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Opinion: The case for Zero Covid - have we reached a tipping point?

UCC’s Professor Ivan Perry says the idea that a Zero Covid approach offers a ‘false promise’ for the elimination of the virus is just wrong.

Professor Ivan Perry

AS WE APPROACH the first anniversary of the arrival of Covid-19 in Ireland, grappling with the third surge of infections that are pushing our health services to the brink and enduring our third lockdown in a grim Covid winter, we are finally reappraising our Government’s strategy in relation to the pandemic.

In particular, the issues of travel restrictions and border quarantine now loom large in the national conversation and the issue of pursuing a Zero Covid virus elimination strategy is now on the political agenda with support from all of the opposition parties – even if some of them prefer not to use the precise phrase.

This week, the Government has announced a series of additional travel restrictions, including mandatory quarantine in dedicated facilities for those arriving from South Africa and Brazil and for those arriving in Ireland without a PCR test. 

Zero Covid should not be dismissed

However, the Government and NPHET have pushed back against the argument for Zero Covid, suggesting that the strategy is unrealistic and unachievable and would be impossible to sustain.

The proposed travel restrictions are not yet fully operational and are best described as tepid, confusing and incoherent.

Based on international experience and data, the only border quarantine regime for which we have clear evidence of effectiveness, in terms of reducing to a minimum the risk of importing the virus, is one based on 14 days of mandatory hotel quarantine for all incoming travellers, regardless of PCR or other tests for Covid-19.

Thus, the travel-related measures announced by the Government this week do not address the urgent concerns in relation to the emergence of three new Covid-19 variants, variants first identified in the United Kingdom, South Africa, and in both Brazil and Japan.

Given the level of uncontrolled community transmission of Covid-19 worldwide, the probability of mutations leading to new variants with increased transmissibility, increased disease severity and or vaccine resistance is high.

In our public health response to the pandemic, we need to anticipate and plan for the worst-case scenarios, such as the emergence of a highly transmissible and vaccine-resistant strain of Covid-19.

For this reason, the case for Ireland adopting a Zero Covid strategy, a strategy to get the virus case numbers down, keep them down and keep the virus out, is now compelling.

It defies logic to suggest that a virus elimination strategy is unrealistic, unachievable, even “risky” and that our only option is to continue the current strategy of “living with the virus” until we achieve herd immunity through vaccination in late 2021, an outcome which cannot, of course, be guaranteed.    

What is Zero Covid?

There is some confusion about what is meant by the term Zero Covid and on what is involved in its implementation. In New Zealand, Zero Covid is defined as the absence of newly diagnosed SARS-CoV-2 virus infections from community transmission within a defined jurisdiction or region for 28 days since the last known case in the community was placed into isolation.

With regard to implementation, it is suggested, on one hand, that a Zero Covid strategy would close down the country for an indefinite period, while on the other hand, the strategy is criticised as offering a false promise of an early and relatively painless exit from our current predicament.

Both of these caricatures of Zero Covid are profoundly misleading. In reality, Zero Covid draws on core principles of controlling infectious disease outbreaks that have been understood and implemented for over 100 years.

From the outset of the pandemic, we have had the option of pursuing a Zero Covid elimination strategy, which offers the realistic prospect (but not an absolute guarantee) of a return to near-normal life and opening up the economy within 3-4 months but with persisting border quarantine until an effective vaccination programme has been implemented. 

The first and most crucial step in the implementation of Zero Covid is the development and articulation at the highest level of Government of a vision to achieve and sustain, insofar as possible, the elimination of community transmission of the virus.

We do that so that we can protect our vulnerable at all ages, sustain the viability and effectiveness of the vaccination programme and move toward opening up our economy with a return to near-normal life within the shortest possible time.

This vision needs to be supported by a clear plan, skilled leadership and an effective and empathetic communication strategy that shares this vision with all stakeholders in the public and private sector and with the general public.

How it would work

In implementing the strategy, we would maintain and, if necessary, intensify the current public health restrictions for several months, until zero community transmission is achieved.

These restrictions might then be lifted in distinct geographical zones, most likely by county. Thus, if a county (say, Galway) reaches zero Covid status, restrictions could be gradually lifted in Galway. County borders would remain controlled. However, if two or more adjacent counties achieved zero Covid, they could form a common “bubble” with free travel between them.

Eventually, all of Ireland will reach Zero Covid status, and only international travel will need to be controlled via an effective border control and quarantine regime to keep the virus out.

On achieving Zero Covid status at a national level, there will still be a risk of imported local outbreaks, but these will be quickly controlled at the local level (with minimal impact on other regions in the country). This could be achieved through testing, contact tracing back 10 to 14 days from the time of testing and supported isolation of infected individuals, led by Public Health Medicine Consultants working from adequately staffed and resourced local Departments of Public Health Medicine.

To some, including colleagues in the HSE, this sounds unrealistic, but it has actually been achieved in Australia, New Zealand and in multiple countries and jurisdictions worldwide.

Furthermore, we now have overwhelming evidence that countries that are trying to eliminate the virus, as opposed to living with it, are more successful in terms of health outcomes (by a very large margin) and economic outcomes.

While it should be emphasised that there is no absolute guarantee that elimination of the virus can be quickly achieved and sustained in Ireland, why would we not set ourselves this goal? Why opt for the alternative strategy of lockdown followed by relaxation of restrictions while the virus is still circulating in the community, thereby, committing us to repetitive cycles of lockdown and partial reopening until an effective vaccination programme has been implemented.

From discussions with public health doctors in Australia and New Zealand, it is clear that they are incredulous at our reluctance in Ireland to even consider a Zero Covid strategy.

Instead, we continue to find reasons to argue that an elimination strategy is unachievable in Ireland because of our “open economy” or the border with Northern Ireland, as if challenges of this nature in implementing Zero Covid were unique to Ireland.

Ideally, we would need agreement at the political level, with the Northern Ireland administration on an all-island Zero Covid strategy. We have worked effectively with Northern Ireland in the past to control foot-and-mouth epidemics in cattle and the Health Committee of the Northern Ireland Executive has already endorsed the principle of a Zero Covid strategy.

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There are good international models from Australia and other countries involving travel bubbles, permits and buffer zones on how the border with Northern Ireland can be managed. If an agreement with Northern Ireland cannot be secured, we should work as quickly as possible towards an agreement on an East-West Zero Covid strategy with the UK Government and the devolved administrations in Scotland and Wales.

Michael Baker (New Zealand Epidemiologist) and Martin McKee (Prof of European Public Health, University of London) have argued this week in the Guardian that it is the behaviour of governments, more than the behaviour of the virus or individuals, that has shaped countries’ experience of the Covid-19 crisis to-date.

While conscious of the challenges and the burden faced by the Government and senior policymakers in responding to this unique global pandemic, it is clear that we can do better.

If Ireland chooses to adopt Zero Covid as our national strategy, supported by Government leadership and buy-in from all sectors of society, there is a realistic prospect that we can get our lives back to normal by mid-2021 and we will reduce our exposure to delays and other setbacks with the implementation of an effective vaccination programme.

However, if we continue to settle for suppression of the virus, for “an acceptable level of infection”, the first Covid-19 winter in Ireland may not be the last.

Professor Ivan Perry is Professor Public Health and Dean of the School of Public Health at University College Cork. He is a founding member of ISAG – the Independent Scientific Advocacy Group on Covid-19.

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