The Australian Medical Association has voiced concerns about Victoria’s contact tracing, and says healthcare settings still need better infection control, as the State Government plans to reveal relaxed restrictions today.

Key points:Victoria’s coronavirus rules are being relaxedBut the AMA is concerned about shortfalls in contact tracing, and infection control in hospitals A national taskforce is being set up to examine guidelines in healthcare settings

In a letter to members, the AMA’s Victorian President, Julian Rait, said the state’s public health teams could struggle to keep daily case numbers under control if restrictions are eased too quickly.

“Living with the virus will require much better contact tracing,” he wrote.

“We are cautiously optimistic Victoria’s new system will be stronger eventually, but is it there yet?”

Dr Rait also warned infection control in hospitals needed to be improved to prevent the virus spreading to healthcare workers, and out into the community.

“Infection in healthcare workers occurring where all prevention interventions have not been applied is not only morally and legally indefensible — it has a massive impact on health service capacity, aged care infection prevention and our outbreak response,” he said.

In the letter, Dr Rait said all hospital staff should be wearing fit-tested N95 masks, and there needed to be an audit of hospital ventilation.

Catch up on the main COVID-19 news from October 17 with our coronavirus blog.

Healthcare worker infections significantly contributed to Victoria’s second wave, and up to 80 per cent of those infections happened at work.

There are 11 active cases among healthcare workers, including from a recent outbreak at Box Hill Hospital in Melbourne’s east.

“We have still been seeing a number of sporadic cases that could only be prevented by having a higher level of respiratory protection,” Dr Rait said.

Dr Rait says fit-testing of N95 masks is vital.(ABC News: Patrick Stone)

In a statement, Victoria’s Chief Medical Officer, Andrew Wilson, said Victoria’s guidelines for the use of N95 masks were upgraded in August, and went beyond the national guidelines.

“All decisions about PPE use in our health services has been guided by expert advice and evidence, with the best possible protection for staff the primary consideration, and supply has always met that guidance,” he said.

The Government has required all Victorian public health services to have a respiratory program in place by the end of October, which includes fit-testing. The Victorian Health and Human Services Building Authority has been tasked with assessing ventilation in clinical settings.

“We are committed to improving understanding of ventilation and air quality in our health services,” Professor Wilson said.

‘We need to think about opening windows’: doctor

The issue of ventilation is gaining momentum among doctors who believe state and federal guidelines do not give enough weight to aerosol transmission in hospitals.

Michelle Ananda-Rajah is conducting a survey of healthcare workers infected with COVID-19 in Australia. She said there was some anxiety among healthcare workers as the state looked to ease restrictions, particularly after recent infections at Box Hill Hospital.

Michelle Ananda-Rajah has been surveying healthcare workers hit with COVID-19.(ABC News)

“We’re still seeing outbreaks among healthcare workers in hospitals even with very, very low community transmission, and that is a red flag,” Dr Ananda-Rajah said.

“I don’t think that hospitals are optimised for safety, and this is a real threat to our recovery as we start to open up.”

She said it was time for hospitals to consider opening windows, particularly coming into the warmer months.

“We haven’t really addressed this issue of ventilation, particularly in hospitals. All hospitals that I know have their windows sealed shut and rely on internal air-conditioning, which in a lot of hospitals are pretty old structures.”

Read more about coronavirus:New taskforce to consider aerosol transmission in hospitals

The Australian Commission on Safety and Quality in Health Care has established a new taskforce to review guidelines, particularly around transmission of COVID-19 in healthcare settings, and will meet for the first time next week.

Its chairwoman, Anne Duggan, said she expected the taskforce would report to governments in a month.

Dr Anne Duggan is the clinical director of the Commissioner’s COVID-19 Rapid Response Unit.(Supplied)

“The evidence certainly is changing but what we’re trying to do is focus down on transmission in hospital environments and see what we should be doing,” Professor Duggan said.

“The objective is to err on the side of patient and healthcare worker safety.”

She said the taskforce would examine whether every healthcare worker should be wearing a fit-tested N95 mask.

“That’s exactly what we’ll be looking at with the taskforce: when should we be recommending what, in what setting,” she said.

Professor Duggan said it was important to examine all the evidence, which was changing every day.

