14th May, 2020

What quarantine measures are required for health care workers travelling to remote communities? - Evidence April 30, 2020

Coronavirus/COVID-19

Context

  • Health care workers (HCWs) are a substantial vector of SARS-CoV-2 (COVID-19)
  • Under the Biosecurity (Human Biosecurity Emergency) (Human Coronavirus with Pandemic Potential) (Emergency Requirements for Remote Communities) Determination 2020 (1)
    • there is a general requirement for 14-day quarantine before any person enters a remote Aboriginal or Torres Strait Islander community (designated area)
    • HCWs are designated as essential workers and can, if certain criteria are met, be exempt from the 14-day quarantine requirement
    • any essential worker, including HCWs, entering a remote area must take reasonable steps where possible to minimise their contact with other people in the remote area
  • Although not all remote communities fall within the Biosecurity Determination 2020, all communities potentially face devastating consequences from transmission of COVID-19
  • In addition to the Biosecurity Determination 2020 (1) there may be state and territory, regional, local and/or community travel restrictions and requirements that need to be considered
  • Maintaining access to high quality primary health care is critical including during the period of restrictions due to social distancing requirements.

Recommendations

All alternatives to visiting the community should be explored including:

  • consultations by telehealth
  • remote support to local health staff
  • cancelling non-essential visits

If there are any feasible alternatives to visiting the community, they should be pursued.

If a visit is considered absolutely necessary:

  • where possible HCWs should quarantine (for example in the closest regional centre) for 14 days before entering a remote community; HCWs may provide services via telehealth while in quarantine, where infrastructure allows

All relief staff workers entering Aboriginal and Torres Strait Islander communities should be assumed to have come from areas with potential for community transmission (ie higher prevalence areas). Therefore, all HCWs are potentially symptomatic or asymptomatic carriers of COVID-19.

The risk of transmitting COVID to remote communities is high because of:

  • high mobility of the population
  • high turnover/visiting HCWs including fly-in-fly-out and locum HCWs
  • high volume of other visitors to communities
  • insufficient housing infrastructure in the community, leading to overcrowding which increases risk of disease transmission and makes it difficult to self-isolate.

The consequence of COVID-19 within communities is potentially devastating because of:

  • high prevalence of co-morbidities that may increase the risk of severe disease from COVID-19
  • reduced access to health services (availability and capacity)
  • limited transport impacting on patient access to clinic services, availability of equipment and supplies, and delayed laboratory test results
  • other barriers to health care including lack of cultural appropriateness and safety of services (2).

It is therefore critical in these settings to be ambitious about prevention and minimise transmission risk through appropriate quarantine policies for HCWs, despite the additional burden this may place on services. We recommend that before entering any remote community, HCWs quarantine in an area with lower suspected prevalence of community transmission of COVID-19 compared to their current place of residence, and with reduced travel time to the remote area (and therefore potential travel-related exposure); this may be the regional town nearest to the remote area. Telehealth activities can be performed while in quarantine (3, 4), where infrastructure allows.

The median incubation period for COVID-19 is estimated at 5 to 6 days (5). Most studies report a maximum incubation period of 14 days. International quarantine policies are based on the 14-day incubation period. However, one case study indicates that the incubation period may be as long as 24 days (6). If the incubation period can be greater than 14 days, an extended quarantine duration may be required to minimise the spread of COVID-19 (6).

Based on current best available evidence (7):

  • Less than 2.5% of infected persons will show symptoms within 2.2 days (Confidence Interval: 1.8 to 2.9 days) of exposure
  • Around half of infected persons will show symptoms within 5 days – this means half will not show symptoms until after 5 days
  • 97.5% of infected persons will show symptoms within 11.5 days (Confidence Interval: 8.2 to 15.6 days)
  • Among people who are infected and go on to develop symptoms, 101 in 10 000 will develop systems after 14 days (i.e. outside of the quarantine period), and this estimate may be conservative.

If a visit is considered absolutely necessary:

  • HCWs may be exempt from 14-day quarantine if, in the last 14 days, they:
    • have not travelled overseas; and
    • have not had fever (≥38°C), chills, and/or night sweats; and
    • have not had acute respiratory infection, including sore throat, cough, or shortness of breath; and
    • have not had contact with a confirmed COVID-19 case without adequate use of PPE.

The Biosecurity (Human Biosecurity Emergency) (Human Coronavirus with Pandemic Potential) (Emergency Requirements for Remote Communities) Determination 2020 (https://www.legislation.gov.au/Details/F2020L00324) (1) states that essential workers (which includes HCWs) can be exempt from the 14-day quarantine if there is an ‘urgent need for service’ (8) and:

  • immediately before the entry, the person does not have any of the signs or symptoms of human coronavirus with pandemic potential; [and]
  • (ii)  in the 14 days immediately before the entry, the person has not been exposed, without adequate personal protective precautions, to human coronavirus with pandemic potential; [and]
  • (iii)  in the 14 days immediately before the entry, the person has not been outside Australian territory.

