key: cord-0818954-iz5uzizo authors: Grout, L. M.; Katar, A.; Ait Ouakrim, D.; Summers, J. A.; Kvalsvig, A.; Baker, M. G.; Blakely, T.; Wilson, N. title: Estimating the Failure Risk of Hotel-based Quarantine for Preventing COVID-19 Outbreaks in Australia and New Zealand date: 2021-02-19 journal: nan DOI: 10.1101/2021.02.17.21251946 sha: 63df163a37acb27256a44c19078138c77c56654c doc_id: 818954 cord_uid: iz5uzizo Aim: With increasing global use of hotel-based quarantine as part of COVID-19 border control efforts, we aimed to assess its risk of failure. Methods: We searched official websites in both Australia and New Zealand (NZ) to identify outbreaks and border control failures associated with hotel quarantine (searches conducted up to 12 February 2021). We used two denominators: a) the estimated number of travelers who went through these facilities during the 2020 year up to 31 January 2021; and b) the equivalent number of SARS-CoV-2 positive people who went through these facilities. Results: Up to 31 January 2021, Australia had seven failures with one causing over 800 deaths and six resulting in lockdowns. In NZ there were nine failures, with one causing an outbreak with three deaths, and also a lockdown. The overall failure risk for those transiting quarantine was estimated at one failure per 20,702 travelers and one failure per 252 SARS-CoV-2 positive cases (both countries combined). At the country level, there were 15.5 failures per 1000 SARS-CoV-2 positive cases transiting quarantine in NZ (95%CI: 5.4 to 25.7), compared to 2.0 per 1000 SARS-CoV-2 positive cases in Australia (0.5 to 3.5), a greater than seven-fold difference in risk. Approaches to infection control and surveillance in hotel quarantine were found to vary widely by country and by state/territory. Conclusions: There appears to be a notable risk of failure with the use of hotel quarantine in these two countries. The large variation in infection control practices suggests opportunity for risk reduction. New Zealand and Australian states have successfully eliminated community transmission of the pandemic virus SARS-CoV-2, 1 albeit with occasional outbreaks from imported cases that have been quickly brought under control. These two countries have mostly used hotel-based quarantine for citizens returning to their countries during the pandemic period. This process is typically 14 days of quarantine combined with PCR testing and mask use in any areas involving shared space (eg, exercise areas). 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 proper ventilation (as per WHO advice on air flow 2 ). 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 based. Given these issues, we aimed to estimate the failure risk of hotel-based quarantine in New Zealand and Australia in terms of the spread of COVID-19 infection into the community. 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 hotel quarantine (searches conducted between 6 January and 12 February 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 hotel quarantine failure or not. We used two denominators: a) the estimated number of travelers who went through these facilities during the 2020 year up to 31 January 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. For New Zealand, we used official data on both travelers going through the hotel quarantine system 3 along with official (Ministry of Health) data on SARS-CoV-2 positive cases, 4 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, 5 health data, 6 and also considered the new caps on travelers for Australia in January 2021. 7 The collated data for hotel quarantine failures is shown in Table 1 , with specific details of each event in the Appendix (Table A1 ). In Australia, seven failures were identified, one causing over 800 deaths and six out of the seven resulting in lockdowns. In New Zealand, there were nine failures, with one causing an outbreak with three deaths, and also a lockdown. Given our estimates of the number of travelers processed via hotel-based quarantine (Table 1) , the overall risks for both countries combined were one failure per 20,702 travelers, and one failure per 252 SARS-CoV-2 positive cases in hotel-based quarantine. The combined data can also be interpreted as one outbreak leading to a lockdown response per 47,319 travelers; and approximately one death from COVID-19 per 412 travelers (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 15.5 failures per 1000 SARS-CoV-2 positive cases transiting quarantine in New Zealand (95%CI: 5.4 to 25.7), compared to 2.0 per 1000 SARS-CoV-2 positive cases in Australia (0.5 to 3.5) -a greater than seven-fold difference in risk. Given the proportion of SARS-CoV-2 positive cases since 1 December 2020 in quarantine has increased to 9.1 per 1000 in New Zealand and 16.3 per 1000 in Australia, this would equate to 1.8 and 0.7 expected failures per month in New Zealand and Australia, respectively -assuming past quarantine practices are constant into the future. Moreover, if new arrivals with SARS-CoV-2 have a variant that may be around 50% more infectious, that would become 2.8 and 1.0 respectively (assuming a linear increase in risk, which is likely an underestimate). . