Chapter 1

1.1 Introduction

1. A fair and constructive examination of what happened in Victoria with its Hotel Quarantine Program must be put into a national and international context. To do otherwise would not be helpful to the way forward, nor fair to those hundreds of people who worked tirelessly in our state to help keep us all safe. Further, to not examine the Program and its component parts measured in response to the growing threat of the novel coronavirus pandemic engulfing the world by early 2020, and the state of knowledge at that time, would be an injustice to those who were tasked with implementing and operating the Hotel Quarantine Program. I do not want that to be the legacy of this Inquiry.
2. Aspects of the Program had serious fault lines through them that need to be identified. Decisions made and not made, and actions taken and not taken, also must be examined. This Inquiry aims to do that for the benefit of all.
3. With that in mind, this section of the Report aims to set out that international and national context, in summary form, as the background to the emergence of the COVID-19 pandemic.

1.2 COVID-19 – The emergence of a pandemic

A new virus is identified in China

4. In late 2019, the world’s attention was being drawn to China where reports were emerging of an unknown pneumonia-like disease.
5. On 31 December 2019, the World Health Organization (WHO) country office in the People’s Republic of China was alerted to cases of ‘viral pneumonia’ in Wuhan City, Hubei Province, China.¹
6. By 3 January 2020, reports of 44 patients with a pneumonia of an unknown cause had been made to WHO by national authorities in China. Of the reported cases, 11 were identified as being severely ill. At this stage, the reported clinical signs of this pneumonia included fever with some patients having difficulty breathing. Chest radiographs also identified invasive lesions in both lungs.²
7. The newly identified virus, provisionally named 2019-nCoV³, was later renamed ‘severe acute respiratory syndrome coronavirus 2’ (SARS-CoV-2) by the International Committee on Taxonomy of Viruses.⁴ The disease caused by SARS-CoV-2 became known as COVID-19.⁵
8. The initial cluster of patients was linked to the Huanan Seafood Market in Wuhan and, at the time, no evidence of significant human-to-human transmission had been reported.⁶ While some dispute about origins of COVID-19 currently remains, the weight of available information leans towards the first case of animal-to-human transmission of the virus occurring in China.⁷
9. The WHO confirmed, on 11 January 2020, that it had received the genetic sequences for the novel coronavirus from China and expected these to soon be made publicly available. These would be used to support other countries in developing specific diagnostic kits.⁸
10. By 14 January 2020, the first case of COVID-19 outside China had been reported. The patient was linked to Wuhan and located in Thailand.⁹ The potential for human-to-human transmission between confirmed cases was also highlighted for further investigation.¹⁰
11. On 16 January 2020, the Japanese Ministry of Health, Labour and Welfare informed the WHO of a confirmed case of novel coronavirus in a person who had travelled to Wuhan.¹¹ This was the second confirmed case detected outside China. The WHO stated, not surprisingly, that, considering global travel patterns, additional cases in other countries were likely to occur.¹²
12. On 20 January 2020, Chinese authorities included COVID-19 in the notifiable report of Class B infectious diseases and border health quarantine infectious diseases, leading to the adoption of control measures such as temperature checks, healthcare declarations and quarantine at transportation depots.¹³ By that date, the WHO had been notified of 282 confirmed cases of COVID-19 in China, Japan, the Republic of Korea and Thailand.¹⁴
13. As of 22 January 2020, a total of 581 COVID-19 cases had been reported globally. Of these cases, 571 were reported in China and 375 were linked to the Hubei Province. Seventeen deaths had also been reported from the Hubei Province. Global cases were all linked to Wuhan and were reported in Thailand, Japan, Hong Kong Taipei Municipality, China, Macau, the United States of America and the Republic of Korea.¹⁵

    The WHO declares a public health emergency

14. On 30 January 2020, the WHO Director-General, Dr Tedros Adhanom Ghebreyesus, convened a meeting of the Emergency Committee on the novel coronavirus under the International Health Regulations (2005). The Committee advised the Director-General that the outbreak now met the criteria for a public health emergency of international concern.¹⁶
15. At that time, there were 7,711 COVID-19 cases confirmed in China and 83 cases were reported in 18 other countries (including Australia). Confirmed cases of human-to-human transmission were reported in three countries outside China.¹⁷

