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The Victorian Health Department allowed workers at the Cedar Meats abattoir, site of the largest coronavirus outbreak of the state’s first wave, to return to work while waiting on COVID-19 tests during contact tracing efforts in May.

Emails tendered by the Brooklyn abattoir to a parliamentary inquiry detail how the state's public health team handled the outbreak at the plant.

Under the current rules, contacts of close contacts of infected people are told to immediately self-isolate – if those rules had been in place earlier in the year, the plant's entire 350-strong workforce would probably have been told to quarantine after it was closed by Chief Health Officer Brett Sutton.

But instead only one section of the workforce was told to quarantine. More than 110 people connected with the abattoir were infected in the outbreak.

In its submission the company described evidence given by former health minister Jenny Mikakos to a parliamentary inquiry in May as "factually incorrect". Ms Mikakos told the committee the company took several days to hand over information about who visited the site.

Ms Mikakos, who resigned in September, wrote to Cedar Meats boss Tony Kairouz in August explaining her evidence. She acknowledged the company handed over timely information but said contact details were sometimes out of date or lacking full names, meaning the process took longer than anticipated and hampered contact tracing. A Health Department spokeswoman said the department stood by the evidence Ms Mikakos gave.

The Cedar Meats outbreak, which prompted a WorkSafe inquiry, put the spotlight on Victoria's contact tracing system during the first wave of COVID-19 infections. About 10 days after the abattoir was closed, the Andrews government announced a $20 million rapid-response team to handle high-risk outbreaks.

A first Cedar Meats employee tested positive on April 2 and told contact tracers they did not attend work. Workers then tested positive on April 24 and April 26.

The Health Department first contacted the company on April 27. Despite the government initially ruling out a link between the first case and subsequent infections, Professor Sutton said in mid-May the cases may have been linked. On April 29 he ordered the site to close by May 1 and later admitted he should have taken this action after the April 26 case.

A department official told Cedar Meats on Friday, May 1, that workers in the boning room, where already-diagnosed staff had worked, should isolate "as best as they can" but acknowledged this may not have been possible due to living arrangements.

The official said other workers could return on the last day of the plant's operation if they did not work in the boning room.

"I don't see a problem if they continue to operate post-testing, just practise social distancing," the public health official wrote.

The official, whose name was redacted in emails, said the whole workforce would not be required to isolate unless there was evidence of widespread transmission. "At the moment I don't have a number for what that threshold is," they wrote.

In the period from May 4 to 8, more than 60 people were diagnosed in the cluster. The incubation period for the virus is up to two weeks and the median incubation period is five to six days.

When a Cedar Meats senior manager developed symptoms on May 1, the department advised them to wear a mask when addressing staff rather than go home to isolate.

Cedar Meats emailed the department on Sunday, May 3, when the cluster had grown to 15 people, offering to send a group text to staff due to confusion over which groups of staff were required to isolate.



Days later the department was still attempting to collate contact details for staff. Just before midnight on May 7, the department requested a log of visitors – including truck drivers, salespeople and others who attended the abattoir – and a roster of workers the following day.

"Do you keep entry and exit records for people who come out of the plant? … We are getting a considerable amount of pressure to ensure that we have been as thorough as possible in our contact tracing efforts," the email said.

On May 3, Cedar Meats emailed the department informing it the company had been named in a Seven News report as the site of an outbreak. The company said a positive outcome of being named was truck drivers who may have been exposed at Cedar Meats would be alerted to the danger.

"We are sorry to hear your facility was named in 7 news, we certainly hope it’s clear we are very supportive of your approach to this response and think you did all you could to mitigate risk to employees," a department official said.

A manager at Cedar Meats wrote to the department on May 5 to complain about not being informed of additional positive cases before the cases were aired in media reports.

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