Recent days have seen a surge in COVID-19 cases across the globe, and a significant worsening of the situation, particularly in Italy and Spain. In Ireland the testing backlog has reached extreme numbers, with the number of people put forward for testing averaging 20,000 a day for the last 10 days, compared to the total number of tests conducted at 18,000, this indicates a backlog in excess of 180,000 tests, at the prior criteria. When considered alongside the global situation, the projections for Ireland and the current response to the crisis, this raises major concerns and many questions.
Global Update and Analysis
The number of coronavirus cases is now over 450,000 worldwide with over 350,000 of those cases outside the People’s Republic of China. There is little sign of a reduction in the growth rate of new cases (Figure 1). As the crisis has escalated world governments have begun to respond to the crisis with several countries now implementing partial or total lockdowns.
Figure 1 – Tracking the COVID-19 epidemic outside China over time. Here we see steady exponential growth in the number of new and total cases outside of China. This pattern is mirrored by the number of new and total deaths outside of China. Source.
Retrospective analysis of the outbreak in China has shown the importance of early and combined interventions in slowing down transmission. It has been estimated that 86% of all infections in China were undocumented prior to the 23rd of January 2020. Due to their greater numbers, undocumented infections were the source of 79% of documented cases (Li et al, 2020).
Studies show that had China acted one, two, or three weeks faster then cases could have been reduced by 66%, 86%, and 95% percent. If they had delayed their actions, case numbers could have shown a 3x, 7x or 18x increase (Shengjie Lai, 2020). Researchers have highlighted that when a reduction in travel is coupled with social distancing measures, the travel reduction will not only delay the spread of the outbreak but could be the deciding factor in eliminating the outbreak (Siegenfeld & Bar-Yam, 2020).
Update on the Coronavirus in Ireland
The coronavirus crisis in Ireland has escalated substantially during recent weeks, with a steady rise in cases, 1564 as of Wednesday evening (March 25th), and a formerly projected 15,000 cases by the end of the month. In response, Ireland has seen the implementation of extreme social distancing measures, and the passing of legislation granting the Irish Government significant power to impose their control on the populace. Included in the measures are the ability to lockdown areas and detain individuals, substantial additions to Garda powers in relation to tackling the crisis, and the ability for the Health Minister to implement new measures, which are not subject to review.
Coronavirus Projections for Ireland
While the total number of cases in Ireland still remains below that of the majorly affected countries, it is important to note that Ireland is in the early days of this crisis and can expect at least several more days of exponential growth before the currently implemented measures have any impact on the growth rate. These figures are particularly worrying when viewed relative to population size. In figure 2 the current number of cases per million is displayed for Ireland and several other majorly affected countries. Here, it can be seen that in relative terms, Ireland is already in a similar situation to some of the much larger countries with more condensed outbreaks.
Figure 2: COVID-19 cases per million of population as of 24/03/2020. Here we see that Italy is by far the worst affected with Spain following a similar path. Ireland is close to South Korea at present. Notably even though the epidemic began several months earlier inside of China, the proportion of the Irish population which are infected is already higher than that of China. Source.
Due to Ireland’s low population, resources are likely to be exceptionally strained at much lower total number cases, considerably so if the Taoiseach’s projection of 15,000 infected individuals at the end of the month is correct. The end of the month represents approximately 30 days after the first case was detected in Ireland. In figure 3 the number of cases per million 30 days after the first case in the country was detected is compared with Ireland’s projected value of 15,000. As is clear from the figure, the penetration of the virus in Ireland was projected to be much higher than was seen in these other countries at a similar point in their timeline.
Figure 3 – COVID-19 cases per million after 30 days from the first case being detected in each of the countries. Here, Ireland’s value is Taoiseach Leo Varadkar’s projection of 15,000 cases at the end of the month, which will be approximately 30 days since the first case was detected in Ireland. It is clear that if the projection had held, then the situation in Ireland would be considerably worse than in other countries due to our small population. Source.
Given that this projection would require Ireland outstripping its current growth rate by a considerable amount, there is a possibility that the projection is inflated to increase confidence in social distancing measures. Another possibility is that the backlog in the testing system means that our number of detected cases is artificially low. However, even if the true number of cases is only half what the Government is projecting, Ireland would still be heavily affected proportionally compared to other countries. In Figure 4 Ireland with 7,500 cases is compared with other countries 30 days after the first case was detected in the country. Even at this number, the level of penetration of the disease within Ireland after 30 days would be much higher than was seen in other countries.
