communicable diseases intelligence 2021 - repatriation

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Repatriat ion operation in South Australia during the COVID-19 pandemic: init ia l planning and preparednessSonali Meena, Joel Chan, Tuong-Vi Phan, Samantha Butenko, Jenny Hurley, Paul McGowen, Emily Kirkpatrick, Lisa Upton, Razlyn Abdul Rahim, Matthew McConnell, Robert Hall

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© 2 0 21 C o m m o n w e a lt h o f A u s t r a lia a s r e p r e s e n t e d b y t h e D e p a r tm e n t o f H e a lt h

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R e s t r i c t i o n s T h e L ic e n c e d o e s n o t c o v e r, a n d t h e r e is n o p e rm is s io n g iv e n f o r, u s e o f a n y o f t h e f o llo w in g m a t e r ia l f o u n d in t h is p u b lic a t io n (i f a n y ):

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D i s c l a im e r O p in io n s e x p r e s s e d in C o m m u n ic a b le D is e a s e s In t e ll ig e n c e a r e t h o s e o f t h e a u t h o r s a n d n o t n e c e s s a r i ly t h o s e o f t h e A u s t r a lia n G o v e r n m e n t D e p a r tm e n t o f H e a lt h o r t h e C o m m u n ic a b le D is e a s e s N e t w o r k A u s t r a lia . D a t a m a y b e s u b je c t t o r e v is io n .

E n q u i r i e s E n q u ir ie s r e g a r d in g a n y o t h e r u s e o f t h is p u b lic a t io n s h o u ld b e a d d r e s s e d t o t h e C o m m u n ic a t io n B r a n c h , D e p a r tm e n t o f H e a lt h , G P O B o x 9 8 4 8 , C a n b e r r a A C T 2 6 01 , o r v ia e -m a il t o : c o p y r ig h t@ h e a lt h .g o v .a u

C o m m u n i c a b l e D i s e a s e s N e t w o r k A u s t r a l i a C o m m u n ic a b le D is e a s e s In t e ll ig e n c e c o n t r ib u t e s t o t h e w o r k o f t h e C o m m u n ic a b le D is e a s e s N e t w o r k A u s t r a lia . h t t p ://w w w .h e a lt h .g o v .a u /c d n a

Communicable Diseases Intelligence (CDI) is a peer-reviewed scientific journal published by the Office of Health Protection and Response, Department of Health. The journal aims to disseminate information on the epidemiology, surveillance, prevention and control of communicable diseases of relevance to Australia.

E d i t o r J e n n ie H o o d

D e p u t y E d i t o r S im o n P e t r ie

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E d i t o r i a l A d v i s o r y B o a r d D a v id D u r r h e im , M a r k F e r s o n , J o h n K a ld o r, M a r t y n K ir k a n d L in d a S e lv e y

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C o n t a c t s C D I is p r o d u c e d b y E n v ir o n m e n t a l H e a lt h a n d H e a lt h P r o t e c t io n P o lic y B r a n c h , O ffi c e o f H e a lt h P r o t e c t io n a n d R e s p o n s e , A u s t r a lia n G o v e r n m e n t D e p a r tm e n t o f H e a lt h , G P O B o x 9 8 4 8 , (M D P 6 ) C A N B E R R A A C T 2 6 01

E m a i l : c d i .e d it o r@ h e a lt h .g o v .a u

S u b m i t a n A r t i c l e Yo u a r e in v i t e d t o s u b m it y o u r n e x t c o m m u n ic a b le d is e a s e r e la t e d a r t ic le t o t h e C o m m u n ic a b le D is e a s e s In t e ll ig e n c e (C D I) f o r c o n s id e r a t io n . M o r e in f o rm a t io n r e g a r d in g C D I c a n b e f o u n d a t : h t t p ://h e a lt h .g o v .a u /c d i .

F u r t h e r e n q u ir ie s s h o u ld b e d ir e c t e d t o : c d i .e d it o r@ h e a lt h .g o v .a u .

1 of 18 health.gov.au/cdi Commun Dis I n te l l (2018) 2021;45 (https://doi.org/10.33321/cdi.2021.45.29) Epub 27/5/2021

R e p a tr ia t io n o p e ra t io n in S o u th A u s tra lia d u r in g th e C O V ID -19 p a n d em ic : in it ia l p la n n in g a n d p re p a re d n e ssSonali Meena, Joel Chan, Tuong-Vi Phan, Samantha Butenko, Jenny Hurley, Paul McGowen, Emily Kirkpatrick, Lisa Upton, Razlyn Abdul Rahim, Matthew McConnell, Robert Hall

A b s t r a c t

With COVID-19 affecting millions of people around the globe, quarantine of international arrivals is a critical public health measure to prevent further disease transmission in local populations. This measure has also been applied in the repatriation of citizens, undertaken by several countries as an ethical obligation and legal responsibility. This article describes the process of planning and prepar-ing for the repatriation operation in South Australia during the COVID-19 pandemic. Interagency collaboration, development of a COVID-19 testing and quarantining protocol, implementing infec-tion prevention and control, and building a specialised health care delivery model were essential aspects of the repatriation operational planning, with a focus on maintaining dignity and wellbeing of the passengers as well as on effective prevention of COVID-19 transmission. From April 2020 to mid-February 2021, more than 14,000 international arrivals travellers have been repatriated under the South Australian repatriation operations. This paper has implications to inform ongoing repa-triation efforts in Australia and overseas in a pandemic situation.