    COVID-19 is declared a pandemic

16. By 11 March 2020, Dr Tedros reported that the number of cases of COVID-19 outside China had increased 13-fold compared with the number of cases two weeks earlier.¹⁸ The number of affected countries had tripled. Specifically, there were 118,319 cases in 114 countries, including China, and 4,292 deaths had been recorded.¹⁹
17. Dr Tedros also noted that the number of cases, the number of deaths and the number of affected countries were expected to climb higher. It was in this context that the WHO declared COVID-19 a pandemic.²⁰

    Figure 1.1: Global number of reported COVID-19 cases and deaths 30 December 2019–30 August 2020

    Source: WHO COVID-19 Weekly Epidemiological Update, 30 August 2020, < https://www.who.int/docs/default-source/coronaviruse/situation-reports/…;.

    What is a pandemic?

18. A pandemic is defined by the WHO as the worldwide spread of a new disease.²¹ For example, an influenza pandemic occurs when a new influenza virus emerges and spreads around the world and most people do not have immunity.²²
19. When declaring COVID-19 a pandemic on 11 March 2020, Dr Tedros highlighted that this was the first pandemic caused by a coronavirus and noted countries would need to strike a balance between protecting health, minimising economic and social disruption, and respecting human rights in managing the virus.²³
20. The WHO called on countries to ‘detect, test, treat, isolate, trace, and mobilise their people’ to change the course of the pandemic.²⁴ In addition, and consistent with health advice provided since January 2020, the WHO reiterated basic principles to reduce the general risk of transmission, including:
    1. Avoiding close contact with people suffering from acute respiratory infections.
    2. Practising socially distant greetings such as a wave, nod or bow.
    3. Frequent handwashing, especially after direct contact with ill people or their environment.
    4. Regular cleaning of high touch surfaces in a home environment.
    5. Practising cough etiquette (maintain distance, cover coughs and sneezes with disposable tissues or clothing, and wash hands).
    6. Enhance standard infection prevention and control practices in hospitals, especially in emergency departments.²⁵

1.3 The Australian response to COVID-19

Figure 1.2: Total COVID-19 cases in Australia 25 January 2020–27 March 2020

Source: COVID-19 current situation and case numbers, Department of Health, < https://www.health.gov.au/news/health-alerts/novel-coronavirus-2019-nco…;; WHO COVID-19 Daily Situation Reports 25 January–27 March 2020: < https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports>.

Table 1.1: Total COVID-19 cases in Australia as of 31 August 2020

Source: Department of Health, < https://www.health.gov.au/sites/default/files/documents/2020/09/coronav…;.

21. According to the Prime Minister, Australia had clearly been monitoring the increase in COVID-19 cases in China and other parts of the world, and was alert to the need to begin preparing for COVID-19 cases to potentially enter the country.²⁶
22. On 20 January 2020, the Australian Health Protection Principal Committee (AHPPC), which comprises the Chief Medical Officer of Australia and all state and territory Chief Health Officers, met for the purposes of considering a national response to COVID-19.²⁷
23. On 21 January 2020, the then Chief Medical Officer for the Australian Government, Professor Brendan Murphy — the Commonwealth Chief Medical Officer — in his capacity as Director of Human Biosecurity, made a written determination pursuant to s. 42 of the Commonwealth’s Biosecurity Act 2015 (Cth) that COVID-19 (designated ‘human coronavirus with pandemic potential’) should be included as a ‘listed human disease’.²⁸ This determination provided authority for the Federal Minister for Health to impose enhanced border screening measures for all travellers entering and departing Australia.²⁹
24. On 25 January 2020, Australia confirmed its first case of COVID-19, a man from Wuhan who had travelled from Guangdong to Melbourne on 19 January 2020.³⁰
25. The Australian Government subsequently raised the level of travel advice for Wuhan and Hubei Province to ‘Level 4–Do Not Travel’ and introduced precautionary measures for travellers arriving in Australia from China to detect unwell travellers and to ensure all returning travellers were provided with information about COVID-19 and the steps to take should they develop symptoms.³¹
26. At the same time, Australia was advised that Chinese authorities had put a stop to transport out of Wuhan city. According to the Prime Minister, flight MU 749, which landed at Sydney Airport on the morning of 23 January 2020, was the last flight out of Wuhan to Australia. All passengers on this flight were met, on arrival, by biosecurity and health officials and received information about the virus.³²
27. In addition, enhanced health advice was provided at every port of entry to Australia for all modes of travel (airline and sea).³³ The Commonwealth Chief Medical Officer stated that every state and territory health department had established designated isolation and testing facilities with clearly established protocols for getting people to these facilities.³⁴ It was reported that, in Victoria, initial potential and positive cases were treated at Monash Medical Centre in accordance with infection control procedures.³⁵
28. Knowledge of symptoms of the virus had apparently progressed from a fever with some patients having difficulty breathing, as identified by the WHO on 3 January 2020,³⁶ to ‘fever, cough, sore throat, vomiting and difficulty breathing’.³⁷

