An Irish solution to the coronavirus problem

And so an eerie calm prevails. Battle has been joined in faraway places, and the devastation has been immense. But for now Ireland, while conscious of the ever-growing threat, remains free of the 2019 novel coronavirus.

The disease was rechristened Covid-19 this week by the World Health Organisation (WHO), after much rumination aimed at ensuring no region of the world or animal species was stigmatised in the process of creating a new name.

The virus has now spread to 25 countries, and experts here regard it as highly likely it will arrive in Ireland at some point. But how prepared are we for the coming contagion? Can our overstretched health system cope? And what about the rest of us, all so dependent on Chinese-manufactured goods in our daily lives?

On the face of it, there is a strange disconnect between the dismaying images coming from China – the body bags, the field hospitals, the hazmat suits – and the calm around the issue here in Ireland.

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As the numbers mounted alarmingly during the week – 64,435 cases and 1,383 deaths by Friday – Irish public-health officials were reporting that all 65 tests carried out by last Monday were negative.

Aside from this slew of fortunate outcomes, virtually the only inkling in Ireland of the threat posed by Covid-19 this week came when the multinational recruitment company Indeed sent more than 1,000 Irish-based staff home over concerns that an employee might have contracted the virus. They returned after a few days when the staff member got the all-clear.

Public-health doctors have been insistent in their assertions that Ireland is ready for the challenge posed by any outbreak, even as the death toll mounts in China and the disease makes limited inroads in other countries.

But as with an anthill, there is often furious activity going on beneath the surface. The weeks that have passed since the threat posed by Covid-19 emerged have not been wasted. Procedures that were put in place for previous pandemics have been dusted off and updated. Committees have been established – or re-established – to co-ordinate the response. Rules have been established for communication with health professionals and the wider public, a key consideration given the jumpiness often associated with viral threats.

Meanwhile, dozens of suspected cases have, luckily, all turned out to be negative so far. These scares have given the health service a valuable opportunity to test and tweak the procedures in place. Testing for Covid-19 at the National Virus Reference Laboratory in UCD is now a same-day service.

Containment and mitigation

"Two strategies get deployed in responding to major and emerging infectious disease incidents such as this. The first is containment and the second is mitigation," explains Dr Tony Holohan, chief medical officer at the Department of Health.

“With containment, that means, irrespective of the severity of the case for an individual, all of the efforts go into identifying that case as early as possible and trying to put in place good quality-control measures to prevent that case leading to further cases and onward transmission,” says Holohan, who chairs the department’s national public-health emergency team and is increasingly becoming the public face of the health response to the virus.

Holohan says the Irish system of prevention is built around “maximising the sensitivity of our system” so that a case can be identified and appropriate measures taken as quickly as possible to prevent further transmission.

Isolation rooms are available in 17 hospitals designated to receive infected patients – notwithstanding the fact that most of them are running already at 100 per cent capacity. These are single rooms with en-suite facilities, which would be served by staff wearing full protective gear. If a large number of cases were to arise, plans have been made to “cohort” these patients together in wards.

The 24 countries outside China that have recorded cases are clearly in containment mode, as public-health officials desperately try to trace all contacts of people who contracted the virus, even if they are only mildly ill. Whether China itself is still at the containment stage is a matter for debate.

"The whole of the Chinese government has certainly been mobilised, and many of the measures introduced are draconian," says Sam McConkey, professor of tropical medicine at Beaumont Hospital and the Royal College of Surgeons in Ireland. "But it's too early to say whether they are working, and the situation is certainly out of control in Hubei province, where the outbreak started."

He adds: "My worry is: has it already spread to resource-poor countries in Africa and Asia where they don't have a CT scan or rapid testing?"

Dublin GP Dr Ray Walley is on a liaison group for family doctors for the coronavirus. "From my perspective, organisation seems to be at an advanced stage, in as much as it can be. GPs' opinions are certainly being aired, and listened to," he says.

