Chief medical officer Dr Tony Holohan Leon Farrell/
through the phases

'It wouldn't be a failure': Why there may be more clusters as Ireland re-opens and the plan to manage them

Dr Tony Holohan said this week we’re “better placed” now to deal with an outbreak or cluster now than we may have been in February.

IRELAND IS JUST over a week away from potentially progressing to Phase Two of re-opening the country. 

The stringent measures in place since March led to Covid-19 being “effectively extinguished from the community” by mid-May

Phase One saw a section of the population returning to work on Monday 18 May, and public health authorities said then that with each round of restriction easing comes an increased risk of the coronavirus spreading again. 

People mixing again, and being in closer contact with others more than they had been before, increases the chance of Covid-19 emerging in the community at a greater level.  

Dr Tony Holohan said as much in the first of the Department of Health’s daily briefings this week. 

“One of the things that’s going to happen as we ease restrictions, and increase the amount of economic activity… we are going to see more clusters of this,” the chief medical officer said. 

These clusters could see a number of people affected in a workplace, a school or a club, according to Dr Holohan.

“We have to be in a position to both identify that and to take action in relation to it,” he said. “The fact that that might occur isn’t necessarily a sign that we haven’t succeeded in terms of applying our measures.

I think we’d be much better positioned to deal with that than we might have been in February had that occurred in that way.

In England, health authorities have said that there could be “flare-ups” of Covid-19 in schools and workplaces which would see them subject to “local lockdowns”.

Government minister Robert Jenrick told the BBC that such measures would allow “greater freedoms to millions of other people across the country”, while the intervention at that specific local level may be “restrictive on the individuals who live and work there”. 

So what are the plans in place if – or when – clusters of Covid-19 break out in specific sections of the country, or within specific workplaces?

Covid-19 clusters in Ireland

A cluster of Covid-19 is defined as three cases or more being diagnosed within a particular setting in 72-hour period. 

According to data (correct as of midnight on 25 May), there have been 846 clusters of Covid-19 identified in Ireland. 

The majority of those (430) have been in either a nursing home or a residential institution. Over 1,000 of the 1,600 people who have lost their lives so far, died in nursing homes. 

Another specific section of society that has seen significant numbers of cases are among those who work in the meat processing industry. There have been 925 confirmed cases among staff in that line of work so far, with outbreaks reported at 16 plants.

Speaking to on issues across meat plants, Siptu divisional organiser Greg Ennis said the lack of physical distancing at these kinds of facilities and conditions within them around ventilation and staff taking breaks together made it a “perfect storm” for the virus to spread.

“These were concerns we had from the start,” he said. “It’s very concerning that as of mid-May there’d been no inspections done [by the Health and Safety Authority] at these plants.”

Ennis said there’d been a “commonality of purpose” among employers and trade unions among other industries with the goal of keeping workers safe while also continuing/going back to work but this wasn’t the case at meat plants.

In the most recent update from the Department of Health, a further 100 cases of Covid-19 in meat plants had been confirmed and Ennis labelled these still-rising figures as “absolutely shocking and most disturbing”.

In a statement, however, Meat Industry Ireland said its members had “acted promptly” to the threat caused by Covid-19 and put in place a range of protective measures to help mitigate the spread.

Where there are clusters, the representative body said companies worked closely and openly with HSE officials. “Communication with the workforce has continued throughout and advice and guidance updated,” a spokesperson said. 

National outbreak control team

To help combat this situation and reduce spread specifically at meat plants, a HSE-led national outbreak control team is in place and guidance had been issued to all facilities.

This team has the aim of controlling the spread of the virus, mitigating the effects of the outbreak and stooping the outbreak by preventing further cases of Covid-19. 

A recently published document by the Health Protection Surveillance Centre (HPSC) outlines the guidance for the management of outbreaks of Covid-19 within particular settings.

It is similar advice that is being followed right now to try to manage the meat plants situation across the country. 

“The aim of this plan is to ensure a rapid, effective and coordinated approach to the identification, investigation and control of an outbreak of COVID-19, regardless of setting,” the HPSC says. 

