Quarantine is Australia’s first line of defence against COVID-19, and continues to play a vital role in Australia’s public health response. The National Principles for Managed Quarantine provide nationally agreed guiding principles to set benchmarks for managed quarantine programs across Australia. This acknowledges that quarantine programs should use strong end-to-end infection prevention and control (IPC) protocols with a systematic risk management approach.
As part of the AHPPC’s framework supporting continuous improvement in managed quarantine, the AHPPC is regularly reviewing the outcomes of reviews, audits and evaluations. This supports making an already rigorous quarantine system even stronger. The AHPPC is using an evidence-based approach to identify and address potential weaknesses in current systems to ensure best practice approaches to quarantine.
The AHPPC has considered the recommendations and findings of recent reviews into managed quarantine (see below), and the causes of SARS-CoV-2 transmission events. The AHPPC has considered options for minimising the risk of transmission in quarantine environments, and have developed the following Principles for Infection Prevention and Control in Quarantine. These Principles apply to managed quarantine of international travellers, however may also support other quarantine arrangements. These Principles build on existing guidance and are informed by the expert medical advice of the Infection Control Expert Group, the Communicable Diseases Network Australia, and the National COVID-19 Health and Research Advisory Council.
National Principles for Infection Prevention and Control in Quarantine
Hierarchy of Controls
- As outlined in the National Principles for Managed Quarantine, quarantine programs must apply effective controls by using the hierarchy of controls. This is a systematic risk management approach to minimise the risk of transmission of SARS-CoV-2. It ranks controls from the highest level of protection and reliability to the lowest least reliable protection. Risk management plans should incorporate all controls, and should prioritise higher-level controls over lower-level controls where possible, noting that a combination of several controls are often required to manage risk.
- When applying the hierarchy of controls, quarantine programs should give due consideration to the modes of transmission of SARS-CoV-2. AHPPC acknowledges that, in line with updated guidance from the World Health Organization, SARS-CoV-2 can spread from an infected person’s mouth or nose in small liquid particles when they cough, sneeze, speak, sing or breathe. These particles range from larger respiratory droplets to smaller aerosols. Current evidence suggests that the virus spreads mainly between people who are in close contact with each other, typically within 1 metre (short range). A person can be infected when aerosols or droplets containing the virus are inhaled or come directly into contact with the eyes, nose, or mouth. The virus can also spread in poorly ventilated and/or crowded indoor settings, where people tend to spend longer periods of time. This is because aerosols remain suspended in the air or travel farther than 1 metre (long-range).
- As outlined in the National Principles for Managed Quarantine, quarantine programs should use strong end-to-end IPC processes. End-to-end quarantine arrangements include from when the individual arrives at the port of entry (e.g. guidance on luggage handling), through to transit to the facility, the quarantine duration including transport to healthcare services if required, and appropriate management of any cases that emerge. Quarantine programs must apply effective controls using the hierarchy of controls at all stages of the quarantine program, including transport arrangements.
Governance and oversight
- States and territories have primary responsibility for quarantine operations within their jurisdiction, including approval of alternative quarantine programs. All states and territories should consider establishing a dedicated team to govern and ensure oversight of jurisdictional IPC requirements.
- This team should be led by experienced IPC practitioners where possible, noting there is a need to enhance workforce capacity. This team should be supported by a range of specialists such as engineers, aerosol scientists, occupational physicians and someone experienced in root cause analyses.
- In addition, Occupational Health and Safety staff can support consideration of IPC issues as well as staffing issues (e.g. rostering, fatigue and welfare management) and compliance with the OHS regulatory framework in the jurisdiction.
- Once established, this team of experts would be responsible for establishing specific jurisdictional quarantine protocols in line with national recommendations, and ensuring quarantine programs operate in accordance with safe IPC practices, OHS regulatory requirements, and jurisdictional public health orders.
- Quarantine programs should designate an appropriately qualified person (e.g. a nurse manager) or group of people who are based on-site to operationalise guidance and tailor it to the particular quarantine environment.
- This person or persons should support a regular process of audit and review, as outlined in the Continuous Improvement Framework, including establishing processes to manage transmission events. To support continuous quality improvement, quarantine programs should undertake frequent unannounced audits of IPC practices, to monitor compliance and identify and address system weaknesses.
