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Explainer: What needs to happen for us to move into Phase One next Monday?

Officials have said they are ‘hopeful’, but it is not guaranteed.

Image: Sam Boal/Rollingnews.ie

IF ALL GOES to plan, the government will begin to ease Covid-19 restrictions from next Monday, 18 May. 

In phase one, while people will still be advised to stay home most of the time, they will be able to meet in a small group outdoors if they maintain physical distancing. A return of outdoor work such as construction will also be allowed and some retailers such as garden centres will be able to reopen. 

Although senior politicians and the Chief Medical Officer Dr Tony Holohan have said they are ‘hopeful’ that conditions will be right to start to make the move into Phase One of the government’s plan on that day, it is not guaranteed. 

There are still issues around the country’s sample, test and trace processes, with some people waiting a week or more for their results. This will be one of the key factors considered by the National Public Health Emergency Team (NPHET) this week. 

When the government published its roadmap for easing restrictions, it laid out a number of “trigger criteria” to be reviewed before moving into each of the five phases in the plan. 

Decision-making on these transitions will be based on:

  1. The latest data regarding the progression of the disease
  2. The capacity and resilience of the health service in terms of hospital and ICU occupancy
  3. The capacity of the programme of sampling, testing and contact tracing
  4. The ability to shield and care for at risk groups
  5. An assessment of the risk of secondary morbidity and mortality as a consequence of the restrictions.

Disease progression

Readers will be familiar with the daily updates provided by the CMO each evening on the numbers of new confirmed cases of Covid-19 and also the numbers of patients diagnosed with the disease who have died. 

Those numbers have been dropping – with 139 new cases confirmed Monday and 107 confirmed Tuesday. 

Source: HSPC

Last week the CMO expressed concern about the number of Covid-19 cases in the community, particularly among younger people.

“We are seeing a persistent number of infections coming from the community, if I’m honest about it, particularly from younger people in the community, it’s a number that isn’t falling as much as we would like and we’re keeping an eye on that,” he said. 

However if numbers this week remain below 200 – especially considering the testing criteria has been expanded again – that will be a positive sign. 

The reproduction number – the number of people infected by a positive case – has also consistently fallen in the last number of weeks. Keeping this number below one is paramount and currently it is between 0.31-0.71.

Hospital and ICU occupancy

Restrictions are, in part, intended to prevent the health service in the country becoming overwhelmed, resulting in poorer outcomes for patients who contract the disease – and patients in the system with other illnesses. 

Over the last two months, we have seen record low numbers of patients on trolleys. 

The majority of people diagnosed with Covid-19 have recovered in the community, with just over 13% hospitalised and 383 in total being admitted to intensive care. 

Yesterday there were 529 confirmed (and 297 suspected) cases receiving treatment in hospital and 71 confirmed cases in ICU. 

He CMO has continuously stressed that this number was around to 70 when the current restrictions were first implemented.

If this number starts to creep up above that level, or the rate of hospitalisation starts to increase, lifting restrictions would be less likely. However Dr Holohan has said, for now, this trend is “moving in the right direction”. 

Sampling, testing and contact tracing

This is the area that has consistently experienced issues – first with shortages of swabs to take samples and then a shortage of the reagents needed to test the samples in laboratories. 

The decision a few weeks into our outbreak to begin testing anyone with any of the symptoms resulted in a massive backlog that could only be worked through with help from a German laboratory.

Those issues have now been resolved – health officials have not blamed recent delays on any shortages or pressure due to the broadening of the case definition for testing. 

A number of weeks ago officials committed to reaching a capacity to test 15,000 people a day. At the weekend, the HSE said the healthcare service has reached this target. 

Without backlogs, supply shortages, or limited capacity to test at centres, in theory the process should be moving swiftly. 

But people who are having swabs taken are continuing to report waits of seven days or more for their results.

On Monday officials said the median (middle) wait time from swab to result is 5 days – and this is before contact tracing begins. 

Last week, Dr Cillian de Gascun, director of the National Virus Reference Laboratory at UCD said the HSE has a team looking into individual cases where a person has been waiting longer than the average. 

“I think it’s important to get that information because the scale of testing has increased significantly and it’s quite possible that there will be individuals who won’t get a result in that time frame. We need to find out why that is so we can address it, if there is a significant issue that we can address it and make sure it doesn’t happen,” he said.

Yesterday De Gascun said in some cases the result is available in the laboratory but some information may be missing, such as a mobile number or details for a GP. 

He also explained said a new system had to be scaled up “over a very short period of time”. 

De Gascun said there are still manual steps in the process and “unfortunately, errors will happen in that situation”. He said work is being done to automate those steps. 

“Ultimately we’re in a situation where we’re testing in the region of 5o,000 or 60,000 tests a week in a system that was put in place eight weeks ago. It is a new system, it’s really important to highlight that to people.”

He said hospitals operate on different computer systems so they “don’t all talk to each other very easily”.

That takes time to put in place and to make sure that it’s robust. We don’t have a unique patient identifier yet, we don’t have a national laboratory information management system, so making sure that all of theses systems talk to each other – for anybody who has ever tried to get a PC to talk to Mac will know what I mean – these things take time.

Shielding at-risk groups

There have been 245 clusters of infection in nursing homes and 147 in other residential institutions. In total, 4,624 residents or staff at nursing homes have been diagnosed with Covid-19. 

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Health Minister Simon Harris has described nursing homes as the “front line” of the outbreak in Ireland. When the scale of infection spread in the nursing home setting became clear, testing of all staff and residents began. 

This testing sweep is finished now and numbers coming from this sector have slowed, particularly in the last week. Right now, we are moving in the right direction with this one. 

But as we move through the phases, if NPHET believes there is widespread infection in any sector involving the care of vulnerable groups, this will play a part in its advice to the Department of Health.

Secondary morbidity and mortality

There are increasing concerns that people with serious non-Covid related conditions have been avoiding GP surgeries and hospitals due to the outbreak. 

GPs and hospitals have reported a reduction in the number of patients presenting with symptoms of stroke and heart attack. 

Screening services like CervicalCheck, BreastCheck, and BowelCheck have been temporarily suspended and there are fears that people who are experiencing symptoms of cancers are not going to their doctors. 

Figures from the HSE show that the number of suspected cancer cases being referred for investigation by GPs through the HealthLink referral system has dropped by more than half.

This is despite consistent messaging for weeks from the government and health officials urging people to continue to seek medical care for non-coronavirus illnesses. 

The Health Minister has said Cabinet will consider the level of secondary deaths occurring in the country every three weeks. 

Other considerations

Although the government’s decisions on moving between phases will take public health advice into consideration, it will not solely be based on this advice.

Its roadmap states “other social and economic consideration” will be looked at, such as the potential for increased employment and improving national morale and wellbeing. 

The CMO has said the public health emergency team will not make a decision on its advice to the government until the end of this week. It will then be up to the Taoiseach to decide on the next step. 

When asked at the latest briefing whether he thought we would be in a position to move into Phase One on 18 May, Dr Holohan said:

“We’ll make a final assessment on Thursday in relation to where we think we are.

“We think we’re making good progress, our reproduction number is where we want it to be and the level of infection that we’re detecting in the community now, with the positivity rate in and around 3% is giving us a sense of encouragement in relation to where we will be and our readiness to move on.

“But that’s not me saying ‘today is the day’, if we’re going to be easing restrictions, this would be in respect of an assessment we will formally do towards the end of this week and in respect of Monday.”

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