Key words: COVID-19, hotel quarantine, infection control, isolation, Medi-Hotel, operational planning, pandemic, quarantine, repatriation, South Australia

O r ig in a l a r t ic le

I n t r o d u c t i o n

The novel coronavirus SARS-CoV-2, which causes the disease COVID-19, continues to pose significant health threats on a global scale.1 Mandatory quarantine of returning interna-tional travellers is an important public health intervention to contain COVID-19.1 The Prime Minister announced the ‘human biosecurity emergency’ declaration under the Biosecurity Act 2015 on 18 March 2020 and mandated 14-day quarantine for all overseas arrivals in Australia.2,3

Australia’s borders were closed to all non-citizens and non-residents from 20 March 2020, and Australians who were still overseas were urged to return via commercial means.4 The repatriation operation is a legal, moral,

ethical obligation and responsibility of the Commonwealth government,5,6 and is under-taken at the level of the Commonwealth as well as by individual state and territory jurisdictions. The Department of Foreign Affairs and Trade and the Australian Health Protection Principal Committee support repatriation by assisting Australians overseas through the provision of consular support and commercial flight infor-mation.7–9

In South Australia, the repatriation operations have been coordinated by the Department for Health and Wellbeing (SA Health), the hazard leader for human diseases and the agency overlooking control of disease outbreaks under the South Australian Public Health Act 2011. Directions under the Emergency Management Act 2004 also mandated all overseas arrivals in

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South Australia to undertake mandatory 14-day quarantine at designated supervised facilities (i.e. hotels) from 28 March 2020.10

Successful repatriation operations are depend-ent on robust planning and preparedness, with a strategy to prevent COVID-19 transmission in the community. In South Australia, this began with the formulation of a clear mission to man-age returning international passengers from the point of arrival to the completion of the manda-tory quarantine period in designated facilities, with the dignity, wellbeing and medical care of those in quarantine needing to be considered at all stages.

This paper aims to describe the process of plan-ning and preparing for the repatriation opera-tion in South Australia during the COVID-19 pandemic, initiated in April 2020, with the discussion of the arrival of the first two flights carrying 721 returning travellers from the South East Asian region9 as an example of the process. This paper has implications for planning simi-lar operations in other Australian jurisdictions as well as overseas in a pandemic situation.

The operational planning is described under the following sections:

1. Interagency collaboration;

2. Development of a COVID-19 testing and quarantining protocol;

3. Identifying the infection prevention and con-trol principles and procedures; and

4. Building a specialised health care delivery model.

With consensus from public health experts combined with a review of existing evidence, guiding principles were formulated to serve as a benchmark guideline while planning different aspects of the operation.

1 . I n t e r a g e n c y c o l l a b o r a t i o n

Guiding principles

To be successfully implemented, this operation required a coordinated approach with inputs from several support agencies.

The State Control Centre – Health (SCC-H) was established within SA Health in February 2020 and was the designated agency in control of the repatriation operation. The Chief Public Health Officer and one of the Deputy Chief Public Health Officers assumed the roles of the State Controller and Deputy State Controller respectively, ensuring that actions taken by the SCC-H were part of a coordinated response to COVID-19. With a forward commander and command team, SCC-H identified and coordi-nated multiple stakeholders in order to form the team for the repatriation operation, comprising representatives from emergency services, health professionals, private sector and local health networks.

Multiple structured channels were used to com-municate between different agencies on a timely basis, via e-mails, phone calls, teleconferences, and regular face-to-face or online meetings, to support coordination. Table 1 shows the agen-cies involved and their respective roles and responsibilities in the operation.


Table 1: Roles and responsibilities of agencies involved in the management and care of repatriated Australians

A g e n c y R o l e s a n d r e s p o n s i b i l i t i e s o f t h e a g e n c y i n t h e o p e r a t i o n

S e c u r i t y a n d c o o rd in a t io n

State Control Centre – Health (SCC-H)

• P r o v id e s t r a t e g i c le a d e r s h ip a n d d i r e c t io n f o r t h e im p le m e n t a t io n a n d m a n a g e m e n t o f S A H e a l t h ’s r e s p o n s e t o m a jo r in c id e n t s , e m e r g e n c ie s a n d d i s a s t e r s . C o o r d in a t e a n y h e a l t h -r e la t e d o p e r a t io n t h r o u g h o u t t h e s t a t e d u r in g a c r i t i c a l i n c id e n t /e m e r g e n c y .

• I d e n t i f y t h e p r o v id e r s a n d m a n a g e lo g i s t i c s o f t r a n s p o r t , a c c o m m o d a t io n .• P r o v id e s e c u r i t y a r r a n g e m e n t s a t h o t e l .

South Australian Police (SAPOL)

• M a n a g e t h e r e s p o n s e a n d r e c o v e r y o p e r a t io n s in a c c o r d a n c e w i t h t h e E m e rg e n c y M a n a g e m e n t A c t 2 0 0 4 a n d t h e S t a t e E m e r g e n c y M a n a g e m e n t P la n .

• C o l la t e in f o rm a t io n f r o m A B F o n e x p e c t e d a r r i v a l fl ig h t t im e a t a i r p o r t , fl ig h t m a n i f e s t o f p a s s e n g e r s /c r e w .

• Id e n t i f y m e d ic a l o r d i s a b i l i t y i s s u e s .• P r o v id e lo g i s t i c a l m a n a g e m e n t o f a c c o m m o d a t io n r e q u i r e m e n t s f o r f a m i ly g r o u p in g s .• I d e n t i f y a le r t s o n p a s s e n g e r s /c r e w o n t h e fl ig h t .• P r o v id e s u p p o r t t o a m b u la n c e c r e w d u r in g t r a n s p o r t f r o m a i r p o r t t o h o s p i t a l i f r e q u i r e d .• E n s u r e (o r e n f o r c e ) s e c u r i t y a n d c o m p l ia n c e o f q u a r a n t in e a t d e s ig n a t e d f a c i l i t i e s .

