What are the lessons from Australia's biggest outbreaks so far?

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What are the lessons from Australia's biggest outbreaks so far?

The coronavirus has made its "explosive potential" felt in some severe outbreaks. What happened and what can we learn?

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A cruise ship. A meatworks. A hospital. Hotels with newly arrived travellers in closed rooms. What was different about these places that infection controls that had contained the coronavirus many times before failed?

As Victoria grapples with a dangerous new spike in cases – and Melbourne shuts down again – questions are being asked about the future of Australia’s pandemic response.

For many weeks, the road ahead has looked promising – an initial peak of cases in March was stamped down with tough restrictions on socialising and hygiene as leaders and communities across the country pulled together (by staying apart).

Some experts say fresh peaks such as the kind seen in Victoria are inevitable until enough of the world’s population has immunity through either a vaccine or exposure to the virus. "It could happen anywhere," says epidemiologist James McCaw at the University of Melbourne. "It’s happened in Singapore, South Korea, it could happen tomorrow in Sydney."

Others, such as infectious disease expert Professor Mary-Louise McLaws, say it's time to plug gaps in our response and shift our ground game out of defence. "We haven’t seen a stuff-up on the scale of the US or the UK, we’ve done well so far," McLaws says. "But this outbreak in Victoria, and others, they can be prevented if we get more proactive."

A virus wants to spread as far as it can and this particular microbe is very good at it – evolved for “explosive potential”, McCaw says. If it had a personality, McLaws adds, “it would be a psychopath with a very high IQ” exploiting human behaviour. Any weak point, and the virus will break through.

So what can be learnt from our key battles with COVID-19 so far?

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The Ruby Princess cruise ship was the source of hundreds of Australian COVID-19 cases.

The Ruby Princess cruise ship was the source of hundreds of Australian COVID-19 cases.Credit: Janie Barrett

The Ruby Princess: 914 infections, 22 deaths

What happened?

When the Ruby Princess cruise ship docked in Sydney in the early hours of March 19, having cut short its cruise around New Zealand by three days, the coronavirus was already coursing through dozens of passengers and crew. But none had yet tested positive and social distancing was not part of the onboard itinerary. Passengers had no idea anything was amiss.

As the ship approached port, NSW Health assessed it as “low risk” despite COVID-19 test swabs being taken from ill passengers on board. Crucially, the decision was made to allow 2700 passengers to disembark on arrival, before the results of those tests came back. They were told to make their own way home and then self-isolate for 14 days. That decision sent infected passengers into all Australian states and territories – and around the world – unaware that they were potentially infectious.

How many infections and deaths followed?

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Of those on board the Ruby Princess, there were a total of 914 cases (including 202 crew) and 22 deaths recorded in Australia. Some passengers with COVID-19 even hopped on international flights but the extent of the spread overseas will likely never be known. In Australia, passengers then went on to infect about 150 others. In north-western Tasmania, a particularly large cluster was traced back to two Ruby Princess passengers treated at North West Regional Hospital in Burnie. (See below.)

What has come out of it?

A special commission of inquiry is examining the decisions made by NSW Health and other state and federal authorities as well as the actions of cruise operator Carnival. It’s due to report back by August 14. Meantime, Shine Lawyers are investigating a class action on behalf of all passengers.

Nineteen residents who caught COVID-19 at Anglicare's Newmarch House in NSW died.

Nineteen residents who caught COVID-19 at Anglicare's Newmarch House in NSW died.Credit: Edwina Pickles

Newmarch House: 69 infections, 19 deaths

What happened?

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The Newmarch House aged care home in Sydney’s outer western suburbs was plunged into a nightmare on the Easter weekend when a staff member and elderly resident tested positive for COVID-19. The staff member, it turned out, had worked several shifts while infectious. The fallout was both immediate and drawn-out. More than 30 staff had to isolate, leaving operator Anglicare scrambling to make up the shortfall as the virus took hold inside the locked-down facility.

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With deaths and positive cases growing in the weeks to follow, it became clear the home was overwhelmed, prompting the Aged Care regulator to step in and order an independent adviser to oversee the operation. Many family members were concerned about the treatment their loved ones were receiving in the struggling facility, and have questioned why they were kept there instead of being removed and treated in hospital. NSW Health’s Kerry Chant repeatedly said decisions on hospitalisations were made by patients and their doctors on a case-by-case basis.