Though there were complaints from some GPs last month about a lack of equipment, this has since been rectified with the delivery of thousands of PPE (personal protective equipment) kits to GP surgeries and out-of-hours services. Each kit includes a surgical mask, sterile gloves, a disposable gown, eye protection, wipes and a waste bag.

At the heart of the public-health response is a series of “algorithms” that set out, step by step, what has to be done to deal with suspected cases. Separate algorithms have been developed for GPs, hospital doctors, ambulance staff and, more generally, for school and work settings. The algorithms have to be continually updated in what everyone agrees is a fast-moving situation.

When containment no longer works, health workers change tack. “Mitigation is a strategy that arises in circumstances where containment measures are no longer appropriate and it no longer possible control the spread of a disease,” Holohan says.

“The focus moves then to identify cases of individuals whose health is worst, the most severely unwell.”

Worst-case scenario

McConkey has previously raised eyebrows with his warning that the epidemic could claim 20,000 victims in Ireland in a worst-case scenario. He still believes we need to prepare for the “possibility” of another Spanish flu, the pandemic that killed up to 100 million people worldwide in 1918.

“It is possible this is another one-in-100-years event. Certainly a Spanish flu would look like what we’ve seen in China. It’s true that he have better health systems and treatments now, but could we cope with 10,000 people in Ireland needing ventilation, if it came to that? I’d say we’d struggle.”

McConkey uses an adage from diving to urge greater preparation for what could happen. “You’ve got to plan the dive, and dive the plan. You need a plan, in advance, and you’ve got to implement it to the letter in a crisis.”

As one small state in a global community, Ireland follows the guidelines laid down by bodies such as the WHO and the European Centre for Disease Control. This is in contrast to other countries, such as post-Brexit Britain, which has taken a tougher line in restricting travel.

This means Ireland has gone no further than advising against non-essential travel to China, and is not carrying out point-of-entry screening at airports. Holohan says this is regarded as inefficient in most circumstances.

In their public statements, Irish public-health officials have repeatedly placed the emphasis on “self-isolation” by individuals as the way of handling suspected cases.

This was the approach taken in relation to passengers on an aircraft that landed in Dublin Airport last month carrying a suspected case (which turned out to be negative).

While Holohan says a quarantine requirement does not form part of the public-health response, this approach may be tested in the event of confirmed cases arising here.

In the UK, police were this week given extra powers to forcibly quarantine people, after a person in voluntary self-isolation indicated they wanted to return home.

Legal changes

Asked what it would do about people with symptoms who do not comply with requests to go into self-isolation, Health Service Executive assistant national director Dr Kevin Kelleher indicated on Thursday that changes are in the offing.

The Department of Health is looking at legal changes that would allow for the forcible isolation of people carrying Covid-19, he indicated. Existing provisions that allow for the quarantining of people with other infectious diseases may also be used to ensure patients can be isolated – an important consideration given the current political impasse.

While the health service has busied itself with preparations, McConkey questions whether the rest of Irish society is taking the threat posed by the virus as seriously as it should be. “Business and the public sector need to make continuity plans to ensure the supply chain remains in place, and to ensure they keep going in face of possible devastation.”

This includes planning for the possibility that up to 15 per cent of the workforce could be out sick at any one time, he says.

Ibec, when asked about its advice to employers in relation to the virus, merely said they should keep abreast with the guidelines issued by the HSE and the Department of Foreign Affairs, and said it would touch upon the economic impact of the outbreak in its forthcoming review of global economic trends.

Ireland’s seemingly laid-back approach to the crisis seems almost quaint to Asian people living here, many of whom have placed themselves in self-isolation on returning from China and have snapped up supplies of face masks.

One Taiwanese resident in Ireland expressed the worry that a lack of safety precautions in Irish airports could put lives in danger. Having flown back from Taiwan last weekend, she expressed surprise at not being checked at passport control.

“I was surprised how easy it was for everyone just to get in this country when this virus is apparently spreading everywhere and there are too many people who hide their condition and travel around the world. They put our lives in danger for their own convenience,” she told The Irish Times.