Australian Defence Force (ADF)

• P r o v id e s u p p o r t t o S A P O L in c o o r d in a t io n o f p a s s e n g e r s ’ s m o o t h t r a n s p o r t f r o m a i r p o r t t o h o t e l .

Australian Border Force (ABF) • P r o v id e in f o rm a t io n t o p a s s e n g e r s a n d c r e w m e m b e r s a b o u t m a n d a t o r y q u a r a n t in e o n a r r i v a l .• E n s u r e e n t r y in t o A u s t r a l i a i s a d h e r e n t t o C o m m o n w e a l t h r e s t r i c t io n s a t t h e t im e .

Airport security • P r o v id e s e c u r i t y a t a i r p o r t p r e m is e s a n d s u p p o r t S A P O L , A B F , a n d A D F d u r in g t h e o p e r a t io n .

Airport operations • In f o rm a r r i v a l t im e s a n d d e t a i l s o f fl ig h t p a s s e n g e r s a n d c r e w t o S A P O L , A B F , a n d A D F .

S u p p o r t s e r v i c e s

Red Cross Telecross REDi

• P r o v id e m e n t a l h e a l t h s u p p o r t f o r p e o p le in q u a r a n t in e : e .g . p r o v id e p s y c h o lo g i c a l c o u n s e l l in g s e r v i c e s t o r e f e r r e d p a s s e n g e r s .

• P r o v id e c h i ld r e n ’s a c t i v i t y p a c k s f o r f a m i l i e s w i t h c h i ld r e n in h o t e l q u a r a n t in e .

Hotel staff • A s c e r t a in a c c o m m o d a t io n n e e d s f o r p a s s e n g e r s d u r in g m a n d a t o r y q u a r a n t in e .

SA Housing • A r r a n g e h o u s in g n e e d s f o r l im i t e d p e r io d , f o r in d iv id u a ls w i t h fi n a n c ia l d iffi c u l t i e s p r io r t o d e p a r t u r e f r o m q u a r a n t in in g s t a t e t o s t a t e o f r e s id e n c e .

C a s e m a n a g e m e n t

Communicable Diseases Control Branch (CDCB)

• P r o v id e p u b l i c h e a l t h m a n a g e m e n t o f C O V ID -1 9 p o s i t i v e c a s e s a n d c lo s e c o n t a c t s .• P r o v id e in f e c t io n p r e v e n t io n a n d c o n t r o l a d v i c e a n d p r o c e d u r e s a s w e l l a s o n s i t e a t t h e a i r p o r t

s u p p o r t .

H e a l t h c a r e

South Australia Ambulance Services (SAAS)

• P r o v id e e m e r g e n c y t r a n s p o r t f r o m a i r p o r t t o h o t e l/h o s p i t a l a n d f r o m h o t e l t o h o s p i t a l a s r e q u i r e d .

Health and Medical Functional Service (H&MFS): Medi-Hotel Nurses Team, border nurses

• P r o v id e h e a l t h s c r e e n in g a n d t e s t in g f o r C O V ID -1 9 o f p a s s e n g e r s a t a i r p o r t .• P r o v id e h e a l t h s c r e e n in g a n d t e s t in g o f p a s s e n g e r s a t h o t e l d u r in g t h e i r q u a r a n t in e / i s o la t io n

p e r io d .• P r o v id e t r i a g e a n d r e f e r r a l o f p a s s e n g e r s f o r f u r t h e r m a n a g e m e n t f o r h e a l t h c o n d i t io n s .

Team of general practitioners • P r o v id e c u l t u r a l ly s e n s i t i v e h e a l t h c a r e t o p a s s e n g e r s d u r in g q u a r a n t in e p e r io d .

General practitioner liaison team

• C o l la b o r a t e a n d c o o r d in a t e G P s s u i t a b le f o r p r o v id in g h e a l t h c a r e t o r e p a t r i a t e d in t e r n a t io n a l p a s s e n g e r s .

Metropolitan referral unit • C o o r d in a t e r e g u la r a s s e s s m e n t o f h e a l t h a n d m e n t a l w e l lb e in g o f p a s s e n g e r s a n d id e n t i f y n e e d s f o r r e f e r r a l f o r C O V ID -1 9 p o s i t i v e in d iv id u a ls .


2 . D e v e lo p m e n t o f a C O V ID -1 9 t e s t i n g a n d q u a r a n t in in g p r o t o c o l

Guiding principles

• The Communicable Disease Network of Australia (CDNA) COVID-19 Series of National Guidelines (SoNG) pro-vided the basis of current knowledge regarding:

◦ Definition of COVID-19 case and close contact;

◦ Incubation period and infectious period, which would determine period of quarantine and isolation, respectively;

◦ Appropriate release from isolation criteria.

• Testing and quarantine protocols were developed based on CDNA guidelines and on advice from public health spe-cialists who were able to exercise clini-cal judgment and discretion.

• The goal was to ensure that repatriated passengers, who may be COVID-19 cases or may have been in close contact with a COVID-19 case, are isolated and quarantined appropriately.