    Escalating confirmed COVID-19 cases in Australia

29. By 1 February 2020, there were 12 confirmed COVID-19 cases in Australia.³⁸ The Department of Foreign Affairs and Trade (DFAT) upgraded its travel advice for China to ‘Do Not Travel’.³⁹ Restrictions were also placed on people travelling or returning to Australia from China:

    Foreign nationals (excluding permanent residents) who are in mainland China from today forward, will not be allowed to enter Australia for 14 days from the time they have left or transited through mainland China ...

    Any foreign nationals who do arrive in Australia notwithstanding the prohibition, and who choose not to immediately return to their port of origin, will be subject to mandatory quarantine.

    We will also be requiring Australian citizens, permanent residents and their families who do enter Australia and who have been in mainland China to self-isolate for 14 days from the time they left mainland China.⁴⁰

30. The Prime Minister announced that a plan was also established to provide assisted departures for isolated and vulnerable Australians located in Wuhan and the Hubei Province in China, with individuals to quarantine for 14 days at Christmas Island.⁴¹
31. The 14-day period was based on medical advice around the incubation period of the virus.⁴²
32. By 29 February 2020, 24 confirmed COVID-19 cases had been reported by states and territories in Australia.⁴³ Of these cases:
    1. 15 had a direct or indirect link to Wuhan City, Hubei Province, China.
    2. Nine cases were associated with the Diamond Princess repatriation flight from Japan to the Northern Territory on 20 February 2020.⁴⁴
33. An additional case with recent travel history to Iran, where the largest number of reported deaths had occurred outside of the Hubei Province in China, was also confirmed by the Prime Minister in his media release of 29 February 2020. DFAT subsequently upgraded the travel alert for Iran to ‘Do Not Travel’.⁴⁵
34. In the context of increasing cases of COVID-19 in Australia, the National Cabinet was established.⁴⁶

    Establishment of the National Cabinet: A governmental response to the pandemic

35. On 13 March 2020, in recognition of the unprecedented scale and potential consequences of the pandemic, the National Cabinet was established following a meeting of the Council of Australian Governments (COAG).⁴⁷
36. It was stated by the Prime Minister that the National Cabinet was created to address and ensure consistency in Australia’s response to the COVID-19 pandemic. Like COAG, it comprised the Prime Minister, Premiers and Chief Ministers of the States and Territories.⁴⁸ It first met on 15 March 2020.⁴⁹
37. The key advisory bodies to the National Cabinet included the AHPPC, led by the Commonwealth’s Chief Medical Officer and comprising the chief health and medical officers from each jurisdiction, and the National Coordination Mechanism (NCM), convened by the Department of Home Affairs. The work of the NCM was described as working across all jurisdictions, industry and key stakeholders to ensure a consistent approach to managing the impacts of the pandemic beyond immediate health issues.⁵⁰
38. In addition to reiterating the health advice around proper hand hygiene and social distancing measures, the National Cabinet announced a range of measures to limit or reduce the transmission of COVID-19 in Australia.

    Decisions made by National Cabinet

    15 March 2020

39. In the wake of its first meeting on 15 March 2020, the Prime Minister announced that the National Cabinet agreed that its core objective was to slow the outbreak of COVID-19 in Australia by taking additional steps to reduce community transmission.⁵¹ To help ‘stay ahead of the curve’ the Commonwealth Government imposed a ‘universal precautionary self-isolation requirement on all international arrivals’, effective from 11.59pm that day.⁵²
40. Further, the National Cabinet implemented a ban on cruise ships from foreign ports (including round trip international cruises originating in Australia) arriving at Australian ports for an initial 30 days, from 11:59pm Sunday 15 March 2020.⁵³ Arrangements were made for cruise ships already in transit to enable Australian citizens and permanent residents to get off those ships.⁵⁴
41. The National Cabinet also endorsed the advice of the AHPPC to introduce further social distancing measures, including the requirement that non-essential, organised public gatherings of more than 500 people should not occur.⁵⁵ It should be noted that Victoria applied these decisions through its declaration of a State of Emergency on 16 March 2020.⁵⁶ Further detail on this is provided at paragraph 58 below.