Figure 4 – COVID-19 per million of population 30 days from the detection of the first case in the country. Ireland’s value has been replaced by half of the Taoiseach Leo Varadkar’s projection, at 7,500 cases at the end of the month which is approximately 30 days. It is clear, again, that this number of infected puts Ireland in dire straits, with a situation still far worse than Italy or Spain at present. Source.
These are not numbers to be considered lightly, given the proportion of cases which will require hospitalisation, 15%, intensive care, 5%, and the mortality rate, 3.4%. When Tony Holohan talks of 2,000 new cases a day this equates to 300 hospitalisations, 100 people in intensive care and likely 68 eventual deaths, per day. Considering the projection of 15,000 for the end of the month, this implies 2250 hospitalisations, 750 people in intensive care, and likely 510 eventual deaths. As the number of cases increases, this will impose considerable strain on the health system.
Ireland’s Response to the Crisis
There are now tens of thousands, if not hundreds of thousands, of people waiting for tests, and yet the Taoiseach has claimed to be following the South Korea model in response to this virus. South Korea provided intimate detail on the cases in the country allowing individuals to make informed decisions about their behaviour to minimise the chance of infection spreading. South Korea also responded very quickly to the crisis and were producing thousands of tests within two weeks of the first case being detected, in addition to having a well organized testing system. Given that these aspects have been and continue to be vital to South Korea’s response it is unclear how the Irish Government is following the South Korean model.
The Health Minister is now asking the people of Ireland to confront small groups of teens in the street. The tone of the Irish Government recently is that the Irish people are not self-isolating well enough and therefore the minister for health requires new powers to better control the population. There appears to be great inequality in the division of responsibility between government and the individual in Ireland at present. Given the limited powers by which an individual can respond to this crisis would the leaders of this country not be better off taking action to combat the virus instead of focusing overwhelmingly on personal responsibility?
However, in the cases detected so far, given that the measures taken cannot yet be expected to have an effect, it is their actions or lack thereof which is to blame. Including a lack of testing and long turnaround time, average of 3-4 days for patients outside of hospital, refusing to share the travel paths of confirmed cases, refusing to close the borders to travel, allowing the Italian fans to come to Dublin, not recommending self-isolation for everyone returning to the country. The Department of Health says they have been preparing for this crisis since late January and claimed to be ready to face it. However, the government is only now attempting to acquire more respirators, personal protective equipment and test kits. This is accompanied by nationwide shortages of masks and hand sanitiser, the lack of which leaves the public vulnerable even when trying to take personal responsibility for the situation. This situation is even more extreme when it comes to the shortages faced by front line staff, who are at higher risk and whose health is vital to society at this time. A similar situation in Spain has led to almost 4,000 healthcare workers contracting the illness, placing considerable additional strain on the healthcare system there.
In hindsight, is it not clear that different actions should have been taken? Would restricting travel in February have done greater damage to Ireland’s economy or public health than the current government projections? Would testing contacts of cases before they displayed symptoms and random sample testing in areas of community spread not have allowed us to slow the spread of the virus?
Even lesser steps, had they been taken faster, such as properly implemented contact tracing or providing information on the location of cases would have been effective at reducing the spread of the virus based on the information above. It is clear that mistakes have been made consistently as the Covid-19 pandemic has developed, rarely by the public and often by the politicians and the public health officials. This is not localised to Ireland, the response of the WHO itself has been very poor, slow and the information it provides is often outdated and based too heavily on information coming out of China.
Information, Latency and Fidelity
One aspect of the coronavirus in Ireland that contrasts most significantly with that of the countries that have responded well to the crisis, such as Taiwan and South Korea, besides testing, is the level of information shared with the public. Both countries provide significant detail on cases, enabling people to make informed decisions, and ensure their population is well informed on the virus, reducing fear. In terms of case information in Ireland, the Department of Health provides only very high summary level data at county level due to privacy concerns. Journalists and politicians in Ireland have focused on calling for the media and government to be used as the sole source of information. In addition to this, both journalists and media have done little to alleviate the anxiety of the population.
