Amid coronavirus outbreaks linked to breaches in hotel quarantine that are forcing lockdowns across the country, the federal government is facing calls to open purpose-built quarantine facilities in each state and territory.
In an interview with Sky News on June 25, Prime Minister Scott Morrison said the hotel quarantine program "had a lot of critics" but defended its record.
" … about 370,000 people have been through that system, and I think there's been about 26 breaches and less than ten of those has led to community transmission. So if I told you a year ago when we did this that, you know, I reckon we do this, we'll get a 99.9 per cent success rate, I think you would have told me that, mate, I know you believe in miracles, but that's a bit of a stretch. But that's actually what's happened."
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Has the hotel quarantine system seen such a high level of success around the country? RMIT ABC Fact Check investigates.
Mr Morrison's claim is spin.
Experts contacted by Fact Check took issue with his measure of the "success" of hotel quarantine.
However, there were differing opinions on which numbers should be used to measure success.
Some experts were of the opinion that the full impact on the community of the breaches should be considered when assessing success.
Others suggested more complex calculations which factor in hotel quarantine leaks that have not been discovered by testing or contact tracing.
Furthermore, more complex modelling in available academic research for coronaviruses in other countries suggests a much more robust method of calculating the success of hotel quarantine is possible.
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Though experts were not able to point to any such research in the context of Australian hotel quarantine, it is clear that the simple calculation that Mr Morrison has performed is not enough to sustain the claim of such a high rate of success.
One expert used the analogy of an airline to illustrate the point: "If an airline had seven crashes in six months and they defended themselves by saying, 'well, we take more passengers than the other airlines,' would you still fly on that airline? For me, risk is binary when it's a critical system with dire consequences."
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What is the purpose of hotel quarantine?
In order to define the success of a system, in this case hotel quarantine, the question needs to be asked: what is its purpose or goal?
The goal of the system has been repeatedly made explicit by the federal government.
After National Cabinet agreed on the system of hotel quarantine on March 27, Prime Minister Scott Morrison said the movement of incoming travellers would be further restricted "in order to help drive down [the] concerning number of imported cases".
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In July, the Australian Health Protection Principal Committee, which is the "key decision making committee for health emergencies," and is comprised of the chief health officers of each state as well as the Commonwealth Chief Medical Officer, said: "The AHPPC recommends that the goal for Australia is to have no community transmission of COVID-19, strengthening the current suppression strategy and updating metrics."
And a national review of hotel quarantine in October 2020 said: "The objective of Hotel Quarantine is to prevent the spread of the virus from any arriving traveler who is infected into the wider community. The design, management and delivery of quarantine services is therefore critical to the achievement of this objective."
Of course, the success or failure of these ambitions needs to be considered in the context of Australians' expectations.
A breach in hotel quarantine in the UK, for example, would have less of an overall impact to the number of infections in that country, given the size of the outbreak there, in comparison to a breach in Australia.
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According to researchers at the University of Toronto, this helps to explain how the relative success of Australia in containing COVID-19 in a global context does not necessarily equate to its measured success at home.
"Effectiveness of a public health intervention should not be defined exclusively in (absolute and objective) scientific terms but rather conceptualised relationally and normatively in public health decision making," they write.
Keeping this in mind, Fact Check considers that the stated goal of hotel quarantine is to achieve little or no community transmission of COVID-19.
Context for the claim
Mr Morrison has made this claim before in a similar manner, sometimes claiming an even higher rate of success.
"I think there's not a country in the world who wouldn't want a quarantine system that has been working as effective as that. But it is not 100 percent foolproof, and in 0.01 percent, in fact less of cases, you will see occasional breaches," he said.
"I mean, a system that is achieving 99.99 per cent effectiveness is a very strong system and is serving Australia very well."
Other members of the government have also made the claim. In a press conference in May, Health Minister Greg Hunt said:
"We've seen 99.9 per cent success around the country. We've seen 100 per cent success to date in Howard Springs."
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And backbencher Jason Falinski made the claim more recently on ABC TV's Q+A, claiming: "We have had 380,000 Australians return from overseas using the hotel quarantine system. There have been fewer than 35 breaches of that system. That's a success rate of 99.9 per cent."[falinski]
But is this a legitimate measure of the "success" of the hotel quarantine system? Fact Check has sought the opinions of epidemiologists to find out.
Are the government's calculations valid?
In an article for the Conversation, Tony Blakely, a professor of epidemiology at the University of Melbourne's Centre for Epidemiology and Biostatistics, along with other researchers at the centre, addressed this question head on.
Noting the government's assertions that the hotel quarantine system is "a system that is achieving 99.99 per cent effectiveness" the researchers referred to their published pre-print (not yet peer-reviewed) paper in conjunction with the University of Otago, which sought to analyse all the hotel quarantine breaches in Australia since the borders closed in March 2020.
The pre-print paper "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."