McLaws says the decision to leave positive residents in the home allowed the virus to spread further. “An aged care facility is basically a big house, it's not a hospital– how are carers supposed to stop it spreading?”

How many infections/deaths followed?

The outbreak resulted in 69 infections: 32 among staff and 37 among residents. Tragically, 19 of those residents died. While the home was declared virus-free on June 12, many residents struck down in April and May are yet to fully recover.

What has come out of it?

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The 19 deaths at the home are being investigated by the NSW Coroner and a spokeswoman for NSW Health said the department would not pre-empt the coronial investigation by commenting. While the Aged Care Royal Commission will examine the impact of COVID-19 on the sector, including the Newmarch outbreak, it will not apportion blame. For some families, that’s not enough. Shine Lawyers, which is investigating the Ruby Princess class action, is doing the same for Newmarch House families. Anglicare CEO Grant Millard said in mid-May that, if he had his time again, he would have sent all the COVID-19 patients in the facility to hospital.

– Jenny Noyes

Infection prevention and control adviser Jennifer White briefs defence force health professionals in the North West Regional Hospital in Burnie, Tasmania, after the hospital's formal handover from contracted cleaning personnel.

Infection prevention and control adviser Jennifer White briefs defence force health professionals in the North West Regional Hospital in Burnie, Tasmania, after the hospital's formal handover from contracted cleaning personnel.

The Burnie hospital outbreak: 114 infections, 12 deaths

What happened?

An outbreak at two hospitals in the Tasmanian town of Burnie in April escalated quickly after the virus spread among healthcare workers, resulting in the closure of both hospitals and sending thousands of people into quarantine – and the state's entire north-west region into lockdown. Despite rumours that the outbreak was caused by an "illegal dinner party" of healthcare workers, or brought in by a fly-in, fly-out locum doctor from Melbourne, an internal inquiry found the origins were much simpler: two infected patients in the COVID-19 ward at the North West Regional Hospital.

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The patients had contracted the virus on board the Ruby Princess and exactly how the nurses caring for them were infected remains a mystery, but key factors exacerbated its spread.

Crowded work spaces, incomplete or delayed contact tracing and workplace "presenteeism" – leading almost half of infected staff to keep going to work at the North West Regional Hospital and nearby Mersey Community Hospital after developing cold and flu symptoms – caused the outbreak to grow rapidly, an interim report found.

At least two staff members who had treated patients who turned out to be infected had fallen through the cracks of the contact tracing system, with a doctor wrongly advised they did not meet the definition of a close contact and could continue to work, while a nurse was missed because, as relieving staff, they were not named on the roster.

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While no specific infection control breaches were identified as the cause of the infection of the initial staff members treating the Ruby Princess patients, the report said that "shortcomings in infection control practices ... may have enabled transmission of this very infectious agent in high-risk settings."

A whistleblower at the North Western Regional hospital has previously told The Sydney Morning Herald and The Age the interim report had failed to examine cultural and structural issues of the health service that made it uniquely vulnerable, with a confidential hospital report dated March 26 raising red flags including staff shortages and supply issues for personal protective equipment such as masks, gowns and hand sanitiser.

How many infections and deaths followed?

The first two healthcare workers tested positive on April 3 and by April 21 the outbreak had spread to a total of 114 people, including 73 hospital staff members, 22 patients and 19 close contacts. Twelve people died.

What has come out of it?

That local lockdown or "ringfence" used to contain the Burnie outbreak has been held up as a success story – and has now helped guide decisions around partial lockdowns elsewhere. The interim report into the outbreak itself found there was no evidence that healthcare workers had held large social gatherings but that movement of both staff and patients between the two hospitals accelerated the spread. It recommended minimising this traffic, screening all staff as they entered the hospitals, social distancing during meal breaks and nursing handover meetings as well as "strengthening the culture of safety regarding infection control practices" to prevent further outbreaks. The two hospitals have implemented enhanced staff screening and improved PPE training. The final report of the inquiry is due in October.

Cedar Meats was at the centre of coronavirus fears in Victoria in May.

Cedar Meats was at the centre of coronavirus fears in Victoria in May.Credit: Simon Schluter

Cedar Meats: 111 infections, no known deaths

What happened?

