On Monday, May 18, Ireland began phase one of easing restrictions and took its first tentative steps towards a return to a more normal society. Our health authorities have made many important and difficult decisions to guide us to this point. However, Covid-19 is very contagious, and important monitoring systems may not yet be at the necessary standard.
When Singapore entered lockdown on April 8, it was troubling news. Until then it was one of the few countries that had been successful in bringing initial outbreaks under control without resorting to mass quarantine. Its situation underlines how easily the virus can return.
Singapore had been containing cases through rigorous testing and tracing with a strict but limited quarantine. The city state had reported a total of 1,600 cases to April 8, but cases climbed rapidly to 22,000 by May 8. Most have been traced to dormitories occupied by foreign workers. These people live in cramped conditions and often do not have the option to adhere to social-distancing advice.
In Ireland, those living in direct provision and those working at close quarters in meat processing factories are at similar risk.
Chinese authorities recently ordered the temporary closure of all public places in the city of Shulan. Sports facilities, cinemas and libraries were shut and all residents ordered to stay home except under “unusual circumstances”. Students returned to online learning. Taxis are not permitted to leave the city and all public transport has been suspended.
Wuhan has also reported its first cluster of infections since its lockdown was lifted a month previously. Five new confirmed cases were diagnosed, all of whom lived in the same residential compound. Chinese officials immediately announced plans to test all 11 million residents. In China the time from requesting a test to its result being reported is four hours, while all contacts are traced within 24 hours.
South Korea is held as an exemplar of the test, trace, isolate strategy and one of the few developed countries not to have needed a strict lockdown. Appointments at drive-through and walk-in testing centres can be booked directly without consultation with a doctor. The mobile centres conduct the tests within ten minutes, with the results sent to people’s phones within 24 hours.
South Korea also uses mobile technology for contact tracing. Contacts are traced by GPS phone tracking, surveillance camera records and credit card transactions. Those details enable authorities to issue alerts, in real time, about where infected people had been before their positive status was confirmed.
Dozens of new cases were confirmed in South Korea last week, nearly all of them linked to nightclubs in Seoul, the capital. A 29-year-old man who visited several bars and nightclubs in early May tested positive. He is believed to be at least one of the individuals behind the new cluster where more than 100 people have tested positive. All bars and nightclubs in Seoul have now been temporarily closed.
Clusters like these in China and South Korea could become the new normal as countries learn to live with the coronavirus while reopening their societies and economies. What is important is that both China and South Korea have an effective monitoring system in place to detect clusters, and the flexibility to tighten restrictions again when needed.
In an interview with Time, Dr Gavin Yamey, the director of the Centre for Policy Impact in Global Health at Duke Global Health Institute said: “It is likely that we will see cycles of easing of restrictions, then tightening again, until we have reached population levels of immunity that would be protective — either from a vaccine or from enough people being infected, recovering and developing long-term, durable immunity.”
The new outbreaks in China and South Korea show that all countries, even once they have controlled their epidemics, must remain vigilant. A single case anywhere could lead to an outbreak.
Unfortunately Ireland’s monitoring systems may not yet be at the required standard to maintain a long-term easing of lockdown restrictions. The country has made tremendous progress in terms of testing capacity and now has the ability to test 100,000 samples a week. However, this great work is being negated by the inability to process these tests in a speedy manner and by difficulties with contact tracing.
Our strategy to test, trace and isolate is falling at the first hurdle. Last week half of all tests were still taking longer than five days to be reported. Even the HSE’s aspiration to have 90 per cent of tests reported within three days is not nearly ambitious enough. We need to aim for 100 per cent of tests reported within 24 hours and all contacts traced within 48 hours.
On the suboptimal processing speed, Dr Cillian de Gascun, chair of the National Public Health Emergency Team’s expert advisory group said: “There’s no single fundamental issue.”
He said errors were occurring during manual processes, while data gaps had also slowed progress, including missing contact details for GPs or patients. Hospitals also operate on different computer systems. “They don’t all talk to each other,” he explained.
Substandard IT systems have been a major source of inefficiency within our health services for decades. Ireland is one of the few OECD countries without electronic patient medical records. Most Irish hospitals have a separate computer system for scans, blood results, appointments and outpatient department letters. There is no integration between these basic functions within a hospital. There is no integration between Irish hospitals or with general practice.
Skilled healthcare staff spend hours each day searching wards for paper notes, logging into archaic IT systems and writing letters to one another. It is not difficult to imagine that software could be the Achilles heel of our testing strategy.
Unfortunately, a digital transformation of our health service is a multi-year project costing hundreds of millions. However, in this time of emergency, perhaps there is a private company specialising in medical software solutions that could come to our aid to speed up testing?
Lockdown is taking an enormous toll on our economy and on our society. Some businesses have already announced their permanent closure. Many others wait tentatively and hopefully but are uncertain if they can survive.
The emotional well-being of our society is at stake. Mental health services have been disrupted. Education has been put on hold. Adults struggle without the stimulation, routine and salary of a working life. Some have not hugged or embraced another in over two months. We cannot afford to re-enter lockdown.
A country’s wealth is the most important predictor of its health. Without income from private industry, a country cannot support cancer treatments or health screening programmes, it cannot pay for education or sports and recreational facilities.
Ireland has not yet released GDP figures for the first quarter of 2020. So far, of the seven OECD countries which have, all reported negative economic growth. The societies that emerge least harmed from the coronavirus pandemic will be those who can return to work and education in a sustainable way. An efficient monitoring system with tests reported within 24 hours and all contacts traced within 48 hours is vital.
Michelangelo is said to have claimed that “the great danger for most of us lies not in setting our aim too high and falling short; but in setting our aim too low, and achieving our mark”. Never has this resonated more.
Dr Domhnall Heron is a pharmacist and GP registrar