
- regularly review controls and their effectiveness
- share results of audits, evaluations and reviews with all states and territories to enable cross learnings.
- End-to-end best practice managed quarantine arrangements should use a system-based risk managed approach which considers risk of exposure and applies appropriate mitigations throughout the quarantine period. This includes arrival in Australia at international ports of entry, transfers and stays in quarantine facilities, and release from quarantine and return home or other location.
- Managed quarantine programs require strong and transparent governance arrangements that include escalation mechanisms. This includes clear chains of command and decision-making processes, with cross-agency coordination, and strong communication.
- Operational plans should be regularly updated in line with the best available advice. Information management systems should support record keeping and reporting, and information sharing to enable shared learnings. Recording and sharing comprehensive information on transmission events and incursions assists to identify weaknesses and optimise best practice arrangements.
- Continuous monitoring and evaluation of managed quarantine is essential for guiding national policies, protocols and procedures.
- High quality and comprehensive data collection strengthens managed quarantine decision-making. Effective data collection, validation and sharing should be supported through daily collection of data required for national reporting, and sharing of case data for contact tracing purposes.
Infection prevention and control (IPC)
- Quarantine programs must use a systematic risk management approach to minimise the risk of transmission of SARS-CoV-2 and apply effective controls using the hierarchy of controls. This is a step-by-step approach to manage risks. It ranks controls from the highest level of protection and reliability through to the lowest and least reliable protection. Risk management plans should use higher level controls where possible.
- Managed quarantine programs should use strong end-to-end IPC processes in line with nationally agreed advice as outlined by AHPPC and its expert sub-committees and jurisdictional standards.
- This includes comprehensive IPC training for all staff, with regular reviews of practices. All staff should be trained to use appropriate personal protective equipment (PPE), in line with jurisdictional requirements.
- Minimise the risk of transmission to quarantine workers. All workers should have an adequate understanding of their role and responsibilities in relation to IPC practices, behaviours and reporting requirements, if concerns are identified. Appropriate supervision is required at all times and a strong reporting culture of speaking up for safety and alerting supervisors to concerns should be fostered.
Minimising transmission risk
- Testing, screening and surveillance for international arrivals and workers involved with managed quarantine programs should align with national guidelines endorsed by the AHPPC.
- Requirements for managed quarantine staff may align with national guidelines endorsed by the AHPPC and expert sub-committees, noting that states and territories have different arrangements in place. This includes requirements regarding:
- daily routine testing of quarantine workers
- secondary employment in high risk settings
- testing following employment in the managed quarantine program.
Ensure staff involved with managed quarantine programs are aware of these requirements.
- To minimise transmission risk, international travellers or other high infectious risk quarantine residents should be quarantined separately from other lower risk residents. This may involve designating different facilities or zoning through allocating separate areas in a facility (i.e. designating floors for international or other high risk travellers). Where possible, staff should be allocated to specific zones.
- Consideration should be given to minimising the risk of transmission among staff, in line with the hierarchy of controls. This may involve moving infected individuals and close contacts to designated areas within the facility or hospital facilities. Designated staff should oversee and care for confirmed cases.
- It is mandatory for all quarantine workers to receive COVID-19 vaccination. This includes those directly employed in quarantine facilities under Commonwealth, state or private arrangements. This also includes anyone who works in places of high infection risk related to the international border (i.e. red zones). Jurisdictions may implement additional requirements for vaccination status for quarantine workers.
- Facilities to be used for managed quarantine must be selected against criteria that meet standards for health, safety and wellbeing, as outlined by AHPPC and its expert sub-committees and jurisdictional standards.
- This includes considering the suitability of the facility for establishing and operating IPC processes in line with the hierarchy of controls:
- Environmental assessment of the facility with consideration of airflow and ventilation, with introduction of additional controls to mitigate risk where relevant. Specific mitigations will depend on recommendations of the environmental assessment noting the unique nature of each quarantine facility, and may include controls such as:
- room spacing (e.g. using every second room in a hotel corridor), sealing above door vents, and application of door sweepers or stoppers
- engineering measures such as scrubbers or changes to building ventilation such as increased air exchanges
- education and training for workers and arrivals to minimise door openings.
- Selecting floor layouts with consideration of door placement and the ability to maintain physical distancing above the standard 1.5m, where possible, including in foyers and common areas.
