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Professor Ruairí Brugha: The current version of mandatory hotel quarantine is not fit for purpose

The public health expert says there are better, more creative ways to bolster the quarantine system and prevent the import of Covid.

Image: Sam Boal

TWO RECENT REPORTS remind us why we must keep variants of concern out of Ireland.

Over half of admissions to intensive care units in Brazil are now in under 40-year-olds, probably as a result of the P1 variant against which the current vaccines are potentially less effective. The P1 variant and political mismanagement have overwhelmed Brazil’s health system.

The second report is of 877 cases of the P1 variant in Canada, mainly from the ski slopes of British Columbia. History repeats itself. Vaccinating ski resort staff has failed to control the outbreaks.

Officials attribute these outbreaks to a delay in implementing the gene sequencing which is necessary for identifying and kickstarting effective responses, and to a delay in implementing an effective quarantine system.

Closer to home

So, is Ireland’s 14-day mandatory hotel quarantine system fit-for-purpose? No. There is any number of rocks on which it is likely to founder over the next days and weeks. A system that relies solely on categorising countries is inherently flawed.

Only Covid-19-free countries – such as New Zealand, Australia and China – can be considered free from such variants of concern.

A consistent application of the current criteria means adding Britain to the red list, given that the Brazil and South African variants are circulating there. On 12 April, 44 definite and 30 probable cases of the South African variant were reported in the London area. Britain accounts for 20-25% of weekly arrivals into Ireland.

If just about any country can be a source of variants of concern, such a system should logically include almost all countries, risking overwhelming the hotel capacity in our current quarantine system.

Applying Ireland’s second criterion for a mandatory hotel quarantine, coming from a country with a comparatively high number of cases, means that the more testing a country does, the more likely it will join the red list.

Presidents Trump and Bolsonaro were right in a perverse way. Less testing helps hide the epidemic. Most African countries lack sufficient testing and have no gene sequencing capacity. Based on those criteria, they should be omitted; and yet some are on the red list, perhaps for good reason.

The system challenges

Irish courts may find the mandatory hotel quarantine system to be unconstitutional. Our legal system values common sense, which is also a touchstone when it comes to our adherence with regulations.

A system that forces two fully vaccinated arrivals from Israel into a 10 to 14-day hotel quarantine, one a health care worker and the second arriving to be at the deathbed of his father, failed the common-sense criterion.

Yes, there have been cases of vaccinated persons becoming re-infected, probably because of the type of vaccine and being re-infected by a variant type of concern. But there have also been cases of onward transmission of the virus by people, after they had come out of a 14-day quarantine.

False-negative tests also occur, enabling onward transmission. A risk assessment can consider these probabilities.

However, the rock on which the hotel quarantine strategy should founder, sooner rather than later, is that it is not designed to achieve its purpose. Its aim should be to detect, isolate and prevent onward transmission in Ireland of all variants of concern that could undermine our vaccination programmes, those currently being the South African (B.1.351) and Brazil (P.1) variants.

This requires a quarantine system that keeps all arrivals isolating, at known settings where they are monitored, to the point where they can be retested – Day 7 for low risk, and Day 5 and Day 10 tests for high-risk arrivals.

All test positives should be gene sequenced, with the outcomes determining next steps. We are gene sequencing 25% of all positive cases, which means this is possible.

How to monitor?

A few days ago, a fully-vaccinated arrival from Israel had to undergo the hotel quarantine. With Israel now off the red list, will an unvaccinated arrival from Israel (or from Britain), who had been frequenting busy nightclubs and/or bars before travelling, be subjected to an effective quarantine on entering Ireland?

Anecdotally, one hears of arrivals into Dublin on a Friday from non-red-listed countries, who complete a location form on arrival, socialise without socially distancing with families and friends over the weekend, and leave on a Sunday or Monday. The latest hiccup is arrivals without hotel bookings.

So, what would a fit-for-purpose border check and quarantine system look like? It would consist of a six-hour period at the arrival (air)port, during which the person arriving has a Day 1 test, whose sensitivity complies with European standards; followed by a self-administered questionnaire and interview by a public health supervised investigator, who assesses the person’s risk. The outcome, along with test results within six hours, would determine what type of quarantine is required.

Arriving from Brazil, South Africa or Canada might currently be sufficient to require a mandatory hotel quarantine; although vaccination status, the reason for travelling and likelihood of complying with a self-quarantine option would be factors to consider.

Appeals against a hotel quarantine would be to a public health specialist panel, not to an appeals officer working from a legislative list of exemptions, lest further time of the courts is wasted.

If quarantining at a specified place (that is safe for others) that is not a designated quarantine hotel is allowed, the person must agree to a smart phone tracking app, spot phones call and visit at the place of quarantine, and phone calls to nominated sponsors who would be liable if the person fails to comply with quarantining conditions.

A person not fulfilling quarantine conditions, including presenting for testing as required, would be subject to sanctions, including the mandatory hotel quarantine. The problem is that we have never established a good monitoring and enforcement system for home quarantine.

This system passes the feasibility test – available hotel capacity can be used for those who bring the greatest risk of importing dangerous variants – and the equity test.

The key? Tracing

Individual risks can be fairly assessed. There could be 1-3 month exemptions to the six-hour assessment – or advance, online approvals – for long-haul drivers, business people, civil servants and politicians making approved trips, all of whom need to comply with a testing regime.

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Port-of-arrival public health assessments and quarantine options need to be part of a broader system for protecting the population from the Covid-19 and future pandemics. The components of such a system include a laboratory testing capacity that can provide timely, high-volume testing and gene sequencing of these and future pathogens, as they emerge; and a pathogen (virus and bacteria) surveillance system that encompasses general practitioners and public health departments, countrywide.

Equally important are a trained and motivated public health workforce, with a commensurate contract for supervising specialists, equipped to investigate, contact trace and control epidemics – and to provide advice to the Government, as NPHET has done, exceptionally well; and political leaders who have learned, and who are willing and have the powers to apply the lessons, from 2020.

Some of these measures will take time to put in place, but we need to plan better for the future, which means constructing the ship as we sail.

Now back to business. In the 15 days between 26 March and 9 April, 413 persons entered the hotel quarantine system, 10 tested positive, and 7,434 cases were reported countrywide.

If as many again did not get tested despite being symptomatic, and others were infected but remained asymptomatic, there were somewhere between 15,000 and 20,000 infections in the community. Some may have variants of concern.

We need vaccines in arms as soon as possible; but we also need laboratory capacity and we need the public health workforce capacity, now, to protect our vaccines and to crush this and future pandemics.

Ruairí Brugha is Emeritus Professor, RCSI University of Medicine and Health Sciences.

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