- Quarantine programs may employ a range of tools to assist with monitoring and evaluation, in line with jurisdictional guidance. This may include additional surveillance tools to support compliance such as CCTV and buddy systems (see below). The designated IPC person or persons should support implementation and monitoring of these tools. Programs should undertake root cause analyses of incidents to identify issues and adjust mitigation measures. Quarantine sites should do this in consultation with the jurisdictional IPC expertise, including an individual experienced in root cause analyses.
- States and territories should establish clear governance arrangements to support controls and IPC practices in quarantine programs. This includes:
- Clear arrangements for supervising and training all staff (including health, security, cleaners, and cliental management) on required controls and IPC practices and behaviours, including the appropriate physical distancing and use and disposal of Personal Protective Equipment (PPE).
- Establishing arrangements for monitoring and maintaining supplies of appropriate PPE (including a diverse range of PPE to allow for differing fits). This should be managed at a jurisdictional level with all programs securing a minimum stockpile of PPE to ensure quarantined individuals can be appropriately managed and cared for at all times including in the unlikely event of an incursion.
- As outlined in the Continuous Improvement Framework, quarantine programs should adopt a culture of safety and constant vigilance. This may include training staff to raise concerns, and incorporating IPC refreshers into briefing and debriefing sessions.
Personal Protective Equipment
- 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’.
- 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’.
- 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.
Airflow and ventilation
- As outlined in the National Principles for Managed Quarantine, site selection should incorporate an environmental assessment of quarantine facilities, with consideration of airflow and ventilation, and introduction of additional controls to mitigate risk where relevant. This may include measures such as scrubbers or changes to building ventilation, use of negative pressure rooms, or room spacing and application of door sweepers or stoppers.
- Quarantine programs should also 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, so as 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.
- Quarantine programs should give appropriate consideration to heating and ventilation and air conditioning (HVAC) systems used within quarantine sites:
- 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. 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).
- 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); and, 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. 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.
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, 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, or 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).
- As outlined in the National Principles for Managed Quarantine, interactions between staff and quarantined individuals should be minimised wherever possible, to reduce the risk of transmission.
- 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.
- It is mandatory for all quarantine workers to receive COVID-19 vaccination and daily routine testing for COVID-19. This requirement applies to those directly and indirectly working in quarantine programs. In circumstances where individuals briefly and indirectly work for quarantine programs, existing requirements for testing following employment in managed quarantine programs apply. In addition, all household and close contacts of quarantine workers are eligible for COVID-19 vaccination. Jurisdictions may implement additional requirements for quarantine workers to reduce the risk of transmission.
- 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.
- 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.
- Quarantine programs should closely adhere to jurisdictional requirements for room occupancy. 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 (see above).
Cleaning and disinfection
- 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.
Evidence base supporting these Principles
As part of the AHPPC’s Continuous Improvement Framework, the AHPPC are regularly considering the recommendations of audits, reviews and evaluations conducted by all states and territories. The AHPPC are meeting on a weekly basis to discuss lessons learned and options for continuous quality improvement for managed quarantine. These reviews form the core evidence base through which these Principles have been developed. To date, the AHPPC have considered the findings of:
- October 2020: National Review of Hotel Quarantine, conducted by Ms Jane Halton AO PSM
- November 2020: National Contact Tracing Review, conducted by Dr Alan Finkel AO
- December 2020: Victorian COVID-19 Hotel Quarantine Inquiry, conducted by the Hon. Jennifer Coate AO
- January 2021: COVID-19 Transmission in the Peppers Waymouth Hotel, Adelaide, November 2020
- February 2021: Joint agency review of the COVID-19 infection of a hotel worker (Hotel Grand Chancellor)
- February 2021: Review of Western Australia’s Hotel Quarantine Arrangements, conducted by Prof. Tarun Weeramanthri
- March 2021: Safer Care Victoria review, COVID-19 Quarantine Victoria
- March 2021: Review of the Management of Variants of Concern of COVID-19 in Hotel Quarantine Settings, conducted by Prof Allen Cheng
- May 2021: Ventilation review of quarantine hotels, Western Australia
- May 2021: Report on Potential Intra-Medi-hotel Transmission of COVID-19, South Australia