- Providing adequate security and monitoring of international arrivals and workers, including using remote means such as CCTV in common areas. Remote observation can support minimising the presence of security staff in close proximity to quarantined individuals, noting that an onsite security presence may also be required.
- The primary objective of managed quarantine is to minimise the risk of transmission. However, where possible, site selection should also consider optimising wellbeing. Where available, preference may be given to accommodation that:
- permits access to fresh air (such as balconies and opening windows), where appropriate, in line with jurisdictional guidance
- rooms that are self-contained apartments with kitchenette and laundry facilities.
- Adequately separating quarantined individuals from the community. This includes considering commercial businesses operating within the facility and guests other than quarantined individuals staying in the facility. Managed quarantine facilities should be used only for quarantined guests wherever possible.
- Providing appropriate resources for health care delivery at the facility, for both quarantined individuals and staff. This includes access to equipment for telehealth services.
- Equipping facilities to support the needs of people with underlying health conditions and impaired function, and considering these needs when allocating appropriate accommodation.
- Ensure managed quarantine facilities are close to international ports of entry and hospital services that are capable and prepared to manage quarantined individuals and COVID-19 cases.
- Consider the vulnerability and cultural needs of both quarantined individuals and the local population of the quarantine facility.
Airflow and ventilation
- Managed quarantine programs should give consideration to airflow and ventilation requirements in other settings within the quarantine program, such as vehicles used to transport individuals to quarantine.
- Risk management should consider the risk of transmission events related to airflow and air pressure within the indoor environment, as informed by a ventilation assessment and monitoring of indoor air quality. Appropriate mitigations should be applied using the hierarchy of controls.
- Airflow should be optimised so that it travels from clean areas to potentially contaminated areas, to reduce the risk of staff and occupants being exposed to aerosols. Door openings should be controlled to manage risk.
- Where engineering measures do not adequately manage risk, additional controls are required. These may include increased distancing, remote monitoring (e.g. CCTV) and/or additional administrative mitigations.
- Air quality may be optimised by controlling occupancy rates and arrangements (i.e. alternate rooms) to support airflow and ventilation in different parts of a quarantine facility.
- Managed quarantine programs should give appropriate consideration to heating and ventilation and air conditioning (HVAC) systems used within quarantine sites:
- Managed quarantine programs should ensure that HVAC systems function as designed and are appropriately serviced in line with relevant standards. Relevant guidance is available through the Australian Health Facility Guidelines (Part D – Infection Control; Part E – Building Services and Environmental Design).
- Technical guidance on strategies that may be employed in response to airborne infectious outbreaks is also available, however, final recommendations should be based on a site assessment in line with the hierarchy of controls and in line with jurisdictional guides.
- Best practice guidelines for HVAC hygiene are available via the Australian Institute of Refrigeration, Air Conditioning and Heating.
- Prior to occupancy, all sites should undergo assessment and inspection to assess ventilation (e.g. checking for damage or leaks).
- Managed quarantine programs should consider engineering controls to reduce the risk of airborne transmission through aerosols of SARS-CoV-2. This should be based on a site assessment, however, controls may include:
- increasing the ventilation rate of the HVAC unit
- optimising air temperature and humidity with consideration of individual tolerance (e.g. 20 - 250C and 40 – 60% humidity)
- upgrading HVAC systems particulate filters, particularly when outdoor air delivery is limited.
- Administrative controls should also be considered, such as cohorting groups (e.g. by date of arrival) to areas supplied by different ventilation systems.
- Additional control measures can be used to complement HVAC engineering controls. Managed quarantine programs may consider the use of High Efficiency Particulate Air (HEPA) filters (including portable units) as part of their risk management approach, in line with jurisdictional guidance.
Personal protective equipment (PPE)
- Managed quarantine programs should undertake facility specific risk assessments and develop management plans which clearly define areas based on risk of transmission. There should be specific policies and procedures based on defined high and low risk areas with advice for when to use PPE and appropriate PPE to use depending on circumstances. For more information see ‘Guidance on the use of personal protective equipment (PPE) for health care workers in the context of COVID-19’.
- Managed quarantine facilities should ensure that all staff are trained in when and how to use appropriate PPE including donning and doffing, and undergo regular refresher training to ensure best practice, in line with jurisdictional recommendations.