“In health, we’ve never had to face something that’s such an unknown, and something we’ve had to respond so rapidly to.”

Mystery cases ‘the key’ to controlling the virus

The two-week total of “mystery cases”, those with an unknown source, is now at 17 in Melbourne and closing out those cases is considered key to getting on top of the virus.

Mystery cases have typically made up 10 per cent of cases in Victoria and are “the hardest ones to find”, Chief Health Officer Brett Sutton said.

“We are at a point where we only have a tiny handful of cases each day but the mystery cases are still averaging one a day,” he said.

“They are making up a bigger proportion of our daily total, in part because they are the hardest ones to find.”

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Upstream testing, genomic sequencing and reinterviewing people with the virus are important tools used by contact tracers to get the vital clues about where a mystery case came from.

While contacts downstream from a positive case are always followed up, contact tracers also work to find out where a case originated, with upstream testing.

Professor Sutton said people with the virus were often reinterviewed to get more clues about the source of the infection, and genomic testing was being prioritised for mystery cases.

“It might flag with an aged care facility, it might flag with another household cluster, so we can go back and ask those specific questions — ‘do you know anyone who works at this setting, or anyone in your extended family or network of friends who has been to this site?’ — so we can follow the trail,” he said.

“We are trying to find out all of those clues that might allow us to link those cases to any other existing case or site.”

AMA president Julian Rait’s letter:

Victoria has arrived at a fork in the State Government’s COVID-19 roadmap.

We are all relieved that the stage 4 lockdown successfully brought the case numbers down from close to 800 per day — an incredibly important achievement in protecting our community from COVID-19 and ensuring our health system was not overwhelmed.

Yet, lockdowns are not a permanent solution. The health implications of a never-ending lockdown are serious. Obviously, all doctors are battle weary and conscious of the mental health effects and secondary health impacts of the stage 4 lockdown on patients and their families. Melbournians are exhausted with the unrelenting nature of Victoria’s lockdown strategy. Socially and economically there have been very substantial costs. Many people have been significantly impacted by isolation, unemployment, and mental distress.

No matter how low our cases go, it is clear we will need to live with COVID-19 going forward and we must be prepared.

Victoria is looking for a way forward. As we carefully begin to open up, living with the virus will require all our ingenuity and rigour to reclaim some sense of normality until we get a vaccine. A cautious balanced middle path — with some modest relaxation of restrictions — would seem to be the best way.

It is very important that as restrictions are released, we do so in a measured and considered way. It might be difficult for our public health teams to keep the daily case numbers at a reasonably low level over the next few months, especially if social interactions increase dramatically ahead of Christmas. Furthermore, logic would suggest that our case numbers could increase again if we open up too far on 19 October. In fact, some would argue that it is almost inevitable that if we do open up more next week, at some point in the future (probably after Christmas) we will have to tighten restrictions again.

Living with the virus will require much better contact tracing. We are cautiously optimistic Victoria’s new system will be stronger eventually, but is it there yet? Modelling our new system on the more successful New South Wales devolved model — with local public health units established across the state – is a good idea but importantly, our new system is not well established and has yet to be truly stress-tested with higher case numbers, so time will tell.

Best practice testing and infection control measures in all healthcare settings and aged care facilities will be required. Infection in healthcare workers occurring where all prevention interventions have not been applied is not only morally and legally indefensible — it has a massive impact on health service capacity, aged care infection prevention and our outbreak response.

All hospital workers should be wearing properly fitted N95 masks with an airtight seal. The fit-testing rollout across all of our hospitals must occur more quickly and we are advocating for this on a daily basis. An audit of ventilation systems, air conditioning and air circulation, is also necessary to make sure there are no dead spaces where the virus might ‘hang about’ inside hospitals and AMA Victoria has argued for such testing to become a priority. We have still been seeing a number of sporadic cases that could only be prevented by having a higher level of respiratory protection.

Additionally, we must monitor health service and staff capacity as we open our health system up, as many public health staff are exhausted and are very concerned about how they will manage with normal (or excess) demand and ongoing need for coronavirus precautions. AMA Victoria recently wrote to the new Victorian Minister for Health outlining these concerns and requesting workforce planning to address this.

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