Wednesday September 23, 2020

Why a Covid elimination strategy may offer the best hope of a normal life

As coronavirus cases continue to rise and our testing system reaches full capacity, we need an inclusive debate on where we go from here

13th September, 2020
More widespread testing is central to an elimination policy. Photo: AFP/Getty

In the continued absence of a vaccine, two broad strategies are being used internationally to combat the coronavirus pandemic: partial suppression and elimination.

To date, our health authorities have failed to communicate a cohesive plan but, in practice, Ireland’s strategy resembles one of partial suppression. This involves accepting that the virus is here to stay while committing to interventions aimed at preventing our hospitals, and in particular our intensive care units, from being over-run.

Ireland reached its lowest number of daily cases, about ten per day, in June and July. Under the partial suppression strategy this has gradually risen to 100 to 300 per day, despite stricter restrictions imposed in August.

Schools have been opened, universities and pubs will follow, and winter will soon be upon us. Under these circumstances, it is reasonable to assume that cases will continue to rise.

Currently our cases are primarily among the young and the death rate is low, but eventually they will seep into the elderly population and back into nursing homes – the experience in Florida, France and Spain tells us so. If we continue to follow our current disorganised path, there is a very real possibility that we will be forced into another national lockdown.

Under the current partial suppression strategy, people are struggling to live a meaningful life, and no group has been affected more than the elderly and more vulnerable.

The strategy has led to the Orwellian concept of cocooning entering our lexicon. Though the word alludes to a sense of comfort and tranquillity – of being warmly wrapped in a silken cloth – the reality of cocooning is isolation, loneliness and fear.

Many of the over 70s are afraid to venture outside and afraid to have visitors. In nursing homes, they don’t even have a choice.

Under the partial suppression strategy, there is also little opportunity for the sustenance for the soul provided by sporting and artistic involvement. Those sports fortunate to go ahead take place in empty stadiums. Live music appears consigned to history, indoor performances of all kinds a luxury of a bygone era.

However, it does not have to be all doom and gloom. There is an alternative which promises the possibility of living in a society closer to normal, a society where economic activity is not suffocated, where people can visit their elderly relatives, have a beer in a pub, enjoy live music and attend sporting events in stadiums.

The Faroe Islands, New Zealand, China and Taiwan have opted for this approach, which is known as the elimination policy. The HSE takes the view that eliminating the virus is not realistic, while elimination is regarded as not possible by the National Public Health Emergency Team (Nphet).

But if other countries have striven for and achieved this for prolonged periods punctuated by small but very manageable outbreaks, then why not us? We need a much deeper, nuanced national debate before disregarding the elimination policy.

Of course, it is not possible to eliminate Covid-19, but a policy of elimination is an entirely different matter. Such a policy aims to seek out the virus before widespread clusters emerge. It does not wait for the virus to reveal itself – it is an active policy where surveillance is key, and which perhaps offers the greatest hope of living in a normal society.

More widespread testing is central to an elimination policy. To achieve it we would need to move from a “test, trace, isolate” system to a “find, test, trace, isolate, support" one, actively seeking out the asymptomatic silent spreaders in the community.

First, imported cases need to be reduced, requiring testing and some quarantining at airports and ports. While only 2 per cent of cases have been identified as related to foreign travel, 20 per cent are from an unknown origin. Reducing cases as they enter the country is a good place to start tackling that percentage.

Secondly, we must consider regular mass testing of higher-risk groups such as healthcare workers, perhaps teachers, and those living and working in congregated settings such as direct provision and meat factories. Once capacity has been sufficiently expanded, regular mass testing could be extended to the entire population.

Unfortunately this remains aspirational. Last week, testing requests exceeded our capacity, causing screening in meat processing plants to be suspended. Conversely, on the tiny Faroe Islands, some 100,000 tests have been performed on 50,000 inhabitants. The country is now three weeks without a new domestic case of coronavirus.

In Britain, Cambridge University will test every student every week. In the US, Boston University will test every student twice a week, every week. All tests will be processed on the campus in a new lab which was rapidly outfitted over the summer. This one university laboratory is capable of processing up to 6,000 coronavirus tests a day. Ireland currently processes 10,000 tests per day.

We know mass testing can eliminate the virus from a region. In May and June, authorities in the city of Wuhan, where the virus originated, tested nearly 11 million people in three weeks using pooled samples, thus eradicating the coronavirus and inviting thousands of people to a party to celebrate.

Pooled testing works by combining swabs from a number of people into one test. If that test comes back as positive, each of the ten swabs must be tested individually. But if the combined test comes back as negative, individual tests need not be performed. As most tests are negative, this greatly reduces the total number of tests needed.

In Italy, the coronavirus was eradicated from the city of Vo by mass testing. Mass weekly testing of a population is to be trialled imminently in Salford, greater Manchester, while phase two of weekly testing using salivary samples will soon be under way in Southampton.

A cost-effective way for mass surveillance is to monitor waste water for evidence of the virus. The city of Somerville in Massachusetts has announced that it is launching a community waste water testing programme which it hopes will identify Covid-19 hotspots one to two weeks earlier than current individual testing.

An elimination policy is not without its setbacks; these are inevitable and to be expected. For over 100 days in New Zealand there were no community-based cases; during this period authorities carried out 1,000-5,000 tests per day on incoming travellers and on people with suspicious symptoms.

On August 11, a community outbreak was identified in Auckland. Within three days, testing moved to over 20,000 tests per day for that one cluster. Ireland has many more clusters, yet carries out 10,000 tests a day.

Adopting an elimination policy could be extremely challenging given our current suboptimal test and trace infrastructure. But as a country, we are not making the best use of our collective abilities.

Ireland has many fine scientists who have already contributed richly to the debate and who are keen to be involved in problem-solving. The private sector includes many individuals who are deeply experienced with logistics and high-performance industrial management too.

With daily cases steadily increasing despite stricter measures and our testing system at maximum capacity, we are moving ever closer to a crossroads. We need a national, inclusive conversation to assess the elimination policy, which may offer us the best hope of living in a more normal society.

Dr Domhnall Heron is a GP based in Sligo

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