A testing and quarantine protocol (Figure A.1 in Appendix A) was developed according to the public health principles outlined in the CDNA National Guidelines,11 and the clinical input was in compliance with the Directions made under the Emergency Management Act 2004.10

All returned travellers were deemed to have epidemiological risk factors, having spent time in countries with high numbers of COVID-19 infections. Rigorous discussions amongst public health physicians at the Communicable Diseases Control Branch (CDCB) occurred to

identify the feasible and accurate time of test-ing for asymptomatic travellers at initiation and completion of mandatory facility quarantine. Development of the testing and quarantining protocol was a continuous quality improvement process12 based on the principle of early detec-tion; it has continued to be a dynamic process as the evidence base has built rapidly in the changing pandemic environment. Figure A.1 illustrates the initial protocol for individual passengers, depending on the outcome of clini-cal assessment and COVID-19 testing while in quarantine.

The strategy of testing at multiple stages was aimed at improving case-finding in returned travellers to prevent onward transmission. CDCB played a pivotal role in planning for the case management aspect of the operation. Case management included advice on timely testing criteria for travellers, disease notification for positive COVID-19 cases, and risk assessments of cases and close contacts for further quaran-tine or isolation. CDCB also provided guidance on release of cases and close contacts from iso-lation or quarantine, including arrangements for notification of negative results to travellers. Figure A.1 and Section A.1 of Appendix A explain the steps taken during planning and preparedness towards successful implementa-tion of the protocol.


3 . In fe c t io n p r e v e n t io n a n d c o n t r o l (IP C )

Guiding principles

• Prevention of transmission of SARS-COV-2 via direct and indirect contact with respiratory secretions or contami-nated objects, by risk-based approach including modified work practices; use of appropriate personal protective equipment (PPE) and maintenance of physical distancing; promoting and practicing hand hygiene; appropri-ate environmental cleaning and waste disposal; and avoidance of sharing of equipment or objects.

Based on the expertise provided by SA Health’s Infection Control Services (ICS), along with the current knowledge about the routes of transmis-sion of COVID-19, the above principles guided the planning and were built into all aspects of the operation. PPE requirements depended on the nature of contact as described in Figures A.2 and A.3 in Appendix A, according to the matrix developed by ICS based on national and international guidelines.13

One of the primary planning steps was the iden-tification of all the situations and settings where IPC measures would need to be implemented, from the point of flight arrival to the com-mencement and completion of quarantine in the hotel rooms. It was necessary to plan for the size of the cohort arriving, the staff who would be involved at each stage of the operation, and the nature of contact that would likely be taking place. This would then determine what type of PPE would be required and in what amounts, especially as closer and/or longer contact would necessitate a higher level of PPE to be worn.

Physical environments also needed to be assessed and planned for: these included the buses designated to transport passengers from the airport to the hotel, as well as the hotel. Not only would such environments need to be cleaned correctly, with particular attention

paid to areas or objects that would frequently be touched; sharing of space by service provid-ers, e.g. nurses collecting testing samples from travellers, security services and areas in which crowding could occur also needed to be consid-ered.

It was necessary to ensure adequate supplies of PPE, facilities and/or equipment for hand hygiene such as alcohol-based hand rub/gel and supplies for cleaning and disposal of gen-eral and medical waste. The distribution of these resources to the appropriate people and places had to occur before the flight arrival. Furthermore, staff, whether border nurses or hotel staff, needed to be educated and trained in the appropriate use of PPE, including correct donning and doffing, as well as in hand hygiene. The dissemination of information and key mes-sages was an important aspect in the effort to ensure repatriated individuals also adhered to IPC measures (including wearing a mask for source control and hand hygiene) at each stage of their journey.

Regular site visits and inspections were planned to mitigate the risk of COVID-19 outbreaks within the quarantine facility, with reporting of any breach of IPC practice at the facilities; assessment of interactions of passengers with service providers, e.g. nurses, security guards and cleaners; and environmental assessment for potential airborne or fomite transmission.


4 . B u i ld in g a s p e c i a l i s e d h e a l t h c a r e d e l i v e r y m o d e l

Guiding principles

• Ensuring health, wellbeing and security of returning travellers through applica-tion of a systematic method of health care delivery, with identified pathways, partnerships and systems.

During the 2020 pandemic, Medi-Hotel models (hotels designated as quarantine facilities with medical services) emerged rapidly around the world as a measure to contain the virus while catering to individual health needs.14 Similar models overseas have been established to sup-port the quarantining of health care workers14 and vulnerable populations.15 For this repa-triation operation, the Medi-Hotel Nursing Support Program (NSP) was developed as a collaborative multidisciplinary, inter- and intra-agency and cross-jurisdictional team model. The Chief Nurse and Midwifery Officer (CNMO) at SA Health took operational respon-sibility for the Medi-Hotel NSP, in partnership with the COVID-19 GP Liaison, Office of Chief Psychiatrist (OCP) and SCC-H.

The aim of the Medi-Hotel NSP was to develop systematic checkpoints to ensure all travellers under mandatory quarantine had their health, welfare and wellbeing needs assessed and man-aged. This included establishing a baseline general health screen on travellers’ arrival; daily phone calls during quarantine that included COVID-19 symptom checks; early identifica-tion of any deterioration of health including mental wellbeing; and social welfare and secu-rity checks alongside or following the testing protocol for COVID-19 for all passengers.

The on-site nursing assessment service pro-vided proactive evaluation and immediate man-agement of any clinical and/or mental health concerns related to COVID-19 or otherwise. Some challenging tasks included coordination

of blood/specimen collection; daily checks on vulnerable travellers including domestic vio-lence risks; allergy management including food and drug/medication; and departure health assessment.