    17 March 2020

42. At its meeting on 17 March 2020, the National Cabinet accepted AHPPC advice that non-essential indoor gatherings of greater than 100 people (including staff) no longer be permitted from Wednesday 18 March 2020.⁵⁷ This was applied in Victoria under the State of Emergency declared on 16 March 2020.⁵⁸

    19 March 2020

43. On the morning of 19 March 2020, the cruise ship Ruby Princess had disembarked into Sydney. It came to be understood that around 39 per cent of the ship’s passengers from Australia and 17 per cent of its crew had contracted COVID-19.⁵⁹
44. The passengers from that vessel had been allowed to disperse, immeasurably compounding the task of contact tracing and infection control.
45. 28 deaths were later found to be associated with passengers from the Ruby Princess.⁶⁰

    20 March 2020

46. On 20 March 2020, the National Cabinet met and agreed, amongst other restrictions and safety measures, to endorse the Commonwealth Government’s decision to stop the entry of non-citizens and non-permanent residents and their immediate families into Australia after 9.00pm that day.⁶¹
47. Most relevant to this Inquiry is the decision made by the National Cabinet on 27 March 2020.

    27 March 2020

48. By 27 March 2020, according to information provided via the Prime Minister’s media release there were more than 3,000 confirmed COVID-19 cases in Australia and 13 deaths. The majority of cases were in New South Wales, Victoria and Queensland.⁶² There was considerable concern that the majority of cases across the nation were coming in via international points of entry.
49. On 27 March 2020, the National Cabinet met and agreed to further restrict the movement of incoming travellers and increase compliance checks on travellers already self-isolating. Notably, the National Cabinet agreed that, as soon as possible, but no later than 11.59pm on 28 March 2020, all travellers arriving in Australia would be required to undertake mandatory 14-day self-isolation at ‘designated facilities’.⁶³
50. Hotels were given as an example of a designated facility, but the exact facilities to be designated and the implementation of the quarantine program was a matter for each state and territory government. The National Cabinet agreed that:
    1. Travellers would be transported directly to designated facilities after appropriate immigration, customs and enhanced health checks.
    2. Designated facilities would be determined by the relevant state and territory government and would ordinarily be in the city of entry where the traveller had cleared immigration, but facilities in other areas could be used if required.
    3. These requirements would be implemented under state and territory legislation and would be enforced by state and territory governments, with the support of the Australian Defence Force (ADF) and Australian Border Force (ABF) where necessary.
    4. The Commonwealth would provide support through the ADF and ABF for these arrangements across Australia, with states and territories meeting the costs and determining any contributions required for travellers arriving within their jurisdictions.⁶⁴
51. Later, on 30 March 2020, the National Cabinet agreed that state and territory governments could consider exceptional circumstance exemptions to the requirement to serve the 14-day quarantine in a hotel or other designated facility in order to enable vulnerable or at-risk individuals to self-isolate at home.⁶⁵

    1.4 Victoria’s response to the COVID-19 pandemic

52. As early as 10 January 2020, Victoria’s Chief Health Officer (CHO), Professor Brett Sutton, issued a health alert with respect to patients who had travelled to Wuhan, China and who experienced the onset of fever and respiratory symptoms within two weeks of their return. The alert acknowledged concern that what was referred to as viral pneumonia may be a novel coronavirus.⁶⁶
53. On 1 February 2020, recognising that COVID-19 (being a human disease) was a Class 2 emergency, as that term is used in the Emergency Management Acts and the Emergency Management Manual Victoria, a designated State Controller – Health was appointed.⁶⁷ Notwithstanding that, under the Victorian State Health Emergency Plan, the State Controller – Health is presumptively the CHO,⁶⁸ the Director of the Emergency Management Branch within the Department of Health and Human Services (DHHS) was actually appointed to the role.⁶⁹ The significance of this is the subject of analysis later in this report.
54. On 10 March 2020, the State Control Centre was activated to oversee and co-ordinate Victoria’s response to the spread of COVID-19.⁷⁰
55. By the start of March 2020, Victorians were nightly watching distressing scenes across the world where alarming numbers of people in international locations were contracting the virus and a catastrophic number of lives were being lost.
56. Predictions about the potential for the spread of COVID-19 throughout the community were being made by experts, including Victoria’s Deputy Chief Health Officer, Dr Annaliese van Diemen.
57. Dr van Diemen’s evidence was that she had observed, primarily through international experience, the disease spread rapidly with very high fatality rates.⁷¹ Further, there was no vaccine, nor was there treatment to mitigate the effects of COVID-19. The virus therefore became an ‘exceedingly significant risk to public health’.⁷²