- Consideration may also be given to implementing a buddy system to optimise compliance with IPC controls, including PPE. This may include requirements for buddy systems and photographing PPE use in high risk areas depending on jurisdictional requirements.
- Staff should be provided with clear information to support PPE training and ongoing practice. This may include placing clear signage within quarantine sites on PPE donning and doffing procedures and providing staff with handouts of frequently asked questions.
- Some staff will be required to wear particulate filter respirators (PFRs) (e.g. P2 and N95 masks), in line with jurisdictional guidance or when indicated by a risk assessment. The facility should develop and implement a respiratory protection program to support staff to appropriately use this PPE.
- Facilities should have sufficient choice and supply of PFRs to meet individual needs, noting differences in fit and individual preference.
- All PFRs must be fit-checked and fit-tested, and quarantine programs should have appropriately resourced fit testing programs. More information is available at ‘Guidance on the use of personal protective equipment (PPE) for health care workers in the context of COVID-19’.
- Managed quarantine facilities should establish processes to minimise exposure risk during donning and doffing of PPE. This may involve having PPE trolleys or kits with dedicated donning and doffing stations strategically positioned throughout the facility as per local risk assessment to ensure PPE is readily available and accessible. PPE should be disposed of appropriately, according to how the facility is zoned.
- It is recognised that PPE is one of several lines of defence and that inadvertent errors and lapses can occur. Particular care should be exercised regarding the use of PPE when other measures cannot be fully implemented (e.g. when close physical contact is required with a guest who is unwell or highly distressed). Further advice on audit and assurance is available in the AHPPC Continuous Improvement Framework.
- Interactions between staff and quarantined individuals should be minimised wherever possible, to reduce the risk of transmission.
- Managed quarantine programs should consider options for remote management of individuals, for example through the use of CCTV for security observation and telehealth for medical consultation to reduce opportunities for contact.
- Once guests arrive in their room accommodation they should avoid entering common areas. Protocols should be in place to minimise the risk of transmission when quarantined individuals enter common areas (e.g. opening doors to hallways, hotel foyers or elevators).
- As a minimum national standard, quarantined individuals must wear face masks when opening doors, and should wait until after staff leave before receiving deliveries. Considerations should also include staggering delivery times and minimising door openings through once-a-day deliveries.
- Managed quarantine programs should take precautions to reduce the risk of transmission between staff.
- Where possible, quarantine staff should minimise their duration in common areas, such as corridors, tea rooms, and bathrooms. Physical distancing should be maintained in these areas. Jurisdictions may considering placing time limits on staff in these areas.
- Managed quarantine programs may consider options to stagger attendance in common areas. This should include consideration of staff rosters and work schedules, and the use of CCTV or other technologies to monitor attendance in common areas.
- Jurisdictions may consider additional requirements to minimise the risk of transmission between staff. Depending on jurisdictional guidance, this may include having designated accommodation for workers during their assignment, implementing restrictions on the use of public transport and ride-share, or implementing requirements for staff to work at a single quarantine site.
- Managed quarantine programs should adhere closely to jurisdictional requirements for room occupancy. Managed quarantine programs may consider implementing additional density restrictions within the quarantine environment (e.g. common areas); this should be done on the advice of jurisdictional IPC expertise.
- Exceptions may occur when housing family groups, however, consideration should be given to minimising the risk of transmission both within the family group and within the facility. This may include establishing buffer rooms around larger family groups and/or establishing maximum occupancy for family rooms. Impacts on ventilation and airflow should be considered.
Cleaning and disinfection
- Managed quarantine programs should undertake regular and thorough cleaning and disinfection of risk areas in line with jurisdictional requirements. Cleaners should use disinfectants approved for use against COVID-19 by the Therapeutic Goods Administration. Guidance regarding cleaning common areas and thorough disinfection of rooms following a quarantined individual or case departing to prepare for new arrivals (terminal cleaning) is available at ‘Information about cleaning and disinfection for health and residential care facilities’.
- Cleaning staff should undergo comprehensive PPE training, as this is likely to be required during environmental cleaning of quarantined individuals’ rooms and common areas.
- Cleaning practices should be considered as part of IPC audits. This may be supported through process measures such as cleaning checklists, visual inspections or the use of UV fluorescent gel markers during audits.