These breaches included anything from infections acquired by hotel quarantine workers from travellers staying in the facilities, to a driver acquiring an infection from travellers they were transporting to hotel quarantine facilities, to doctors and nurses infected while working at hospitals treating COVID-19 patients.
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"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)," the paper said.
The pre-print paper found 14 "failures'' that occurred in Australia between April 2020 and March 2021. In the article published on June 2, 2021, the researchers found 21 between April 2020 and June 2021.
The researchers calculated that the leaks to June 2021 amounted to 4.9 breaches per 1,000 COVID-positive travellers in hotel quarantine.
"This means that one outbreak from hotel quarantine is expected every 204 infected travellers," they wrote.
"Since April 2020, on average 308 infected travellers arrived in Australia each month, so that is 1.5 expected outbreaks per month," the researchers continued.
"This doesn't sound like a system that is 99.99 per cent effective."
This is an assertion that experts contacted by Fact Check agreed with.
Michael Toole, an epidemiologist and technical advisor to Burnet Institute's COVID-19 Knowledge Hub, described success in the context of hotel quarantine in Australia as "binary".
"To me, in any risk management or risk mitigation system, it either works or it doesn't," he said.
Professor Toole described the number of returned travellers passing through hotel quarantine, as used in the government's calculations, as "irrelevant".
"I often use the analogy of airlines. If an airline had seven crashes in six months and they defended themselves by saying, 'well, we take more passengers than the other airlines,' would you still fly on that airline? For me, risk is binary when it's a critical system with dire consequences."
"These leaks can be avoided by addressing airborne transmission in quarantine hotels through improving ventilation and giving frontline staff respiratory masks (N95/P2). Neither has been done in Qld and NSW," he told Fact Check in an email.
Professor Toole called the breaches already seen in Australia and their consequences "a clear failure" and the reason why multiple Australian cities went into lockdown in early July.
"It’s causing enormous economic and psychological damage," he said.
Epidemiologist at the University of New South Wales and member of a World Health Organisation Experts Advisory Panel on COVID-19 Prevention, Mary-Louise McLaws agreed that the success of the hotel quarantine system should be measured by "how many people are infected because of our leaks or breaches".
"I think that [the government's calculations are] conveniently using a denominator that provides disinformation really, with statistics you can use all sorts of denominators to tell a story and I'm looking at it from the other end," she said.
"That's how you measure the effectiveness. By zero cases, if it were 100 per cent effective."
But Catherine Bennett, the chair of epidemiology at Deakin University told Fact Check that accounting for the impact on the community is "not a measure" and "just our response to a leak or breach".
"I think indicators should be based on how many positive people actually transmitted the virus and then how many returnees are impacted and how many workers are impacted," she said.
Asked whether the government's measurements were an appropriate measure of success, Maximilian de Courten, the director of the Mitchell Institute for Education and Health Policy at Victoria University said: "The answer is very simple: no … because of the consequences of the outbreak."
"If you look at the [recent] Melbourne lockdown it's estimated at $1 billion cost … In the previous outbreak, 90 per cent of the deaths in Australia go back to this one outbreak — the second wave in Melbourne. So then you have to say, look, this 99 percentage thing is hiding the true impact of those outbreaks and there you have to say — it's not good enough," he said.
Indeed, an inquiry into Victoria's "second wave" outbreak in 2020, where cases rose above 20,000 and deaths reached 800, found a link between two hotel quarantine breaches and the vast majority of cases in that wave.
"The expert evidence, based on genomic testing, was that 99 per cent of Victoria's second wave of COVID-19 cases in the community came from transmission events related to returned travellers infecting people working at the Rydges and the Stamford Plaza Hotel. The movement of the virus from these infected workers into the community was characterised by high rates of local transmission."
But it's important to note that the inquiry did not find that these leaks directly caused the outbreak.
"The transmission of COVID-19 from returned travellers to those working within the program and its subsequent proliferation into the community were underwritten by a considerable range of contributing factors," it said.
Recent research published in the Lancet found that 98.4 per cent of locally acquired cases in Melbourne's second wave were "derived from a single incursion from hotel quarantine".
Is there a way to measure the success of hotel quarantine?
None of the experts contacted by Fact Check said they were aware of any research which attempts to quantify the effectiveness of hotel quarantine in Australia during the COVID-19 pandemic.
But researchers have attempted to do so in other settings.
Following the outbreak of SARS-CoV, which occurred in February 2003, Canadian researchers released a study which used a mathematical model to ascertain the effect of quarantine on outbreaks of SARS in Toronto, Hong Kong, Singapore and Beijing.
"The results reveal that achieving a reduction in the contact rate between susceptible and diseased individuals by isolating the latter is a critically important strategy that can control SARS outbreaks with or without quarantine. An optimal isolation programme entails timely implementation under stringent hygienic precautions defined by a critical threshold value. Values below this threshold lead to control, but those above are associated with the incidence of new community outbreaks or nosocomial infections, a known cause for the spread of SARS in each region," the authors wrote.