    Figure 1.3: Daily new COVID-19 cases in Victoria 25 January 2020–31 August 2020

    

    Source: Department of Health and Human Services, Victorian COVID-19 data, < https://www.dhhs.vic.gov.au/victorian-coronavirus-covid-19-data&gt; (data extracted from ‘daily new cases in Vic’ graph).

    Declaration of a State of Emergency in Victoria

58. On 16 March 2020, a State of Emergency under the Public Health and Wellbeing Act 2008 (Vic)(PHW Act) was declared in Victoria by the then Minister for Health, the Hon. Jenny Mikakos MP, on the advice of the CHO and after consultation with the Minister for Police and Emergency Services and the Emergency Management Commissioner under the Emergency Management Act 2013 (Vic), due to the serious public health risk posed by COVID-19.⁷³ This activated the emergency management powers and enabled the CHO to issue orders and directions, including enforcing 14-day isolation requirements for all travellers entering Australia and cancelling mass gatherings of more than 500 people as agreed by the National Cabinet.⁷⁴
59. The initial State of Emergency was implemented for a four-week period, as specified in the PHW Act. Thereafter, successive sets of Directions (State and Commonwealth) were issued up to, and including, 28 March 2020 as set out below.

    Date	Declaration or Direction	Detail	Government (Victoria/Commonwealth)
    16 March 2020	Declaration of a State of Emergency Issued under s. 198(1), Public Health and Wellbeing Act (Vic)	Declaration activated the emergency management powers and enabled the Chief Health Officer to issue orders and directions, including social distancing measures and quarantining of groups of people.	Victoria
    	Direction from the Chief Health Officer in accordance with emergency powers arising from declared state of emergency Issued under s. 200(1)(b) and (d), Public Health and Wellbeing Act (Vic)	Direction contained two parts that: prohibited non-essential mass gatherings (Part 1): directed persons arriving in Victoria from overseas to undertake a 14-day period of ‘self-quarantine’ (Part 2).	Victoria
    18 March 2020	Biosecurity (Human Biosecurity Emergency) (Human Coronavirus with Pandemic Potential) Declaration 2020 Issued under s. 475, Biosecurity Act 2015 (Cth).Varied under s. 476, Biosecurity Act 2015 (Cth)	Declaration made by the Governor-General established that there was an existing Human Biosecurity Emergency by the name of COVID-19 or SARS-CoV-2. The declaration gave the Health Minister expansive powers to issue any direction to any person (s. 478) and set any requirements (s. 477) provided that these actions were to prevent or control the entry, emergence, establishment or spread of the outbreak (ss 477(1), 478(1)). This was the first time these powers under the Biosecurity Act 2015 (Cth) were used.	Commonwealth
    	Airport Arrivals Direction Issued under s. 200(1)(b) and (d), Public Health and Wellbeing Act (Vic)	Direction replaced Part 2 of the Direction from the Chief Health Officer (Communicable Disease) in accordance with the emergency powers arising from declared State of Emergency issued on 16 March 2020. Issued to people arriving in Victoria from overseas (between 5.00pm 18 March 2020 and midnight 13 April 2020) directing that they must go into immediate compulsory isolation for 14 days at a ‘premises that it suitable for the person to reside in for a period of 14 days’.	Victoria
    	Mass Gatherings Direction Issued under s. 200(1)(b) and (d), Public Health and Wellbeing Act (Vic)	Direction replaced Part 1 of the Direction from the Chief Health Officer in accordance with emergency powers arising from declared state of emergency issued on 16 March 2020. Prohibited gatherings of 500 people or more in a single undivided outdoor space and gatherings of 100 people or more in a single undivided indoor space.	Victoria
    19 March 2020	Cruise Ship Docking Direction Issued under s. 200(1)(b) and (d), Public Health and Wellbeing Act (Vic)	Direction applied to any person who disembarked at a port in Victoria from an international cruise ship or an Australian cruise ship between midday 19 March 2020 and midnight 13 April 2020. Directed that returnees must travel from the port in Victoria to a premises suitable for the person to reside in for a period of 14 days.	Victoria
    21 March 2020	Mass Gatherings Direction (No. 2) Issued under s. 200(1)(b) and (d), Public Health and Wellbeing Act (Vic)	Direction replaced the Mass Gatherings Direction made on 18 March 2020. Directed that a gathering of fewer than 100 people was only permitted in a single undivided indoor space where the space had minimum of four square metres per person or where the space was a private residence, a private vehicle or a commercial passenger vehicle.	Victoria
    	Visitors to Residential Aged Care Facilities Direction Issued under s. 200(1)(b) and (d), Public Health and Wellbeing Act (Vic)	Direction prohibited people visiting residential aged care facilities between 6.00pm 21 March 2020 and midnight 13 April 2020 except for certain groups of people, including: employees or contractors of the facility people visiting the facility for the purpose of providing a care and support visit to a resident (of no longer than 2 hours, by one person or two people made together) people attending for the purpose of providing health, medical, pharmaceutical goods or services to a resident people visiting for the purpose of providing end of life support to a resident prospective residents.	Victoria