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) This analysis identified 16 failures of hotel quarantine in Australia and New Zealand combined (up to 31 January 2021) . The significantly higher failure risk per 1000 SARS-CoV-2 positive cases transiting quarantine in New Zealand vs Australia could reflect a lower quality approach in the former and/or possibly better detection in New Zealand from greater use of border worker testing over a longer period. However, it must be noted that since 1 December 2020, the proportion of SARS-CoV-2 positive cases among international arrivals is greater in Australia (16.3 per 1000) than in New Zealand (9.1 per 1000). These estimates are both subject to chance variations due to low numbers of failures, and as an estimate of all breaches of quarantine an underestimate. That is, there will probably have been instances of viral incursion out of quarantine that failed to spread substantially and be detected. Genomes of the first 649 viral isolates collected in New Zealand show that only 19% of introductions were estimated to infect more than one other person. 9 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 went undetected. Looking forward, the failure risks per month in New Zealand and Australia are likely to increase, given that the proportion of travelers 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. 10 Indeed, in February 2021 there have been two clearly documented cases of spread within quarantine hotels in Melbourne, highlighting the increased risk and evolving situation with more highly infectious variants arriving from overseas. Offsetting this trend will be measures such as vaccinating quarantine workers (assuming the vaccine prevents transmission, which appears likely with overall infection rates halved for the AstraZeneca vaccine 11 and perhaps 70% less for the Moderna mRNA vaccine, as indicated by using swab results for asymptomatic infection plus symptomatic cases 12 ). Another risk reduction practice would be using better facilities in rural locations as these have less risk from close contacts in CBD hotels and within-building spread from poor ventilation systems. Furthermore, the level of testing of hotel quarantine workers has been increasing (eg, 13 ; which will find some failures before they have a chance to establish as an outbreak in the community), and there have been other improvements in hotel quarantine in late 2020 (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 14 15 ). Limitations of our analysis include residual uncertainty around the cause of some outbreaks (eg, the Auckland August 2020 outbreak), and imprecision with denominator data on traveler numbers for Australia (eg, some travelers 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, the most obvious action is to reduce arrivals, or even suspend arrivals, from high infection locations. Beyond this, there are a range of other potential improvements in ongoing arrangements and processes as detailed in Table 2 . . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) Further reducing the in-flow of travelers by suspending flights to Australia and New Zealand (NZ) from very high incidence countries where the pandemic is out of control. Of note is that these governments have the capacity to legally put conditions on the existing rights of their citizens to enter their country of citizenship (ie, on public health grounds). Travel could be made contingent on completing a course of approved vaccination, assuming the vaccine is effective at preventing transmission. Top priority 2. Pre-flight testing plus/minus prearrival quarantine An expansion of existing requirements for pre-flight testing to additional traveler source countries. Pre-flight testing could be expanded from not only a PCR test within 72 hours of departure to also add an additional 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-arrival quarantine (eg, for a week), would provide additional 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. Top priority 3. Use passenger booking systems to reduce infection risk NZ has a system where passengers book spaces in quarantine facilities prior to travel. Such a system could be adopted more widely in Australia and also be used in to promote and document infection control measures by travelers (eg, requiring declarations from travelers about key precautions). High priority Exploring means to reduce the risk of in-flight infection as documented on a flight to NZ. 16 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. 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 6. Improve local transport arrangements There may be a need to have better physical distancing of travelers on arrival and in transit to quarantine (eg, lowering density on buses). For such arrangements, N95 masks could be required. Shifting 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 1 ) of the Howard Springs facility (a converted workers' camp 8 ) 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 travelers from the highest risk countries. High priority . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 19, 2021. ; https://doi.org/10.1101/2021.02.17.21251946 doi: medRxiv preprint Our priority rankings Reserving hotel quarantine in large cities to the lowest risk category of travelers, with hotels in more minor cities being used for the highest risk category of travelers. 