This Appendix explains the process through which NSW Health staff can encourage, facilitate, and if needed, require a person to comply with orders to refrain from certain behaviours and/or enter quarantine following exposure to a contact order condition.
Public health orders are an available legal option to achieve compliance but are considered a measure of last resort to prevent a public health risk and, in the case of exposure to contact order conditions, are only used when voluntary quarantine recommendations are refused.
Table 1. Contact order conditions and expiry periods11
Division 4 of Part 4 of the Public Health Act 2010 (NSW) sets out provisions related to public health orders made in respect of a person exposed to a contact order condition. Under Section 62(1)(b) of the Act, an authorised medical practitioner2 may make a public health order in respect of a person if satisfied, on reasonable grounds, that the person:
• has been exposed to a contact order condition, and
• is at risk of developing the contact order condition, and
• because of the way the person behaves, may be a risk to public health.
The Legal and Regulatory Services Branch, NSW Ministry of Health are to be involved in the consideration of issuing a public health order.
The management of people exposed to a contact order condition begins with a voluntary stage, seeking to support the person to comply with recommendations to avoid certain behaviours and/or enter into voluntary quarantine.
It is important to stress to contacts the importance of quickly achieving appropriate3 quarantine arrangements to ensure that other people are not exposed to the serious condition.
Key points for consideration
For contacts of a typhoid case, the focus of public health measures is to restrict specific activities that have a higher likelihood of transmission, such as preparing food for others or caring for vulnerable people (such as childcare work and aged care). Contacts who are assessed to be at higher risk of transmitting infection because of occupational or personal characteristics must not engage in these activities until they can be excluded as having typhoid infection. As people infected with typhoid may have no symptoms, this usually is achieved after they provide 2 negative stool samples at least 24 hours apart. If feasible, they may undertake other duties (not high-risk) while awaiting specimen results. Other restrictions are unlikely to be recommended for typhoid contacts.
A person’s ability and willingness to comply with quarantine restrictions may be impacted by a range of factors, including housing and financial concerns, mental illness, real or perceived stigma, and competing responsibilities, including work, childcare, and education.
The LHD is to work with appropriate agencies to overcome barriers to the person’s compliance. Appropriate agencies may include multicultural health services, mental health services or social work services or other locally available services.
If a contact does not agree to the LHD PHU recommendations, or has been found not to comply with these, the need for a public health order can be considered. The LHD PHU should convene a case conference with local care services, a representative from the relevant HPNSW branch, and if required, the NSW Specialist Service for High Consequence Infectious Diseases (NSW Specialist Service for HCID) to address specific management issues and develop a comprehensive quarantine and monitoring plan. The outcome of the conference should be escalated to the relevant HPNSW Branch Director, and the Legal and Regulatory Services Branch, as appropriate.
A case conference should also be held if there are complex management needs for the individual, so that the individual can be supported to comply with the recommended requirements and monitoring.
Table 2. Health Protection NSW Branches responsible for each contact order condition
When a contact refuses to comply with recommended quarantine and monitoring, and this poses a risk to public health, the below steps should be taken. Please note that these steps are intended as a guide only. Flexibility should be applied when managing individuals on a case-by-case basis, at the discretion of the PHU Director.
The individual’s primary care provider and a public health physician and/or infectious disease physician should work together to explain the public health importance of complying with the required measures. These clinicians should maintain ongoing communication and counselling with the individual, providing clarification and reinforcing the public health rationale and the steps involved at each stage of the process.
1. Initial Response
• Counsel the individual to explain the public health risks and the possible implications of refusal such as a public health order.
• Identify barriers to compliance and offer practical incentives (e.g. entertainment, food, internet access) and support (e.g. counselling, accommodation).
• Hold a case conference as above.
2. Formal Warning
• If non-compliance continues, issue a formal warning letter from the PHU Director.
• Consult NSW Ministry of Health, Legal and Regulatory Services Branch before sending the letter to ensure appropriate legal oversight.
• The relevant HPNSW branch director should be notified if a formal warning letter is required.
4. Additional Support and Oversight
• If concerns persist, the PHU must consult either the Director, CDB or the Director, OHB, depending on the condition for further advice.
• If necessary, the PHU Director may escalate to the Executive Director, Health Protection NSW (ED HPNSW).
5. Expert Panel
• HPNSW may convene an expert panel to review the case and advise on further strategies including the possibility of a public health order.
• The expert panel may include representatives from other Ministry of Health branches, including Legal and Regulatory Services Branch, Centre for Aboriginal Health, Mental Health and may include other LHDs or agencies.
• Responsibility for managing the individual remains with the LHD throughout.
Note that in the case of people considered contacts of a confirmed typhoid case, a public health order would usually only be considered for those contacts who are in a high-risk occupational group, such as a food handler, and who have refused the recommendation to cease high-risk work until they have been confirmed to be non-infectious through stool screening. This includes where a high-risk typhoid contact is refusing to submit a stool sample for testing.
The expert panel convened by the ED HPNSW can advise on the management of individuals exposed to contact order conditions, including whether a public health order is needed. If a public health order is not required, the panel can still provide guidance on local management strategies. The PHU Director or representative is responsible for presenting information about the source case and contacts to the panel, which will review the public health response and recommend any additional or alternative approaches.
The expert panel should include:
• NSW Ministry of Health
• NSW Specialist Service for HCID (if required)
• From relevant LHD:
The panel should also include:
Public health orders for contact order conditions are made by an authorised medical practitioner under the Public Health Act in consultation with the ED HPNSW and the Legal and Regulatory Services Branch, NSW Ministry of Health.