Regrettably, there are several concerns about their ability to distinguish between what is useful information and what is not. One focus this week was on a message warning people about transmission at petrol pumps, this was dismissed as “utter rubbish” by Colm Henry, HSE clinical lead. However, considering the droplet transmission methods of SARS-COV-2, the requirement of frequent handwashing so as not transmit the virus, that it can survive on metal and plastic for up to three days, and given that a petrol station will usually receive visits from many different communities, is it not likely that taking extra precaution when using a petrol pump is sensible advice? The counter argument to this is that it increases fear in the population, however, as we have seen the numbers provided by the government present a picture of this country as the worst affected in the world in per capita terms pointing to an extremely large number of fatalities. As we have seen in figures 3 and 4, the government’s projection of 15,000 cases seems to be far more alarming than notices to take caution when using petrol pumps.
Given that the government response to the crisis so far has not been fast enough to get ahead of the virus and the damage that providing inconsistent information could have on public trust, the next few months must be carefully considered now that the democratic right to organise and gather in public has been temporarily removed from the Irish people. The government is asking the Irish people to put a lot of faith in them as they are confined to their homes and atomized into small groups. This separation of society and the government’s desire to control the flow of information leaves the Irish people in a very vulnerable state. This lack of transparency can be contrasted with the United Kingdom. While they provide guidelines for the public to follow, all the scientific evidence that is directing their response is regularly updated on the Scientific Advisory Group for Emergencies website, making it inclusive. This allows oversight from the public, journalists and other scientists and researchers.
When the Irish people can no longer observe or oppose the actions of the Irish Government, how can it be ensured that their decisions are properly scrutinized? We must ensure the future wealth of the Irish people is not squandered by virtue of zero accountability, lest we forget the lessons of the National Children’s Hospital. How can it be ensured that people receive quick access to treatment and testing instead of a situation similar to the current hospital waiting list? What is the approach of the government when making decisions on the trade off between the economy and the welfare of the Irish people? The Government must be given space to make decisions but the rationale for those decisions should be made publicly available.
The steady global escalation of the pandemic, the disturbing projections for Ireland, the failure of the response to the crisis at present, and the lack of accurate information give rise to several questions:
1. What provisions are being put in place to make sure the people’s voices are being heard during this time? With the rights to organise, demonstrate and even gather in groups taken away, the ability of the Irish people to voice their opinions, share information and communicate is vital to ensure the liberal democratic values of Ireland are upheld during this crisis.
2. Conversely, what provisions are being put in place to make sure the Irish people are able to observe the actions of the Government and its response during the crisis?
3. What are the factors considered by the Department of Health regarding the level of information that is released to the public? There is currently considerable uncertainty regarding the progress of the disease in Ireland and the motivations for the decisions being taken. When trying to reduce panic would the Department of Health not be better off increasing the level of transparency and information that is available rather than mediating between the public and the facts?
4. What is the source of the discrepancy between the projected figure of 15,000 and the current figure of 1329 cases? Is this due to the significant backlogs in testing or due to lesser spread in Ireland than projected? What is the true backlog in the number of tests to be done? What will the effect of raising the criteria for testing have on the detection rates of the virus? With a backlog potentially in excess of 180,000 tests how can contact tracing be effective? Contact tracing requires that contacts of cases be contacted quickly to be effective, however, given the backlog of testing and the reduction in testing criteria it is likely that many cases will be identified late or not at all.
5. What metrics are being used to track Ireland’s experience in this crisis and justify the imposition of counter-measures? There is currently considerable uncertainty about the progress of the crisis and what metrics are being used to make decisions. This is most clearly exemplified by the change to case definitions.
6. What actions are going to be taken and what counter-measures will be implemented by the government during this crisis? At what stage of the crisis will the measures be introduced? If Ireland is intending to take the approach of South Korea, for whom rapid and wide scale testing was vital to the response, then at what point will the testing backlog be cleared, and what is the time frame for the rollout of larger levels of testing capacity? Or will the focus be on implementing a large scale and intrusive tracking system similar to the system operated there?
The recent surge in people looking to assist the HSE during this crisis shows the willingness and ableness of the Irish people to contribute to the fight against this virus. Instead of taking a restrictive and reactionary approach to the crisis, would a better approach not be to look at countries who have had success in fighting the virus and try and replicate their actions. Taiwan started screening passengers in the airport before the virus in late December and quickly implemented testing and contact tracing. South Korea has halted their epidemic by implementing an expansive and well organised testing system. Instead of accepting the wide scale damage to the public, economy, and culture of Ireland over the next 12-18 months would we not be better to act decisively now and attempt to minimise the damage we suffer by taking innovative and bold steps to stop the crisis as soon as possible.