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 9. Expand use of PCR testing of saliva in facility workers (and travelers) 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 travelers, albeit potentially still combined with existing testing regimens. High priority 10 . Upgrade processes at quarantine facilities Further upgrading processes at quarantine hotels 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 hotel rooms to those with external windows. Medium priority 11. Prosecute rule breaking in quarantine facilities Rule breaking, which is relatively common in NZ facilities, 17 could start to be prosecuted (given no prosecutions during 2020). Mandating that hotel quarantine workers 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. Travelers could be required to use such technologies for two weeks after completing their time in hotel quarantine. There is also a case for travelers using these tools within quarantine as (at least in NZ) quarantine hotels are sometimes evacuated for fire alarms and burst water pipes. Medium priority 17. Accelerate or mandate vaccination for hotel quarantine staff Rapidly accelerating plans to vaccinate all hotel quarantine workers against COVID-19 and even making vaccination a requirement to work in these settings. This measure will be particularly valuable if vaccines are found to prevent transmission in addition to protecting recipients from illness. Top priority . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) 18 19 and over 800 deaths 20 Genomic testing indicated that 99% of Victoria's second wave of community COVID-19 cases were linked to transmission events related to returned travelers infecting workers at the Rydges Hotel in Carlton and the Stamford Plaza Hotel in Melbourne's central business district (CBD), which were used as facilities for quarantine. 21 The virus then spread from the infected workers to the community, with high rates of local transmission. 21 The outbreak led to a stringent lockdown for 112 days in the state, with particularly strict measures in the major city of Melbourne. 22 At 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. 23 Two of those cases worked while infectious. 23 Parafield outbreak in South Australia (December 2020) 33 cases 20 Genomic testing indicated that Adelaide's Parafield cluster was linked to transmission events related to a returned traveler in a quarantine hotel infecting workers in the facility, possibly due to poor ventilation at the facility. 21 The virus spread from the workers to the community, resulting in a strict lockdown. 21 Avalon outbreak in New South Wales [NSW] (January 2021) 151 cases (as of 11 January 2021) 24 It has been reported that genomic sequencing suggests that the strain is of US origin and entered Australia via an infectious returned traveler who entered hotel quarantine upon arrival. 25 It has been reported that genomic sequencing linked the outbreak back to infectious international travelers. 26 A patient transport worker transferred infectious travelers from Sydney Airport to a hospital. 24 26 Another patient transport worker who was a close contact of the first then also tested positive. 24 26 The virus then spread from the second infected worker into the community, seeding the Berala outbreak. 26 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) 28 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. 29 It was later revealed that there were six genomically linked cases within the quarantine facility, including the hotel quarantine worker and five returned travelers. 27 Four Points by Sheraton hotel, Western Australia (January 2021) A single worker A Perth quarantine hotel security guard, who worked 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. 30 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 traveler 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. 31 This comes a week after Western Australia committed to daily testing of the hotel quarantine staff, instead of weekly. 32 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. 30 It has been announced an inquiry will be held. 31 Auckland August 2020 outbreak A total of 179 cases, with 3 deaths 33 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". 34 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 34 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." 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, 35 with the sharing being only minutes apart. 34 The genomic sequencing indicated the same virus infecting the worker as per a recent traveler in the same facility. 34 Border facility health worker infected (September 2020) 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. 36 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 associated patient did not have a mask on . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 19, 2021 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. 38 This infected traveler appears to have then infected another person (the Ministry suggest this may have occurred on a charter flight after leaving the facility). 38 A household contact was also reported as becoming infected. 