- Waste management should follow usual practices, with clinical waste disposed of in clinical waste streams (in line with advice from the on-site designated IPC person), and non-clinical waste disposed of in the general waste stream.
Managing high-risk individuals
- To minimise transmission risk, international travellers or other high infectious risk quarantine residents should be quarantined separately from other lower risk residents. This may involve designating different facilities or zoning though allocating separate areas in a facility (i.e. designating floors for international or other high risk travellers). Where possible, staff should be allocated to specific zones.
- In line with jurisdictional guidance, managed quarantine programs should identify individuals who, despite current arrangements, pose a greater risk of transmission events.
- Risk is based on individual assessments which may consider a range of factors including:
- the person or groups point of origin
- family size and dynamics
- consideration of medical conditions (e.g. immunocompromised individuals may present with higher loads)
- mental health or behavioural issues
- treatments (e.g. those requiring nebulisers or CPAP machines).
- The designated on-site IPC person or person/s may assist in identifying individuals in these higher risk circumstances, to ensure they can be managed appropriately. Consideration may be given to alternative management options such as transfer to a different facility (e.g. medi-hotel).
- Risk is based on individual assessments which may consider a range of factors including:
Health and mental health
- The health, mental health and wellbeing of international arrivals and workers is paramount in all managed quarantine programs. Proactive supports need to be available, in-line with ‘Advice on mental health screening, assessment and support during COVID-19 quarantine’.
- Managed quarantine programs should give due consideration to the health and functional needs of individuals entering quarantine (such as people with underlying health conditions, impaired function and disability). Quarantine programs may provide additional services to support these needs or consider alternative accommodation arrangements.
- States and territories should have processes in place to consider individuals’ circumstances and functional needs when assessing applications for exemptions on compassionate and medical grounds. This includes considering circumstances where individuals’ functional needs cannot be adequately met in a quarantine environment (e.g. individuals with assistance animals where no appropriate accommodation for animals is available).
- Managed quarantine programs should be able to manage underlying and chronic medical conditions of quarantined individuals. Clinical care should be available through telehealth and onsite when required. Individual states and territories may explore alternative quarantine arrangements (e.g. on-farm quarantine) for certain low risk cohorts in regional or remote locations.
- Managed quarantine programs must have clear escalation processes with the ambulance and hospital sector for a health emergency. Consider separate facilities for positive cases or those with complex needs.
Post quarantine arrangements
- All travellers leaving managed quarantine must get tested and isolate until they receive a negative test result if they develop symptoms at any time in the 14 days after leaving quarantine.
- AHPPC agrees that all international travellers should get tested at days 16 or 17 following quarantine, if there have been potential exposure sources within the quarantine facility, regardless of whether they have symptoms.
- Options are being explored to support post-quarantine testing at the national level. AHPPC will continue to explore the management of persons post-quarantine to reduce the risk to the community whilst testing is being undertaken.
Continuous improvement framework
- States and territories will regularly review their managed quarantine programs to identify and address areas for improvement as they arise.
- Jurisdictions should develop assurance processes for managed quarantine programs to inform and refine processes and support continuous improvement.
- Programs should consider the inclusion of routine regular monitoring and compliance.
- Formal reviews should be conducted following transmission events to inform best practice arrangements.
- Assurance processes should take into account differences between jurisdictional guidance and operations.
- Jurisdictions may also consider peer reviewing managed quarantine programs from time to time.
- Checks, audits and reviews are to focus on assuring compliance and identifying aspects of the system that could be managed by the modification of existing controls, or by the application of additional controls.
- Risk mitigation strategies and resourcing decisions should be informed by the Hierarchy of Controls to prevent and reduce transmission of COVID-19.
- The hierarchy of controls ranks mitigation measures by the level of protection and reliability, so that higher level controls are implemented, where possible. For example, pre-flight testing of individuals aims to prevent importation of COVID-19 into Australia – a higher level control. Whereas the use of PPE is a lower level control aimed at protecting workers from transmission.
- Managed quarantine programs should encourage an environment of constant vigilance, reinforcement of best practice, and high levels of support for quarantine workers to raise concerns and issues within their employment setting through a culture of speaking up for safety.
- The results of audits, evaluations and reviews may be shared with all states and territories as appropriate to facilitate learning and the continuing development and implementation of best practice.