Given the risks associated with not following full quarantine (see above), HCWs can only seek exemption from full quarantine where a visit is considered absolutely necessary (8, 9). For example, this may include when a health service cannot meet the needs of the communityusing the combination of available staff providing in-person services and telehealth services by quarantined staff members, where relevant. 

We recommend that to be eligible for exemption, HCWs must not have experienced any of the signs or symptoms of COVID-19 (fever, chills, night sweats, or acute respiratory infection – including sore throat, cough, or shortness of breath) over the period of 14 days prior to entry – not only ‘immediately before the entry’. The rationale for including symptoms over the 14 day period prior to entry is that, under current guidelines, HCWs should be tested for COVID-19 if they have a fever (≥38°C, or history of fever) or acute respiratory infection (10).

HCWs should be aware of other symptoms of COVID-19 as they are identified. The Centre for Evidence-Based Medicine provides a ‘COVID-19 Signs and Symptoms Tracker’ that is updated as data emerges (11).

There are currently no guidelines specific to Aboriginal and Torres Strait Islander communities or to Australia on risk assessment on COVID-19 risk after exposure in the health care setting. Until local guidelines are developed, HCWs can assess their risk using the CDC (12) or WHO (13) risk assessment tools. 

If a visit is considered absolutely necessary:

As above, the Communicable Disease Network Australia (CDNA) COVID-19 guidelines (10) recommend that HCWs be tested for COVID-19 if they have experienced fever or respiratory symptoms. If HCWs have experienced symptoms in the last 14 days but return a negative PCR test for COVID-19, they may enter a remote community, noting that: ‘A risk assessment should be undertaken for suspected cases who initially test negative for SARSCoV-2. If there is no alternative diagnosis and a high index of suspicion remains that such cases may have COVID-19, consideration should be given to continued isolation and use of the recommended infection control precautions, pending further testing’ (10).

Remote communities should consider determining additional precautions for their community as guided by local needs and preferences.

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References

1.  Biosecurity (Human Biosecurity Emergency) (Human Coronavirus with Pandemic Potential) (Emergency Requirements for Remote Communities) Determination 2020. F2020L00324 (2020).

2.  Communicable Diseases Network Australia. Coronavirus Disease 2019 (COVID-19) Outbreaks in Residential Care Facilities. CDNA National Guidelines for the Prevention, Control and Public Health Management of COVID-19 Outbreaks in Residential Care Facilities in Australia. Online, Australia CDN. 2020. 13 March 2020.

3.  COVID-19: Whole of population telehealth for patients, general practice, primary care and other medical services [press release]. 2020.

4.  Australian Government Department of Health. Temporary Telehealth Bulk-Billed Items for COVID-19 2020 [Available from: http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/Factsheet-TempBB.

5.  Del Rio C, Malani PN. COVID-19—New Insights on a Rapidly Changing Epidemic. JAMA. 2020.

6.  Bai Y, Yao L, Wei T, Tian F, Jin D-Y, Chen L, et al. Presumed asymptomatic carrier transmission of COVID-19. JAMA. 2020.

7.  Lauer SA, Grantz KH, Bi Q, Jones FK, Zheng Q, Meredith HR, et al. The incubation period of coronavirus disease 2019 (COVID-19) from publicly reported confirmed cases: estimation and application. Annals of Internal Medicine. 2020.

8.  Biosecurity (Human Biosecurity Emergency) (Human Coronavirus with Pandemic Potential) (Emergency Requirements for Remote Communities) Amendment (No. 1) Determination 2020. 7 April, F2020L00324 (2020).

9.  Australian Government Department of Health. Keeping communities safe from coronavirus: remote area travel restrictions. Version 1.0. 8 April. Available from: https://www.health.gov.au/resources/publications/keeping-communities-safe-from-coronavirus-remote-area-travel-restrictions. 2020.

10. Communicable Diseases Network Australia. Coronavirus Disease 2019 (COVID-19): CDNA National Guidelines for Public Health Units v. 2.5. Available from: https://www1.health.gov.au/internet/main/publishing.nsf/Content/cdna-song-novel-coronavirus.htm. Communicable Diseases Network Australia. 2020. 26 March 2020.

11. Centre for Evidence-Based Medicine. COVID-19 Signs and Symptoms Tracker. Available from: https://www.cebm.net/covid-19/covid-19-signs-and-symptoms-tracker/ Oxford, United Kingdom: Centre for Evidence-Based Medicine. 2020.

12. Centers for Disease Control and Prevention. Interim U.S. Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease (COVID-19) 2020 [updated 7 March 2020]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html.

13. World Health Organization. Health workers exposure risk assessment and management in the context of COVID-19 virus. 2020. 19 March 2020.