In early May, Victorians began learning details about the state's most serious COVID-19 outbreak at the Cedar Meats abattoir in Brooklyn in Melbourne's west. However, the drama began a month earlier, when its first worker tested positive. According to management and Victorian health authorities, this worker had not been on site. Soon after, Cedar Meats' workers became concerned about other colleagues displaying coronavirus symptoms. But management and the labour-hire company that supplied much of the workforce appear to have been slow to act.

More positive test results from Cedar Meats workers began returning in the last half of April. But Victorian health authorities failed to inform management about them for several days, instead relying on the labour-hire firm to pass it on. This allowed the virus to spread among workers and close contacts, resulting in the abattoir being shut down for two weeks.

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How many infections/deaths followed?

At least 111 infections: 67 workers and 44 close contacts. No known deaths.

What has come out of it?

Meatworks have been the site of serious breakouts overseas because of the nature of the close-quarters work. Cedar Meats was no different, with many workers concerned the virus was transmitted in the communal kitchen. Workers were not given access to masks until April 29, just before the plant was closed. Interestingly, Cedar Meats also supplied a huge load of lamb for the city of Wuhan in China, the origin of COVID-19, in April.

The handling of the Cedar Meats breakout was the first time the Victorian public had cause to question the Andrews government's performance in relation to the coronavirus. The government's initial reluctance to identify Cedar Meats as the site of the outbreak and revelations of its owners' ties and financial support of Labor helped fuel suspicion, although the government said any Labor links were irrelevant. A breakdown in communication between health authorities, Cedar Meats management and the labour-hire firm was perhaps the biggest problem. Chief Health Officer Brett Sutton said if he had the chance again he would have shut Cedar Meats earlier than he did. WorkSafe continues to investigate.

Lax hygiene has been blamed for infections among security staff and their contacts in government-run hotel quarantine.

Lax hygiene has been blamed for infections among security staff and their contacts in government-run hotel quarantine.Credit: Getty Images

Victoria's quarantine hotels: 54 infections, no known deaths

What happened?

On March 27, the national cabinet of state and federal leaders decided that all returned travellers from overseas would spend their 14-day quarantine in hotels – at government expense. Across the country, the move was hailed a success. New cases were largely contained and community spread stayed flat and low. But in Victoria, a fast decision by the state government to hire private security – rather than rely on police and soldiers keeping watch at hotel sites – would dramatically turn around its caseload numbers.

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How many infections/deaths followed?

In May, the first infection of a guard at one of the hotels, the Rydges on Swanston, was made public. At least 19 guards and their contacts have since tested positive in that cluster. Even larger issues emerged from another quarantine hotel, the Stamford Plaza in Melbourne’s CBD, where an outbreak via security guards has grown to more than 35 people.

But unlike previous outbreaks these chains of transmission were not hacked back before they spread beyond just hotel staff and their immediate contacts.

Scientists analysing the genetic code of the virus to emerge in Victoria so far have found this second surge of cases all look different to those earlier in the year - and all seemed to start from just one or two sources. Health officials believe these hotel outbreaks "seeded" much of the state's current cases as hotel workers took the infection into their homes and spawned large family clusters – in one case, an infected hotel guard was found to have started the large Hallam outbreak which also reached into Monash Health.

The government has not yet revealed how many new cases in total are linked back to the hotel outbreaks but Premier Daniel Andrews has said it is a significant number and breached infection protocols at the hotels seem to have been a factor.

"At least a significant number and potentially more of the outbreaks in the north of the city are attributable via genomic sequencing to staff members in hotel quarantine breaching well known, well-understood infection control protocols," Mr Andrews said. It is still unclear exactly how the virus initially spilt over – some have suggested staff got too close to those in quarantine while the Premier has given one example of investigations centring around the sharing of a cigarette lighter.

What happens next?

Prison guards have now been called in to help manage Victoria's quarantine hotels and staff run through proper infection control training (previously some security contractors had claimed they were given less than "three minutes" of training). But the government is keeping tight-lipped about exactly what happened in the hotels and why the private security industry was selected in the first place. It says the $3-million judicial inquiry it has since ordered into the affair will reveal those answers in time. A snap national review of the broader hotel quarantine regime is also under way as some states raise concerns about international flights.

One of Victoria's biggest outbreaks took hold at Al-Taqwa College.