39 Border facility health worker (Case A) in Christchurch (Nov ember 2020) 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. 35 "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. 19 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. 40 Another border facility health worker (Case B) (see above) This was a separate work-related infection associated with a border control facility -see in the row above. 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 travelers who are part of a family group in the quarantine facility". 41 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. 42 Traveler infectious after leaving a quarantine facility (January 2021) 1 traveler A traveler was identified as being infectious in the community after leaving a quarantine facility (Pullman, Auckland). The traveler reportedly had the South African variant (lineage B.1.351) of the pandemic virus. 43 Genome sequencing has linked this case to another traveler who was in the same facility. 44 The transmission mechanism has not been precisely identified with investigations still proceeding as of mid-February 2021. However 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) 2 travelers and a contact Two travelers (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). 45 A close contact (the mother of the child) also became infected. 46 The transmission mechanism has not been precisely identified with investigations still proceeding as of mid-February 2021. Table A2 details the various approaches to hotel quarantine used in both countries. Key features of which are summarised below: • The length of quarantine in all jurisdictions is 14 days. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 19, 2021. ; 1 1 • Almost all jurisdictions require at least two separate PCR tests for travelers: one shortly after arrival and another closer to the end of the quarantine period. • Many jurisdictions have introduced or are considering additional tests for travelers, 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 hotel quarantine staff in different jurisdictions were particularly difficult to identify and information often was not available by staff role (eg, security guards vs cleaners). . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 19, 2021. ; The testing process has changed over time with a day 0/1 test introduced in January 2021 for travelers from most countries (excluding those from some lowrisk countries). On some occasions the infection control processes in the facilities were found to be suboptimal (eg, 19 mariners infected while in one facility 40 ). Some facilities run daily bus trips to take travelers to outdoor exercise areas, a practice which has raised concerns from epidemiologists. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 19, 2021. No smoking, ecigarette use, or outside exercise allowed while in hotel quarantine. 59 61 In February 2021, NSW introduced a test for travelers on day 16. 24 However, this requirement was introduced after the 31 January 2021 date used for the data in this Table. 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). 60 Transport workers . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 19, 2021. 69 In some managed supervised quarantine locations, they do not allow for delivery services. 69 Movement of staff within the Howard Springs quarantine facility is restricted. 67 Staff buddy systems are in place, and careful monitoring of PPE use with photographs of PPE taken before each shift at Howard Springs quarantine facility. 68 South Australia Tests are required on days 0, 5, and 12. 70 Staff are required to have nose and throat swabs once every 8 days. 71 72 Masks must be worn when opening hotel doors. 70 Returned travelers are only allowed to leave their rooms in an emergency situation. 'Hotel staff must wear appropriate PPE and maintain at least 1.5 meters distance from guests at all times'. 73 Travelers must remain within their hotel room. 70 A requirement for a day 16 test for travelers after leaving hotel quarantine may be introduced in February 2021. 74 Additionally, as of 8 February 2021, after the 31 January 2021 date used for data in this table, hotel quarantine workers were required to have daily saliva tests. 74 . It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted February 19, 2021. 77 Travelers must remain within their hotel room. 75 Hotel quarantine workers given wage supplements to prevent them taking second jobs in effort to reduce risk of COVID-19 transmission -December 2020. 78 Victoria Tests are required on days 3 and 11. 79 Daily testing is required for staff. 15 Travelers are not allowed to leave their rooms unless there is an emergency. 15 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 travelers must remain in their rooms. 15 After the significant failure that led to over 19,800 cases,(1, 2) and over 800 deaths, Victoria began welcoming returned travelers 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. 15 room; any exercise must be done inside the hotel room and no smoking is allowed in hotels. 80 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. 30 . It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. 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