Referral pathways for emergency or urgent care, including preparations for coordinating ambulance transfer and SAPOL support when required, were identified early during the plan-ning stage in consultation with the state’s local health networks. A team of general practitioners (GP) and GP referral pathways were identified at the planning stage for non-emergency rou-tine medical care including mental health care.

Figure A.4 shows the model; Section A.3 in Appendix A lists the functions and services of the model.

D i s c u s s i o n

The World Health Organization defines public health as ‘the art and science of preventing disease, prolonging life and promoting health through the organized efforts of society’.16,17 Despite the risk of repatriated citizens as poten-tial SARS-CoV-2 carriers, there is a duty of care towards every citizen, to ensure appropriate care and support at the earliest instance while undertaking quarantine. In some settings, strict methods of monitoring home quarantine such as ankle bracelets have been used for surveil-lance which may be seen as infringing indi-vidual rights.18

Quarantine in facilities presents many difficul-ties, as highlighted by the initial repatriation operation in South Australia during the COVID-19 pandemic. One significant challenge was the urgency required, with the initial planning process taking place over 48–72 hours. The first two repatriation flights had been destined for another jurisdiction, but were diverted to South Australia for operational reasons. Therefore, the different agencies to be involved in the repatriation operation also had to be swiftly coordinated, and established networks in the state’s public sector were utilized. Besides those


agencies responsible for defence and security, those focused on management of passengers’ health and wellbeing operated under the aegis of SA Health. While building on these networks can be considered a strength, the pandemic response was unprecedented. Only time and experience with managing COVID-19 cases and contacts from international arrivals could help clearly define roles as well as processes of the agencies, especially as there were no positive COVID-19 cases on the first two flights. From April 2020 to mid-February 2021, more than 14,000 international arrivals travellers have been repatriated under the (ongoing) South Australian repatriation operations.

The protocol for identifying COVID-19 cases in quarantine presented some practical challenges. Since many passengers were planning onward travel to their home states, one priority was to conduct testing and relay negative results in a timely manner so that they could be released from quarantine after 14 days. In April 2020, there was a minimum of 24 hours’ time of pro-cessing the collected swab for COVID-19 testing to release of results. This not only meant that testing could not occur too late, but also not too early if a passenger had an incubation period in the upper limit of that expected (i.e. 14 days). This was the main reason for including a test between 12 and 14 days, depending on the lab’s capacity to notify results, and including a health assessment before release from quarantine. A certificate of successful completion of quaran-tine was provided to all passengers on day 14 to present as an evidence to authorities in other jurisdictions, and if needed, as an evidence of completion of quarantine. In subsequent repa-triation flights, post April 2020, another issue that arose, not foreseen in the initial planning and preparedness, was the management of persistently PCR-positive cases despite symp-tom resolution for several months since their initial exposure. This necessitated assessments of whether they were still infectious. The proto-cols were then subsequently revised to include additional tests such as serology, taking into account the current knowledge about SARS-CoV-2, which was and is continually evolving.

It is clear that a secure quarantine process is of utmost importance to prevent any breaches within the designated facilities. The success of this model is heavily reliant on clear instruc-tions and high compliance.19 This has been demonstrated by quarantine facilities outbreaks due to mismanagement of a small number of infected persons, including breaches in IPC measures, ventilation system errors, and with emerging new variants concerning increased transmissibility.20 Since the initial repatriation operation in April 2020 in South Australia, sev-eral further IPC measures have been added to reinforce the robustness of the response. These include intensive training of hotel staff in IPC procedures, and focus on Medi-Hotel structural changes such as appropriate ventilation, having dedicated zones with the highest level of PPE, having a designated floor or area or hotel for only COVID-19 cases, and legislation to sup-port compliance with testing and PPE use, both for passengers and Medi-Hotel staff.

The aim of quarantine is to protect the local population from infectious disease transmis-sion, but a stringent approach must be balanced against the rights and wellbeing of the indi-vidual. In the first and subsequent repatriation flights, there were individuals who were vul-nerable and at very high risk of adverse health outcomes, such as unaccompanied minors, individuals living with disability, individuals with mental health conditions including psy-choactive substance use, and those with com-plicated pregnancy. While the multidisciplinary team who comprised the specialised health care delivery model were able to provide services to such clients once they were identified, there was no a priori knowledge of passengers’ medical histories. Quarantine and isolation may also exacerbate mental health issues, and it is neces-sary to have Medi-Hotel staff who are trained to recognise, and respond to, such issues.

While there have been several articles describ-ing similar operations around the world,21–23 this paper represents the first such description of the planning and preparedness for an Australian repatriation operation. The response described


here is important for understanding the com-plexities involved, both for staff and for indi-viduals undergoing quarantine in a designated facility, from evolving scientific knowledge to logistics. This understanding can contribute to the sharing of information around Australia and serves to inform subsequent needs for plan-ning of similar operations during current and future public health global emergencies requir-ing quarantine as a public health intervention.

A c k n o w le d g m e n t s

The authors are sincerely thankful to our Public Health colleagues in New South Wales (Communicable Disease Control Branch, Health Protection NSW, NSW Ministry of Health; SESLHD Disaster Management Unit, South Eastern Sydney Local Health District, NSW Ministry of Health) for sharing their jurisdiction’s repatriation experiences during the planning phase of the SA operation. The team of authors is also thankful for the feed-back and inputs from the Public Health team at Communicable Disease Control Branch in SA Health to improvise the draft of this article.

