August has seen growing uncertainty in Ireland as, despite achieving remarkably high vaccination rates, daily Covid-19 case numbers remain stubbornly high. Uncertainty, even doubts, about our approach appears to be infecting the Government’s response, which has been characterised by a lack of clear messaging to people. This is at a time when schools are about to reopen. The shift from a regulatory approach to one of personal responsibility is appropriate at this stage of the pandemic, but only if people are given clear and simple messages on how they should behave, based on the latest science.
Covid-19 has a knack of punishing complacency and preventive vigilance is going to be critical for some time to come. Ireland’s approach to date –a cautious relaxation of controls in public spaces, predicated on high vaccine uptake – puts us in a strong position as we head towards the winter. Still, we need to analyse where the walls may be breached, yet again.
The reopening of our schools over the coming weeks – which is an imperative for children, parents and society – presents the greatest risk
Vaccination coverage rates of 80-90 per cent should still mean that half the battle is won. However, our hopes need to be tempered by an understanding of the behaviour of the Delta variant and the likely emergence and circulation of new virus variants. It is now clear that vaccines do not prevent infection – they greatly reduce the risk of serious complications and hospitalisation– and additional preventive measures are essential.
If high vaccine coverage is only half the battle won, the other half lies in having strong and consistent measures in place, based on clear messaging on behaviour that is taken on board by all segments of society. Here, given the complacency that can come from vaccination programme successes, two of our failures to date will come back to bite us.
The first is the lack of public debate and the puzzling silence from the Government, HSE and alcohol industry about the need to tackle the most important determinant of high-risk behaviour in Ireland – excessive alcohol intake where people gather, whether in public or private settings. Then there is our ineffective quarantine system and our failure to put in place a risk assessment and tracking system for travellers arriving into Ireland. However, the reopening of our schools over the coming weeks – which is an imperative for children, parents and society – presents the greatest risk.
During 2020, high rates of illness among adults stretched virus testing systems and health services, which meant that asymptomatic infections in children often went unnoticed. The science, to which we paid insufficient attention, showed that the main direction of transmission was from households into schools with limited transmission between children in schools. Yet, almost alone in Europe, we kept schools closed in May and June 2020, with little justification.
A recent report by the European Centre for Disease Control has alerted us to the likelihood that non-vaccinated children will be an important reservoir and potential transmitters of the virus in Ireland. The highly transmissible Delta variant means that we face the risk of transmission and outbreaks in school classes not yet eligible or not fully vaccinated. Moreover, a more transmissible virus could spread in the reverse direction, from schools into households. We can choose to wait for the studies that will confirm these risks, and risk the consequences, or we can offset the risks by reinforcing social distancing in schools and the use of masks in unvaccinated classes, when adequate social distancing is not feasible.
It took long enough in 2020 for health professionals to acknowledge that masks worn consistently in high-risk settings prevent people transmitting and getting the virus. But it now appears that fully vaccinated adults are unclear about if, where and with whom to maintain social distancing and mask-wearing.
That uncertainty, together with the behaviour of our leaders at social events, is giving confused messaging to young people who are about to start school. The precautionary approach has served us well till now, so the question should be: why wouldn’t we increase the protection of our unvaccinated children by requiring them to wear masks in what will be high-risk indoor settings, that is in classrooms? If such an additional measure helped keep classes and schools open, wouldn’t parents support it?
There is little time for the Government and HSE to establish the essential measures, in and out of schools, for getting us safely through the next six months
The case is clear. Firstly, reducing the transmission of the virus among children will reduce the risks of existing and new Covid-19 variants entering households, some of which contain elderly and vulnerable adults. Secondly, the risk of long-Covid and serious complications in children are rare and very rare, respectively, but not to be ignored. Thirdly, our children have largely been protected over the last 16 months from a wide range of “winter viruses”. And, above all, keeping schools open is the priority for the educational, social and mental health needs of children; and the sanity of parents.
An epidemic of coughs, colds and sore throats in unvaccinated children between now and spring 2022 will pose major dilemmas for parents, schools and GPs. Guidelines will require symptomatic children to stay at home and many to be tested to distinguish Covid-19 from the wide range of other respiratory infections that lie in wait. The consequences of relaxing social distancing and not making mask-wearing the norm in partly vaccinated as well as unvaccinated classes will be a disrupted six months for parents and schools, possibly to the point of intermittent class and even school closures, all for want of preventive measures that carry minimal risk and discomfort.
In support of this precautionary approach and to provide good example and solidarity to children, the State needs to make clear that masks are mandatory for adults in all public indoor settings until spring 2022, regardless of vaccination status, except while eating and drinking; and every effort and incentive should be in place to minimise indoor drinking and eating in public settings.
There can be exceptions to mask-wearing for children who have educational or health disabilities. There is also likely to be an age gradient for transmission that could be applied, balancing the risk of interfering with learning by limiting mask-wearing to seven- to 11-year-old children, and older unvaccinated children, allowing younger children and fully vaccinated teachers to stay mask-free in the classroom.
There is little time for the Government and HSE to establish, and make clear to parents and children, the essential measures, in and out of schools, for getting us safely through the next six months: masks, social distancing and ventilated classrooms. I look forward to an evidence review and recommendations on these matters from the Health Information and Quality Authority, which has been among the unsung heroes in guiding Ireland’s Covid-19 response.
A new roadmap at the end of August is not a substitute for clear messaging, now, on how the vaccinated and unvaccinated, old and young, should behave.
Ruairí Brugha is emeritus professor, RCSI University of Medicine and Health Sciences