    23 March 2020	Non-Essential Business Closure Direction Issued under s. 190(1)(a) and 200(1)(d), Public Health and Wellbeing Act (Vic)	Direction prohibited the operation of the following non-essential businesses or undertakings between noon 23 March 2020 and midnight 13 April 2020: businesses characterised as pubs, bars or clubs that supply alcohol hotels, except to the extent they provided accommodation, bottle shop or meal takeaway or delivery services gyms indoor sports centres casinos cinemas, nightclubs or entertainment venues of any kind restaurants and cafes (other than meal takeaway or delivery services) places of worship, other than for the purposes of weddings or funerals.	Victoria
    	Hospital Visitors Directions Issued under and s. 200(1)(b) and (d), Public Health and Wellbeing Act (Vic)	Direction prohibited non-essential visits to hospitals in the State of Victoria between midnight 23 March 2020 and midnight 13 April 2020.	Victoria
    25 March 2020	Isolation (Diagnosis) Direction Issued under s. 200(1)(b) and (d), Public Health and Wellbeing Act (Vic)	Direction issued to people who have tested positive to COVID-19 between midnight 25 March 2020 and midnight 13 April 2020, requiring that they self-isolate until: written clearance from self-isolation had been provided by an officer of DHHS; they met criteria for discharge from self-isolation.	Victoria
    	Non-Essential Activity Direction Issued under s. 190(1)(a) and (g) and 200(1)(d), Public Health and Wellbeing Act (Vic)	Direction replaced the Non-Essential Business Closure Direction made on 23 March 2020, and extended and further particularised restrictions on non-essential business in the State of Victoria, including introducing restrictions to non-essential retail facilities such as beauty and personal care facilities and animal facilities such as zoos and aquariums.	Victoria
    	Prohibited Gatherings Direction Issued under s. 200(1)(b) and (d), Public Health and Wellbeing Act (Vic)	Direction replaced the Mass Gatherings Directions (No. 2) made on 21 March 2020, and added two new categories of prohibited gatherings: social sport gatherings weddings and funerals.	Victoria
    25 March 2020	Biosecurity (Human Biosecurity Emergency) (Human Coronavirus with Pandemic Potential) (Overseas Travel Ban Emergency Requires) Determination 2020 Issued s. 477(1) of the Biosecurity Act 2015 (Cth)	Determination prohibited Australian citizens and permanent residents from leaving Australian territory by air or sea as a passenger. It also prohibited the operator of an outgoing aircraft or vessel from leaving Australian territory with an Australian citizen or permanent resident on board as a passenger. This overseas travel ban did not apply to the following persons: a person who was ordinarily a resident in a country other than Australia a person who was a member of a crew of an aircraft or vessel but was travelling as a passenger on another aircraft or vessel a person engaged in the day-to-day conduct of inbound and outbound freight a person whose travel is associated with essential work at an offshore facility (for example, offshore oil rigs) a person who was travelling on official government business (including a member of the Australian Defence Force). This entered into force at noon 25 March 2020, 15 hours after it was announced following a meeting of the National Cabinet.	Commonwealth
    26 March 2020	Non-Essential Activity Direction (No. 2) Issued under s. 190(1)(a) and (g) and 200(1)(d), Public Health and Wellbeing Act (Vic)	Direction replaced the Non-Essential Activity Direction made on 25 March 2020, and: removed hair salons and barber shops from the list of non-essential retail facilities, as well as the 30-minute time limit, thereby permitting those facilities to operate so long as they comply with the density, cleaning and signage requirements added ‘sex on premises’ venues to the list of non-essential entertainment facilities.	Victoria
    28 March 2020	Revocation of Airport Arrivals Direction and Cruise Ship Docking Direction Issued under s. 200(1)(b) and (d), Public Health and Wellbeing Act (Vic)	Direction revoked the Airport Arrivals Direction and Cruise Ship Docking Direction with effect from midnight 28 March 2020. If the Airport Arrivals Direction or the Cruise Ship Docking Direction, as the case required, applied to a person before the revocation of that Direction by subclause (1), the direction continued to apply to the person after that revocation as if the Direction had not been revoked.	Victoria
    	Direction and Detention Notice (No. 3) Issued under s. 200, Public Health and Wellbeing Act (Vic)	Direction issued to people arriving in the State of Victoria from overseas (on or after 11:59pm on 28 March 2020) advising that they must go into immediate compulsory quarantine for 14 days. It noted that the person was detained due to the serious risk posed by COVID-19 and the fact that their detention was reasonably necessary for the purpose of eliminating or reducing the serious public health risk. Direction also outlined that: detainees must not leave their room under any circumstances unless they had permission detainees must not permit any other person to enter their room, unless the person was authorised to be there for a specific purpose (for example food or medical reasons) a person’s detention be revisited every 24 hours to determine that it was still necessary.	Victoria