E t h i c s

As per the 5.1.22 and 5.1.23 statements from the National Statement on Ethical Conduct in Human Research, the current research work carries only negligible risk and is exempt from ethical review. Further details of the above mentioned statements can be found at: https://www.nhmrc.gov.au/about-us/publications/national-statement-ethical-conduct-human-research-2007-updated-2018

A u t h o r d e t a i l s

Dr Sonali Meena, Public Health Medicine Registrar1

Joel Chan, Medical Intern2

Dr Tuong-Vi Phan, Public Health Medicine Registrar1

Samantha Butenko, Nursing Director Infection Control Service3

Jenny Hurley, Chief Nurse and Midwifery Officer4

Paul McGowen, Chief Commander5

Dr Emily Kirkpatrick, Deputy Chief Public Health Officer, Deputy Chief Medical Officer1

Lisa Upton, COVID Infection Control Coordinator3

Dr Razlyn Abdul Rahim, Public Health Physician, Human Biosecurity Officer3

Dr Matthew McConnell, Public Health Physician, Professional Leadership and Governance6

Dr Robert Hall, COVID stream Director3

1. Department of Health and Wellbeing, Gov-ernment of South Australia

2. University of Adelaide

3. Communicable Disease Control Branch, Health Regulation and Protection, Depart-ment for Health and Wellbeing, Govern-ment of South Australia

4. Nursing and Midwifery Office, Clinical Col-laborative, System Leadership and Design, SA Health, Government of South Australia

5. State Control Centre, Department of Health and Wellbeing, Government of South Australia


6. Rural Support Service, Regional Local Health Networks, Government of South Australia

C o r r e s p o n d in g a u t h o r

Dr Sonali Meena Public Health Medicine Registrar, Department of Health and Wellbeing, Government of South Australia Telephone:(08) 83886288 Email: [email protected]

R e f e r e n c e s

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3. Australian Government Federal Register of Legislation. Biosecurity Act 2015, No. 61, 2015. Compilation No. 8. [Legislation.] Canberra: Australian Government, Fed-eral Register of Legislation; 25 March 2020. Available from: https://www.legislation.gov.au/Details/C2020C00127.

4. Prime Minister of Australia. Border restric-tions: media release 19 March 2020: Prime Minister, Minister for Foreign Affairs, Min-ister for Women, Minister for Home Affairs. [Internet.] Canberra: Australian Govern-ment Department of the Prime Minister and Cabinet; 19 March 2020. [Accessed on 1 September 2020.] Available from: https://www.pm.gov.au/media/border-restrictions.

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6. Lytras T, Dellis G, Flountzi A, Hatziana-stasiou S, Nikolopoulou G, Tsekou K et al. High prevalence of SARS-CoV-2 infection in repatriation flights to Greece from three Eu-ropean countries. J Travel Med. 2020;27(3). doi: https://doi.org/10.1093/jtm/taaa054.

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Response Plan for Novel Coronavirus (COV-ID-19). Canberra: Australian Government Department of Health; 18 February 2020. Available from: https://www.health.gov.au/resources/publications/australian-health-sector-emergency-response-plan-for-novel-coronavirus-covid-19.

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10. Government of South Australia Attorney-General’s Department. Emergency Man-agement Act 2004. [Legislation.] Adelaide: Government of South Australia, Attorney-General’s Department; 2020. Available from: https://www.legislation.sa.gov.au/lz/c/a/emergency%20management%20act%202004.aspx.

11. Communicable Diseases Network Australia (CDNA). Coronavirus Disease 2019 (COV-ID-19). CDNA National guidelines for pub-lic health units. [Internet.] Canberra: Aus-tralian Government Department of Health, CDNA; 2020. Available from: https://www1.health.gov.au/internet/main/publishing.nsf/Content/cdna-song-novel-coronavirus.htm.

12. Institute for Healthcare Improvement (IHI). How to Improve. [Internet.] Boston: IHI; 2016. Available from: http://www.ihi.org/resources/Pages/HowtoImprove/de-fault.aspx.

13. Government of South Australia Depart-

ment for Heath and Wellbeing (DHW). Infection Prevention and Control: COV-ID-19 Personal Protective Equipment (PPE) Decision Matrix. Adelaide: Govern-ment of South Australia; 2020. Available from: https://www.sahealth.sa.gov.au/wps/wcm/connect/952a07a8-a676-4e53-9603-67c44f2162c3/COVID+PPE+Matrix+-+v2.1+%28FINAL%29.pdf.

14. Ramírez-Cervantes KL, Romero-Pardo V, Pérez-Tovar C, Martínez-Alés G, Quintana-Diaz M. A medicalized hotel as a public health resource for the containment of Covid-19: more than a place for quarantin-ing. J Public Health (Oxf ). 2020. doi: https://doi.org/10.1093/pubmed/fdaa129.

15. Gillert J, Hall J, Pastor C. Medicalisation of hotels in the context of coronavirus-COV-ID-19. [Internet.] Chicago: Baker McKenzie; 31 March 2020. Available from: https://www.bakermckenzie.com/en/insight/publica-tions/2020/03/medicalisation-of-hotels-in-context-of-covid19.

16. Higginson IJ, Koffman J. Public health and palliative care. Clin Geriatri Med. 2005;21(1). doi: https://doi.org/10.1016/j.cger.2004.08.003.

17. WHO Regional office for Europe. Public health services. [Internet.] Geneva: WHO; 2012. Available from: https://www.euro.who.int/en/health-topics/Health-systems/public-health-services/public-health-services.

18. Walline JH. Quarantine wristbands, face masks, and personal freedom in Hong Kong. J Emerg Med. 2020;59(4):604–5.

19. Zhu Y, Wang C, Dong L, Xiao M. Home quarantine or centralized quarantine, which is more conducive to fighting COV-ID-19 pandemic? Brain Behav Immun. 2020;87:142–3.