One of Victoria's biggest outbreaks took hold at Al-Taqwa College.Credit: Joe Armao

Al-Taqwa College: 113 infections, no known deaths

What happened?

What started as a teacher testing positive at Al-Taqwa College in Melbourne’s west has now morphed into one of Victoria's biggest clusters. While the outbreak also has links to other family clusters in the area, Victoria’s Chief Health Officer Brett Sutton has said the Al-Taqwa outbreak is unusual compared to other school cases seen so far because many cases of the virus seem to have been picked up inside the college itself rather than outside in the community.

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The state government was notified of the first known case on June 27, after the school had closed for holidays. This teacher is believed to have worked for two days while infectious. More than 2000 students and hundreds of staff at the large school have now been sent into quarantine and are being tested for the virus. It's believed the bug was mostly spread by senior students after they returned to face-to-face learning in term two.

"[Older kids] tend to have more transmission that is akin to adults if they’re not doing the physical distancing appropriately," Professor Sutton said, adding the rapid-fire increase in cases at the school was a reminder to get tested for even the mildest symptoms, whatever your age.

How many infections or deaths have followed?

Infections have exploded from the single case first identified on June 27 to 102 by July 8 and then 113 by July 9.

What has come out of it?

The school has issued a statement defending its hygiene and social distancing regime. "Temperature checks on a daily basis were conducted for all staff, students and anyone needing to visit the school," it said. "Any staff or student that presented with even the mildest cold and flu symptoms were sent back home as a safety precaution." Details of how the outbreak spiralled are still being investigated.

So are there any main takeaways?

When it comes to solving the mystery of an outbreak, there’s often not one smoking gun to be found but several. "For Victoria now, it seems to be a coming together of many factors in a perfect storm," McLaws says.

“Sometimes it’s about mistakes and blame, and these outbreaks need to be investigated but sometimes, even with all the right controls the virus will still get through,” McCaw adds. “But it’s clear communication between government departments can be challenging and communication with the broader community needs to improve.”

New evidence, too, is emerging about how easily the virus can spread and ventilation may need greater consideration in reopening plans. McLaws, who helped the World Health Organisation revise its public advice on masks, notes Australia has been even slower than the UN agency to recognise the need for masks as cities wake up from shutdowns.

In the case of Victoria’s resurgence, McCaw says modelling suggests Melburnians are actually some of the best social distancers in Australia – showing notably reduced socialising patterns compared to many other states.

“Victoria tells us just how easily it can happen – it looks like it only took one event to take [the state] from almost eliminating the virus to another lockdown.”

Still, the southern outbreaks are “more concerning than the first” wave of cases that hit Australia, he says, because the virus is spreading through the community rather than turning up in people returning from overseas already infected. Deputy Chief Medical Officer Nick Coatsworth also says Melbourne’s surge is distinct from any before it, emerging in "large families” before spreading through the wider community and, so far, resulting in lower hospitalisation rates due to a younger patient cohort.

So far experts do not expect it will overrun the rest of the country.

“They’ve got what they need down there to mop it up," McCaw says. "But COVID-19 is not going away. All the talk a month ago that we were somehow already post-COVID was incredibly naive. We need to be ready for multiple outbreaks, we could have years of this ahead of us if we don’t get a vaccine.”

McLaws argues a key early mistake Australia made was “using a computer model to decide which countries to close our borders to first – it should have been them all”. Hotel quarantine has since been a huge improvement, she says, “except when infection control is left to private security”. But most Australians with COVID-19 still remain at home with family and roommates rather than recovering in isolated facilities (as happens in places such as China to avoid family clusters). Keeping people home potentially "dooms" their household to infection too if they can't isolate properly, McLaws says.

“Even if people don’t need to go to hospital, they can still be highly infectious. We needed to have facilities set up a while ago, particularly for aged care. Really, we needed to try for elimination, get rid of [the virus] completely.”

Dr Coatsworth says that while health authorities are "constantly learning", each of the outbreaks seen in Australia so far are different – as all outbreaks take on their own characteristics.

"When we think about what we've learnt from … Newmarch, that has led to new levels of vigilance from aged care providers, increased funding from the government [and in part to] the new code of conduct for aged care providers during COVID-19."

McLaws notes all governments are learning on the job during this pandemic. “It’s happening so fast but you have to act fast too. Otherwise, we’re always going to be two or three steps behind the virus.”

– with Ben Schneiders

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