Accounting for imported cases
A large proportion of cases reported in Australia from January until now were imported from overseas. It is critical to account for two distinct populations in the case notification data – imported and locally acquired – in order to perform robust analyses of transmission in the early stages of this outbreak. The estimated time-varying R𝑒𝑓𝑓 value is based on cases that have been identified as a result of local transmission, whereas imported cases contribute to transmission only (Thompson et al., 2019).
Specifically, the method assumes that local and imported cases contribute equally to transmission. The results under this assumption are presented in Figure 2. However, it is likely that imported cases contributed relatively less to transmission than locally acquired cases, as a result of quarantine and other border measures which targeted these individuals (Figure 1—figure supplement 2). In the absence of data on whether the infector of local cases was themselves an imported or local case (from which we could robustly estimate the contribution of imported cases to transmission), we explored this via a sensitivity analysis. We aimed to explore the impact of a number of plausible scenarios, based on our knowledge of the timing, extent and level of enforcement of different quarantine policies enacted over time.
Prior to 15 March, returning Australian residents and citizens (and their dependents) from mainland China were advised to self-quarantine. Note that further border measures were implemented during this period, including enhanced testing and provision of advice on arrivals from selected countries based on a risk assessment tool developed in early February (Shearer et al., 2020). On 15 March, Australian authorities imposed a self-quarantine requirement on all international arrivals, and from 27 March, moved to a mandatory quarantine policy for all international arrivals.
Hence for the sensitivity analysis, we assumed two step changes in the effectiveness of quarantine of overseas arrivals (timed to coincide with the two key policy changes), resulting in three intervention phases: prior to 15 March (self-quarantine of arrivals from selected countries); 15–27 March inclusive (self-quarantine of arrivals from all countries); and 27 March onward (mandatory quarantine of overseas arrivals from all countries). We further assumed that the relative infectiousness of imported cases decreased with each intervention phase. The first two intervention phases correspond to self-quarantine policies, so we assume that they resulted in a relatively small reduction in the relative infectiousness of imported cases (the first smaller than the second, since the pre-15 March policy only applied to arrivals from selected countries). The third intervention phase corresponds to mandatory quarantine of overseas arrivals in hotels which we assume is highly effective at reducing onward transmission from imported cases, but allows for the occasional transmission event. We then varied the percentage of imported cases contributing to transmission over the three intervention phases, as detailed in Table 2.
Table 2.  Percentage of imported cases assumed to be contributing to transmission over three intervention phases for each sensitivity analysis.
We assume two step changes in the effectiveness of quarantine of overseas arrivals, resulting in three intervention phases: prior to 15 March (self-quarantine of arrivals from selected countries); 15–27 March inclusive (self-quarantine of arrivals from all countries); and 27 March onward (mandatory quarantine of overseas arrivals from all countries).
Imported cases contributing to transmission
Sensitivity analysis  Prior to 15 March  15–27 March  27 March–
1  90%  50%  1%
2  80%  50%  1%
3  50%  20%  1%
The results of these three analyses are shown in Figure 2—figure supplements 1, 2 and 3, respectively.