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Recommendations Volume 1. Melbourne: Government of Victoria COVID-19 Hotel Quarantine Inquiry; December 2020. Availa-ble from: https://www.parliament.vic.gov.au/file_uploads/0387_RC_Covid-19_Final_Re-port_Volume_1_v21_Digital_77QpLQH8.pdf.

21. Yamahata Y, Shibata A. Preparation for quarantine on the cruise ship Diamond Princess in Japan due to COVID-19. JMIR Public Health Surveill. 2020;6(2):e18821.

22. Mansoor SN, Gill ZA, Rathore FA, Uttra KM. Establishing and managing a quar-antine and isolation centre in COVID-19 pandemic. J Pak Med Assoc. 2020;70(Suppl 3)(5):S11–4.

23. Shaikh Abdul Karim S, Md Tahir FA, Mo-hamad UK, Abu Bakar M, Mohamad KN, Suleiman M et al. Experience repatriation of citizens from epicentre using commercial flights during COVID-19 pandemic. Int J Emerg Med. 2020;13(1):50. doi: https://doi.org/10.1186/s12245-020-00308-7.


A p p e n d i x A i

S e c t i o n A .1 . C O V ID -1 9 t e s t i n g a n d q u a r a n t in in g p la n n in g

The following planning was done to enable timely testing of passengers and successful completion of quarantine or required isolation.

• Border nurses and infection prevention and control staff present at the airport were briefed to conduct clinical assessment of in-coming passengers soon after disembarking and to swab passengers with signs or symp-toms compatible for COVID-19 as shown in Figure A.1. Asymptomatic passengers were swabbed for COVID-19 at the state-designated facility, i.e. hotel, within 72 hours of arrival and at day 12 following arrival. An online screening questionnaire, to be filled out prior to landing, was subsequently intro-duced to speed up processes at the airport.

• Provision was made for proactively main-taining a list of names of all staff (at airport and hotel) present during the arrival, quar-antine and release from designated quaran-tine/isolation facility of returned travellers on a daily basis. This was done to assist in contact tracing at a later stage especially if there was a breach in infection prevention and control practices by any staff member, e.g. border nurses not using appropriate PPE while performing examination of a positive case, or security staff coming in contact with positive cases while on duty without PPE.

• It was recommended that a risk assessment be undertaken for all positive cases and close contacts. The ‘isolation and CDCB contact tracing and case management pathway’ (Figure A.1) was developed and implemented by CDCB for risk assessment of each positive case and their contacts. If feasible, confirmed cases were to be isolated

i N o t e : T h e a r t ic le d e s c r ib e s in i t ia l p la n n in g a n d p r e p a r e d n e s s o f t h e r e p a t r ia t io n o p e r a t io n in A p r i l 2 0 2 0 . T h e p r o c e s s e s m e n t io n e d in t h is a r t i c le h a v e b e e n m o d ifi e d s ig n ifi c a n t ly s in c e t h e in i t ia t io n o f t h e r e p a t r ia t io n o p e r a t io n a s p a r t o f t h e c o n t in u o u s r e v ie w a n d im p ro v e m e n t o f t h e o p e r a t io n b y S A H e a lt h .

from other household members. Asymp-tomatic family members of travellers who were defined as close contacts were advised to self-quarantine, if feasible, at a designated facility for 14 days following the last con-tact with the infectious case. The start day of isolation was planned to be reset even if an individual decided to stay with the COVID-19-positive family member. In case of young children, pregnant females, el-derly individuals, individuals with disability requiring self-care, isolation requirements were to be decided on a case-to-case basis. The decisions in such situations were aimed at minimal impact on mental wellbeing.

• Close contacts were advised to monitor for the development of any COVID-19 compat-ible signs and symptoms for 14 days follow-ing their last contact with a confirmed or probable COVID-19 case.

• In order to ensure a compliant quarantine for all travellers, private security was lo-cated onsite at all times at the designated facilities. The number of security personnel onsite was based on a risk assessment giving consideration to the site layout, staff rest/welfare requirements, evacuation/fire alarm procedures and the number of persons to be located at the site. Furthermore, there was on-site SAPOL presence overseeing the security arrangements of quarantine at all times.

• Hotel cards were programmed to allow a once-only entry into rooms, allowing for the identification of returned travellers who leave their rooms without authorisation.

• Consideration was given to locking/secur-ing/alarming external exits in order to secure the site effectively. It was ensured that this must not obstruct designated emergency exits. A secure area (including temporary fencing as required) was established in close proximity to the accommodation to allow the secure containment of travellers in the event of an emergency evacuation.


Figure A.1: International repatriation passenger COVID-19 testing and quarantine protocol, for the initial planning phase from April to August 2020


S e c t i o n A .2 . I n f e c t i o n p r e v e n t i o n a n d c o n t r o l p la n n in g

The following advice was provided by CDCB Infection Control Service Nursing Director during the planning stage:

D u r in g a i r p o r t t r a n s f e r

• Unnecessary staff members or any other people were not allowed to be present at the airport terminals during passenger arrival.

• Two surgical masks were provided for each passenger at the time of disembarkation.

• Passengers were instructed by ADF and ABF staff at airport to not use drinking fountains, vending machines or shops. These areas were also fenced off where possible. Avoidance of the use of multiple-terminal toilets and use of designated facilities only was ensured.

• Passengers were allowed off the plane in groups, of maximum 20 per group, to avoid gathering points and crowding in the airport e.g. customs and screening points etc.