Some of those researchers later released another paper which sought to ascertain when quarantine is a useful strategy to control an emerging infectious disease using a similar mathematical model.
Abba Gumel, foundation professor of mathematics in the School of Mathematical and Statistical Sciences at Arizona State University, who is also one of the authors of both of these studies, told Fact Check that Mr Morrison's approach was "overly simplifying things".
Professor Gumel suggested that quarantine effectiveness should be evaluated based on the number of cases where the quarantine system has failed to prevent a leak, divided by the number of returned travellers who are infected but did not cause a leak.
However, he said that the calculation also needs to take into account the probability of undetected leaks, as well.
"It is a hard problem to estimate this probability reasonably well for a disease with a relatively long incubation period (10-14 days) that is readily transmissible by people who do not even know they have the disease (asymptomatic and presymptomatic infectious individuals)," Professor Gumel said in an email.
For this reason, Professor Gumel suggested multiplying by a number between 1 and 0 which represents the probability that individuals did not transmit the virus to anyone during quarantine.
This number, the professor agreed, was a known unknown. But the figure would account for the level of inaccuracy of COVID-19 tests (none of which are 100 per cent accurate) and the likelihood of undiscovered chains of transmission within hotel quarantine. Fact Check has not attempted to calculate this figure.
Professor Bennett said there are likely cases since the beginning of the pandemic where the virus leaked from hotel quarantine that we do not know about.
"I think we likely missed many crossovers and transmission among travelers across rooms before regular testing of workers, or [before testing more] frequently than day 1 and 12-13 in travellers unless symptomatic and in cabin crew," she told Fact Check in an email.
"When we did track them they often petered out with no spread, so this probably happened over and over without working large enough clusters for us to detect. it wasn't until [the Northern Beaches outbreak] that we found one that had not been detected at a breach."
Recent research using mathematical approaches has been done in other countries with regards to COVID-19.
Researchers in China used such a model at the beginning of the pandemic to show that the trend of cases in that country "mainly depends on quarantined and suspected cases".
And Cochrane recently conducted a rapid review into the effectiveness of COVID-19 and other coronavirus-related diseases.
Cochrane systematic reviews attempt to "identify, appraise and synthesize all the empirical evidence that meets pre-specified eligibility criteria to answer a specific research question".
The review found a majority of studies used mathematical models to estimate the effectiveness of quarantine in controlling the virus.
It noted however that for this reason the evidence for the effectiveness of quarantine in general was limited because these studies "make different assumptions on important model parameters".
Nonetheless, it is clear that a range of more sophisticated approaches to calculating the success of hotel quarantine exist beyond the approach taken by Mr Morrison.
Professor Gumel told Fact Check said the government's estimate and methodology seemed "a stretch" and "a little strange" to him.
"To be able to make such a claim, Australia needs to be able to consistently test everyone in quarantine (using a diagnostic test with perfect or near-perfect specificity and sensitivity) and detect almost all infected people in quarantine and to ensure that these detected infected folks do not escape quarantine (until numerous tests show that they have truly recovered from the infection)," he said.
"So, claiming near perfect success requires equally hefty evidence."
Principal researcher: , additional research: Sonam Thomas
- Sydney Morning Herald, Purpose-built quarantine facilities proposed in Queensland and Western Australia, June 25, 2021
- Scott Morrison, Interview with Sky News, June 25, 2021
- Scott Morrison, Media release, March 27, 2020
- Department of Health, Australian Health Protection Principal Committee
- Department of Health, Australian Health Protection Principal Committee statement on strategic direction, July 24, 2020
- Scott Morrison, Press conference, April 27, 2021
- Greg Hunt, Press conference, May 17, 2021
- Jason Falinski, Q+A, July 1, 2021
- Tony Blakely, Ameera Katar and Dris Ait Ouakrim, Hotel quarantine causes 1 outbreak for every 204 infected travellers. It's far from ‘fit for purpose', June 2, 2020
- Tony Blakely, Ameera Katar, Dris Ait Ouakrim et al, Estimating the Failure Risk of Quarantine Systems for Preventing COVID-19 Outbreaks in Australia and New Zealand, April 30, 2021
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- Troy Day, Andrew Park, Neal Madras, Abba Gumel, Jianhong Wu, When Is Quarantine a Useful Control Strategy for Emerging Infectious Diseases?, American Journal of Epidemiology, March 2006
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- Barbara Nussbaumer-Streit, Verena Mayr, Andreea Iulia Dobrescu, Andrea Chapman, Emma Persad, Irma Klerings, Gernot Wagner, Uwe Siebert, Dominic Ledinger,Casey Zachariah and Gerald Gartlehner, Quarantine alone or in combination with other public health measures to control COVID‐19: a rapid review, Cochrane Database of Systematic Reviews, September 2020