The Australian Health Protection Principal Committee (AHPPC) notes:
- the escalation of community transmission of the Omicron variant of COVID-19 as Australia continues to move through the National Plan to transition Australia’s National COVID-19 Response (the National Plan).
- that current and expected future high caseloads necessitate a change in public health actions including policies and processes for test, trace, isolate and quarantine (TTIQ) to support public health sustainability, social cohesion and economic recovery.
- that as local epidemiology is rapidly becoming similar across jurisdictions, nationally consistent definitions and public health recommendations will assist clear communication and community adherence and lead to public confidence.
As case numbers in Australia increase, the effectiveness of TTIQ declines. The recommendations below take a pragmatic approach to TTIQ in a high case environment and the living with COVID policy approach. The AHPPC acknowledges that public health efforts may not identify considerable numbers of cases and may not manage a significant proportion of the transmission risk. Public health efforts will be required to focus on highest risk and rely on individuals and workplaces to manage their own risk. Consequently, the AHPPC stresses that the proposed changes will likely limit the ability of TTIQ to suppress transmission of COVID-19 at a population level but taking a focused outbreak approach can reduce the impact on the most vulnerable in our community. Other population level approaches including public health and social measures (PHSM) and ongoing vaccination, particularly achieving high booster coverage, are key to keeping cases within manageable levels and therefore preventing health system overwhelm. A shift to greater use of RAT tests by individuals, industry and the community over PCR tests will also be required. AHPPC will continue to monitor the outbreak situation, including epidemiology, booster effectiveness and treatments and review TTIQ measures as necessary.
The AHPPC notes current settings for testing are placing considerable pressure on available laboratory resources and recommends that PCR tests should only be used where they will change the public health or clinical management of an individual. Specifically, the AHPPC recommends that PCR testing should not be required for interstate domestic travel or surveillance testing.
The AHPPC recognises that whole genome sequencing (WGS) is no longer able to be performed on each positive case and needs to be directed to areas with the greatest utility for clinical decision-making, pandemic control and advancing knowledge of the Omicron variant. AHPPC recommends that all critical care COVID-19 cases and, where feasible, all cases admitted to hospital wards, have WGS performed and details of vaccination and clinical status collected for analysis and reporting. Additionally, at least one case in an outbreak in a Residential Aged Care Facility (RACF) should similarly have WGS performed to support review and analysis of characteristics of Omicron outbreaks in RACFs. Whole genome sequencing should also continue for overseas acquired cases to assist surveillance of the potential import of new variants.
Public health actions for cases and contacts
In a higher caseload environment where resources are strained, public health resources and clinical vigilance need to be directed to identification of cases most at risk of infection and/or severe disease, and settings where there are people at risk of severe disease, with rapid identification and management of outbreaks in these settings and most routine contact tracing either automated or transferred to individuals or organisations.
Management of contacts
Detailed follow up of individual cases and identification of all individuals with whom they have been in contact is not possible with high caseloads. Given significant levels of population exposure and consequent disruption to social and business functioning, it is also not desirable if large numbers of contacts are quarantined. Therefore, household or household-like contacts are the key group who should be required to quarantine as these individuals are the most likely to develop disease. These will be defined, except in exceptional circumstances, as those who usually live with or who have stayed in the same household as a case during their infectious period. The public health evidence shows that those living in the same household as cases generally have a high chance of becoming positive. In addition, where a significant transmission event has been documented those who were at this site or venue may be determined to be close contacts. This may include worksites. Worksites and businesses are strongly encouraged to have business continuity plans in place to ensure workplace health and safety is achieved and outbreaks can be contained as quickly as possible.
There is still risk of transmission based on the nature of exposure for other contacts (such as in social, educational or workplace settings) who have had less extensive exposure to a case than household-like contacts. This group will not be required to quarantine, except in exceptional circumstances, and may be required to undertake other behaviours to decrease their risk of transmission to others as outlined below.
AHPPC notes that for effective control of outbreaks, different management approaches will be needed for contacts in closed, high-transmission settings, particularly when there are a large number of individuals at risk of developing severe disease (e.g. outbreaks in RACFs and remote Aboriginal and Torres Strait Islander communities).
Management of exposure locations and use of QR check-ins
The AHPPC notes there is limited utility of listing exposure locations at high case numbers due to the large number of locations. The AHPPC recommends maintaining QR code check-ins at higher risk exposure locations as this allows rapid identification of high-risk transmission events and venues. The AHPPC also recommends ongoing use of QR code check-ins for locations where there is high risk of transmission to vulnerable individuals (e.g. hospitals and RACFs), large numbers of unvaccinated individuals, or settings where an outbreak would cause social and economic disruption (e.g. critical industries where isolation of multiple positive individuals could lead to significant disruption of essential services). The AHPPC recommends reviewing the utility of QR code check-ins at lower risk exposure locations and given the low yield of secondary cases with the majority of these settings.
Isolation and quarantine in a high-case load environment
In a high case-load environment, there is a need for a modified, risk-based approach to quarantine and isolation settings. AHPPC advises that the isolation period for COVID-19 cases should be standardised regardless of vaccination status to a length of 7 days. Household contacts or those identified as being at risk of significant transmission should quarantine for 7 days after last exposure to a case regardless of vaccination status and then, subject to a negative test on day 6, monitor for symptoms for a further 7 days and repeat testing if these occur. Other contacts who have been potentially exposed to a case but who are at lower risk of infection should monitor for symptoms and have RAT or PCR test if these occur. All contacts should wear a mask when outside home, monitor symptoms and avoid visiting high risk settings for 14 days following exposure to reduce their risk of transmission to others. If RAT tests are positive, these should be followed by a positive PCR test to confirm the diagnosis, allow notification and to link individuals into social and medical support. PCR tests are the preferred test for symptomatic individuals.
In certain critical occupations where an exposure occurs, arrangements for management of contacts can be further modified to allow business continuity, subject to a thorough risk assessment process.
Community and Industry self-management
Outside of those instances prioritised by public health for contact tracing, AHPPC supports empowering the community and industry to undertake self-managed contact tracing, testing and quarantine, where appropriate.
Cases would notify their Household and other contacts identified as being at risk of significant transmission and advise them to follow relevant public health advice. Industry would similarly identify contacts and balance their management with workforce impact and business continuity.
Clear communication of these requirements will be required in a manner that is accessible and acceptable and tailored to each jurisdiction where relevant.