    Source: Victorian Government Gazette Archives < http://www.gazette.vic.gov.au/gazette_bin/gazette_archives.cfm?bct=home…;; Federal Register of Legislation – Legislative Instruments < https://www.legislation.gov.au/Browse/ByTitle/LegislativeInstruments/In…;

    Victoria’s hotel quarantine program commences
60. It was in this context that Victoria’s Hotel Quarantine Program, later known as ‘Operation Soteria’, was established, following the National Cabinet’s decision on 27 March 2020 requiring returned travellers to undertake mandatory quarantine.
61. The Deputy Chief Health Officer issued Direction and Detention Notice No. 3 on 28 March 2020, as set out in the Table 1.2 above, thus creating the detention orders that mandated all international arrivals into Victoria into hotel quarantine after 11.59pm on 28 March 2020. The detail of the set up for Victoria’s Hotel Quarantine Program, over the weekend of 28 and 29 March 2020, is contained in Chapter 3.

    1.5 Conclusions

62. Following its emergence in late 2019, COVID-19 rapidly proliferated across the globe, leading the WHO to declare the virus a pandemic on 11 March 2020.⁷⁵
63. The first Australian case of COVID-19 was reported on 25 January 2020,⁷⁶ with 12 cases confirmed by 1 February 2020.⁷⁷ Local case numbers then continued to increase, with there being more than 3,000 confirmed cases of COVID-19 by 27 March 2020.⁷⁸
64. Understandably, as these numbers continued to swiftly rise, so too did concern among government, the medical and scientific community, and the general public. In the view of Dr van Diemen, the anticipated trajectory of the virus posed a significant risk to public health.⁷⁹
65. At a state level, the Victorian response included the appointment of a State Controller – Health,⁸⁰ the activation of the State Control Centre⁸¹ and a declaration of a State of Emergency.⁸² At the federal level, the National Cabinet was established on 13 March 2020 to ensure consistency in Australia’s response to the COVID-19 pandemic.⁸³
66. Many of the National Cabinet’s agreed measures were aimed at addressing the concern that international arrivals were fuelling the rise in domestic COVID-19 case numbers. These measures included imposing a self-isolation requirement for international arrivals and a ban on foreign cruise ships,⁸⁴ as well as prohibiting the entry of non-citizens and non-permanent residents.⁸⁵
67. It was in this context that the National Cabinet, at a meeting on 27 March 2020, resolved to implement a mandatory 14-day quarantine period for international arrivals,⁸⁶ setting the wheels in motion for the establishment of Victoria’s Hotel Quarantine Program.