• Cleaning was undertaken of airport surfaces and any equipment used by passengers e.g. wheelchairs, trolleys, as well as high touch surfaces including grab/stair handrails, walking conveyer handrails, lift buttons, toilets. Special attention to high touch points e.g. toilet cubical locks, bag hooks, taps etc.

• Buses used for transport of passengers were decontaminated after use as per environmen-tal decontamination recommendations.

• The usual COVID-19-related decontamina-tion of the plane was to be followed.

• All cleaning equipment was to be disposable or, if reusable (e.g. buckets, handles, cleaning trolleys), decontaminated immediately after completion of all cleaning tasks from the flight.

• Items of PPE, including masks, were to be placed in a plastic bag and disposed of as

clinical waste (yellow medical waste bin).

A t M e d i -H o t e l

• Staff and visitors were not permitted to enter any area of the Medi-Hotel if unwell with COVID-19-like symptoms as described in the CDNA SoNG.

• Signage was to be displayed at all entrances to the Medi-hotel. Consideration was given for the use of signage in different languages as required.

• Hand hygiene was to be performed on entry and exit to the quarantine hotel and defined areas with the hotel.

• Facilities for waste disposal were to be avail-able and clearly marked.

• Guests were required to wear a face mask when transiting through the Medi-Hotel entrance lobby area and if transferring to another hotel, hospital, for medical care etc.; luggage was to be wiped over with a com-bined detergent / disinfectant wipe.

• External deliveries (i.e. online orders, mail, food) ordered by guests were to be left in the main foyer in a designated area. Hotel staff would then deliver to the guest wearing ap-propriate PPE.

• Any PPE breaches or potential exposure to COVID-19 in the course of work were to be notified to the Team Leader (nursing), or the most senior person for the work group.

• All quarantined / isolated guests were to remain in their rooms.

• Health checks were to be undertaken re-motely where possible. Staff taking the speci-mens at the hotel would not enter the room. Passenger should present to their doorway wearing their facemasks.

• Items (e.g. toys, books, newspapers) were not to be shared between guests.


Figure A.2: Requirements of personal protective equipment for all staff and passengers involved in the repatriation operation for initial planning phase from April to August 2020


Figure A.3: Infection prevention and control (IPC) principles and procedures implementation during each stage of the operation for initial planning phase from April to August 2020.


S e c t i o n A .3 . M e d i -H o t e l N u r s in g S u p p o r t P r o g r a m P la n n in g

• Passengers flagged as high risk/symptomatic by a Border Nurse were triaged for referral. The onsite Nurse Team Leader (NTL) was to be alerted in case of emergency to coordi-nate the referral emergency. Arrangements for out-of-hours services were made in collaboration with SAPOL and COVID-19 emergency department at state tertiary hos-pitals i.e. Royal Adelaide Hospital (RAH), Flinders Medical Centre (FMC) and Wom-en’s and Children Hospital (WCH). The hotel concierge was to call ‘000’ for emer-gency situations and was to advise the onsite SAPOL team. The onsite SAPOL team was to liaise with the SCC-H and to transfer passengers with assistance from ambulance services as required. No baggage was to be transported in ambulances.

• All passengers were to be actively monitored, by border nurses, on a daily basis for devel-opment of any COVID-19 compatible symp-toms (e.g. fever or respiratory symptoms) during this quarantine period. COVID-19 testing of high-risk/symptomatic passengers was to be undertaken where practicable.

• Cases were to be encouraged to report any clinical deterioration of symptoms to their care provider as soon as possible.

• Each passenger at the hotel was to have a face-to-face health assessment undertaken by Medi-Hotel team members, utilising a health screen check list.

• The initial health assessment would identify health/mental health, safety and wellbeing needs including medications and appropri-ate referrals.

• All passengers were to be provided with lo-cal pharmacy contact details to obtain access for pharmaceutical supplies (both prescrip-tion and non-prescription medication). Pharmacies would collect payments over the

phone. Pharmaceutical supplies ordered by guests would be left in the main foyer in a designated area. Hotel staff would then de-liver to the guest wearing appropriate PPE.

• Daily phone calls for health assessment were to be managed by nurses under the Medi-Hotel NSP for passengers with no or very low clinical needs.

• Border nurses were to work in pairs, for their own personal safety, when interacting with passengers face-to-face for clinical as-sessment or COVID-19 swabbing.

• COVID-19 positive results to passengers would be notified by a medical practitioner from CDCB as per the South Australian Public Health Act 2011.

• Passengers with a positive COVID-19 result were to be referred to the Metropolitan Referral Unit (MRU) for continued clinical care management. The MRU would then implement daily phone calls for checking symptoms and would assess needs for sup-port including mental wellbeing support. The MRU would consider referral to the GP team if required.

• Border nurses were to be updated on a list of positive cases and close contacts by CDCB after seeking informed consent from indi-viduals identified as positive cases and close contacts. This would assist in better clinical care and monitoring of symptoms.

• If any passenger in quarantine were to refuse a swab, the refusal was to be noted and CDCB was to be informed for further ac-tion.

• At the time of completion of quarantine period, at day 12, another COVID-19 swab and face to face health assessment was to be done by the nurse’s team. Passengers with clinical issues would be referred utilising the referral pathways to GP.


• A copy of health records, COVID-19 results, quarantine completion certificate, mental health and wellbeing information, general information about preventing COVID-19 spread was to be provided at departure to all passengers at successful completion of quarantine.

Figure A.4. Medi-Hotel Nursing Program Model developed during planning of the repatriation operation for initial planning phase from April to August 2020.

communicable diseases intelligence 2021 - repatriation

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