An authorised medical practitioner may make a written public health order in respect of a contact order condition if satisfied on reasonable grounds that the person:
The authorised medical practitioner should be acting on the advice of the expert panel if a panel is convened.
In deciding whether to make a public health order, the authorised medical practitioner must consider:
• the principle that any restriction on the liberty of a person must only be imposed if it is the most effective way to prevent any risk to public health, and
• the matters set out in the Public Health Regulation 2022 [NSW] (section 59) which include:
The matters set out in section 59 of the Public Health Regulation 2022 do not need to be taken into account in the case of an emergency or if it is otherwise not reasonably practicable.
A public health order relating to exposure to a contact order condition may require the person subject to the order to do any one or more of the following5:
• to refrain from specified conduct, such as to not make physical contact with other people or maintain a specified distance from others
• to undergo specified treatment (whether at a specified place or otherwise)
• to undergo counselling by one or more specified persons or by one or more persons belonging to a specified class of persons
• to submit to the supervision of one or more specified persons or of one or more persons belonging to a specified class of persons, (such as an infectious diseases physician or infectious diseases unit staff)
• to notify the Secretary (via the PHU) of other persons with whom the person has been in contact within a specified period
• to notify the Secretary (via the PHU) if the person displays any specified signs or symptoms
• to undergo specified examinations or testing for the relevant condition.
A public health order may authorise the person subject to the order:
• to be detained at a specified place for the duration of the order, or
• in relation to an order that requires the person to undergo specified treatment at a specified place—to be detained at that place while undergoing the treatment.
A public health order must specify who is responsible for managing the person subject to the order. This will generally be the Director of the PHU of the LHD where the person resides or an infectious diseases or public health physician.
A public health order does not take effect until it is served personally (by anyone) on the person subject to the order. The Legal and Regulatory Services Branch can advise on the rules about how orders are served under the Act.
A public health order must state that it expires at the end of the expiry period for the particular contact order condition, unless earlier revoked. The PHU (or whoever is the leading authority) is responsible for regular clinical (and situational) review of the person to determine if order can be revoked earlier than its expiration date.
If a person is served with a public health order due to exposure to a contact order condition, the order will expire after 3 business days unless, within that time, they are also served with a copy of an application to the NSW Civil and Administrative Tribunal (NCAT) to confirm the order under Section 64 of the Act.
If the application is not served within 3 business days, the order lapses, and the person must be notified that they are no longer subject to the order. No further action can be taken under the lapsed order—for example, if the person was detained, they must be released.
Once an application is made, NCAT must promptly review the circumstances surrounding the public health order.
Following its inquiry, NCAT:
• may confirm the public health order, or
• may vary the order and confirm it as varied, or
• may revoke the order.
If the authorised medical practitioner considers that the person subject to the order is no longer a risk to public health, the authorised medical practitioner must revoke the order and immediately give notice in writing of the revocation to the person and the NCAT.
While any condition in a public health order restricts a person’s liberty, detention is a particularly serious measure and should only be used as a last resort. It must be considered only when no other condition, such as limiting certain behaviours, can effectively reduce the public health risk.
All LHDs must identify appropriate facilities and staff who are able to implement an order for secure detention under the Public Health Act 2010 (NSW).
Where the person to whom the public health order applies is already detained under a custodial sentence, consideration must be given to the unique circumstances of implementing the public health order, including:
• that client confidentiality, legal and safety issues be considered, and
• that quarantine/isolation measures may require negotiation with Justice Health NSW, Corrective Services NSW and Youth Justice NSW.
When accommodation is required for voluntary quarantine of a contact who is medically stable, quarantine at the person’s home or at a commercial residential property is preferred. LHDs must consider how best to accommodate contacts in such situations and ensure arrangements to monitor them in quarantine. The NSW Ministry of Health may be able to assist LHDs with identifying suitable accommodation for contacts through its links with other government agencies.
When accommodation is required for the purpose of involuntary quarantine (e.g. subject to a public health order) for a contact who is medically stable, quarantine at a person’s home may not be appropriate. If a public health order includes an order for detention, the order will specify where the person is to be detained. If the place of detention is on LHD property, LHDs must consider how best to accommodate contacts in such situations so that quarantine can be enforced in accordance with the conditions of the public health order.
LHDs must:
• Identify a suitable location for accommodating a contact who is detained under a public health order. This location is specifically named in the public health order.
• Develop a management plan addressing the needs of the contact. This plan must be approved by the PHU Director. The Director, CDB, or the Director, OHB are to be consulted in the plan’s development.
• Provide adequate staff training.
• If required, consult NSW Ministry of Health, Legal and Regulatory Services Branch for any questions or concerns around enforcing the conditions of detention.
People exposed to a contact order condition may have concurrent medical conditions or mental health concerns which can potentially be exacerbated by quarantine. LHDs must ensure that relevant expertise and services are available to safely and effectively manage such contacts.
The NSW Biocontainment Centre can be used as a location to accommodate people that are medically stable for involuntary quarantine. The PHU Director, Executive Director, HPNSW, and the Director, CDB, or the Director, OHB are to be consulted if the NSW Biocontainment Centre is considered an option for accommodation. The NSW Specialist Service for High Consequence Infectious Disease are to be contacted on 1800 424 300 to discuss referrals.
The use of acute care facilities as locations for the involuntary quarantine of medically stable contacts is not recommended but remains an option if no other suitable alternative can be found.