It adds: “An outbreak of Covid-19 can happen in a variety of settings e.g. the home, community, residential care facilities, hospitals and the workplace.

Due to the variation in settings of outbreaks, the vulnerability of those involved or potential for increased transmission, a more sensitive definition of an outbreak may be used for public health action. For example, in residential care facilities (RCF) a single suspected case of Covid-19 should prompt immediate public health action.

An outbreak control team would have a number of people assigned to it with specific roles. A medical officer of health would lead the team with the authority to detain and isolate persons in certain circumstances.

The team would also have an epidemiologist, a microbiologist, an infectious diseases physician and nursing staff all with dedicated roles to help mitigate the effects of the outbreak. 

The HPSC suggests a number of actions that must be taken to manage the outbreak, from an investigation and risk assessment of the situation to reporting and monitoring of those who’ve been confirmed as having Covid-19. 

A specific investigation is required into how cases were exposed to Covid-19 to inform how they aim to control the spread. 

In the risk assessment phase, it should be determined if there is an “ongoing significant threat to public health”. 

It says: “Conclusions derived from the risk assessment are principally a matter of professional judgement. However, for reasons of public accountability and understanding, it is essential that this process is as transparent as possible.

Once the risk has been assessed, a decision should be made on how the risk is likely to be perceived by the public. This should inform the development of specific public communications about the risk and how it is being mitigated.

All confirmed cases will be monitored and updates provided on their condition. There should be daily surveillance for fever or respiratory symptoms on an ongoing basis, and this should persist for 28 days after the last person shows symptoms. 

People affected by the outbreak should be delivered the healthcare they need, and those potentially affected by the outbreak given advice on hand hygiene and PPE. 

In order to declare an outbreak over – regardless of setting – that site must not have experienced any new cases of infection over two incubation periods, again that’s 28 days.

Speaking about meat plants, Dr Holohan said the outbreak control team had considered a “full gamut of measures” that needed to be thought out to try to prevent the disease spreading both in the workplace setting and in the wider community.

“I think we have evidence that the rate of infection is dropping [as a result],” he said. 

Close down specific settings

On Tuesday, Dr Holohan was asked specifically what would happen in the case of an outbreak in a school and if it would be the case that the school would close down at a local level.

The chief medical officer said: “If that’s the right response at a point in time, then that might be the response exactly. 

All I’m really doing is trying to sort of raise people’s awareness and understanding of the fact that we will have events or circumstances in which we see transmitting of the virus occurring, either in an outbreak or cluster form in particular settings.
We will have to be in a position as quickly as we possibly can to pick that up either locally or nationally, and make interventions we think are necessary in relation to that. 

Dr Holohan emphasised that as Ireland re-opens, it is likely we will see such instances of clusters breaking out. 

He stressed it would be important for the public not to interpret this as that the “whole strategy had failed”. 

He highlighted examples of social activity such as nightclubs in Asia and restaurants in parts of Europe that have presented challenges to authorities seeking to stop the spread of the virus. 

“But for the most part, the authorities there have been able to contain that,” he said. “That’s what I’m pointing at to is an expectation that there is a pattern we might expect to see here that wouldn’t necessarily represent failure.”

However, all of this is not to say that health authorities here will deem it acceptable if we have a significant increase in cases.

They have emphasised that it is likely we’ll have clusters over the coming weeks and months, but it is essential that people do all they can to prevent the spread of the virus. 

Ireland’s re-opening is contingent on factors like the number of hospitalisations, and the number of admissions to intensive care. 

It is an extremely delicate balance. If they rise sharply, then that will be a cause for concern.

Here’s what Dr Holohan had to say on Wednesday: “By increasing the amount of activity, whether it’s economic or social or cultural, or whatever it may be, the increased interaction between people, all things being equal, can lead to an increased risk of transmission of infection.

And we look at some of the figures today that we’ve seen in the last 24 hours: five people admitted to intensive care and 15 people admitted to hospitals overall.
That’s an increase that’s… we’re going to watch that, we’re worried about that.

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