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Prof Ruairí Brugha Four questions people have about Ireland's approach to Covid-19 right now

People need hope – but they also want answers about what’s happening with Covid in Ireland right now, writes Prof Ruairí Brugha.

PEOPLE NEED HOPE but they also want answers to questions. Firstly, is Ireland on track to control Covid-19. Secondly, why are we are being asked to go the extra mile over the next two months? Thirdly, why is what we have done – lockdowns, compliance with public health measures and among the highest vaccination rates worldwide – not sufficient? Were we sold a pup? And finally, as masks in primary schools are advised, are we dumping on our children?

Much of the anger and heat earlier on this week was about antigen tests; some of the public and media were as frustrated with decision makers as the Government appeared to be with NPHET. Some people will use antigen tests correctly (when they have no symptoms), potentially leading to modest but important reductions in Covid transmission – for example when used in advance of a visit to an elderly or vulnerable person.

Others will use them incorrectly (when they have symptoms), contributing to increased transmission if a negative test result is seen as permission-giving. These two outcomes might well cancel each other out. On balance, there is a good case and widespread demands for making more subsidised antigen tests available. But an antigen test, of itself, will not prevent Covid-19 transmission, which depends on people’s preceding and subsequent behaviour. So let’s turn to the bigger questions.

Is Ireland on track? 

Any residual doubt that prevention of unmanageable levels of hospitalisation requires a three-dose vaccine schedule has gone. A third shot can also reduce transmission. Ireland has shown that it can deliver high vaccination coverage rates – however, at 200,000 shots per week, it could take up to late-March to deliver the third shot to all previously vaccinated adults. This needs to be accelerated, focusing first on the vulnerable, which will be tricky. We need, but don’t yet have, a national register of vulnerable persons.

If we can provide the third dose by the end of January to all those over 40 years of age, we can suppress the worst of the pandemic, giving time for vaccines with longer-term effectiveness to be developed, tested and rolled out. So yes, there is good reason for hope; but only if we are willing to forego risky behaviours in the next two months, which would snatch away the hope for many.

Not just what, but why

That brings us to the second question, and the two consequences of not going the extra mile. It is no longer enough for the Government to tell us what we should be doing. Most of us know all that, even if some don’t comply. The answer to “why” matters a great deal.

Most of the vulnerable people who have yet to get their third vaccine shot live at home. Older people are well on the way to being fully covered with three shots, but those with underlying medical conditions are vulnerable to being infected by relatives and friends who are not willing to go that extra mile. Many could become seriously ill and some die, as a result.

The second consequence is the impact of the current pandemic wave on doctors, nurses and other health staff who treat patients every day. There are few if any others in society whose are willing to take such high levels of risk. Like most countries, we are blessed by having women and men who put their health and lives on the line each day without counting the cost.

Even if we feel immune to the complications of Covid, following two vaccine shots, we and our loved ones need a health service that can meet all of the other healthcare needs – timely cancer diagnoses and treatments, mental health services (partly because of the effects of lockdowns), and care for trauma, heart attacks and strokes.

Were we sold a pup? 

Thirdly, while frustration is understandable, we knew from the results of the various trials that the new vaccines would not prevent infections: that they would have a large effect on reducing serious complications and a smaller impact on transmission of the virus. Somehow, in the excitement of seeing vaccines developed, tested and rolled out in record time, the small print escaped us. Perhaps health authorities or politicians over-sold their benefits. Next time, let’s not oversell the benefits or under-estimate the challenges of achieving effective pandemic control.

We were also warned about the likelihood of variants from the start of the pandemic. The maths of the Delta variant is simple, but difficult to comprehend: in the absence of control measures, one person with the original Covid-19 virus could infect between 15 and 40 others, after three transmission steps, or a period of two to three weeks. One person with Delta could lead to around 250 further infections in the same period. 

Instead of reducing transmission of the virus by 70-80%, vaccination results in a more modest 50% reduction in Delta virus transmission. Yet many people who should know better feel they can dispense with masks in public indoor settings and in the stands at matches. The latest scare of a new variant, with the first European case detected in Belgium yesterday, is reason for them to rethink their behaviour. 

National decision makers – the Government, HSE and NPHET – have done most things well but have often been slow in initiating actions, most recently with the third dose of vaccines. More puzzling than the inertia in accepting the evidence on waning immunity was the delay in introducing mandatory mask-wearing (or at least masks as the norm) in primary schools. Requiring masks in secondary schools, where pupils can be vaccinated, but not in primary schools, where most children cannot be vaccinated, was counter-intuitive to the point of absurdity.

The rapid rise in Covid cases among 5- to 12-year-olds was evident by early October at a time when contact tracing in schools had stopped, which meant that the real rise in case numbers was being under-estimated. By the end of October, by which point a further review of the evidence on extending the use of masks to younger children had been suggested by the Covid Expert Advisory, case numbers had doubled.

Impact on our children 

So, finally, as NPHET advises that children nine years and older should wear masks in school and public indoor settings, are we dumping on our children? While there will be good reasons for some children not to wear them, negative effects of masks in younger as well as older children are for the most part negligible; and the ‘good enough’ evidence of their effectiveness has grown stronger in the last month.

Mask-wearing in schools and other congregated settings will reduce the impact of circulating airborne viruses on general practices and PCR testing centres. Unlike antigen tests, masks are a primary prevention tool that directly reduce virus transmission, reducing the need to determine if symptoms are due to COVID-19 or another infection. They directly benefit children by making it less likely to have to take time off school, because of symptoms and because of class and school closures. And a mask-wearing policy will give us the breathing space to roll out vaccines to 5- to 11-year-olds in the early months of 2022.

However, the question is rightly being asked: are we asking more of our children than our adults when we advise children to reduce socialising outside of school – justified as that advice is – but we don’t put the same expectation on adults?

Let there be no doubt about where lie the greatest dangers and the greatest need for consistent mask-wearing. They lie in pubs, restaurants and night clubs, where adults are least likely to wear them; and in the crowded stands of large sports events where clear advice and enforcement of mask-wearing is needed. If we are asking our children to step into the breach, for their and our benefit, they deserve more of adults.

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

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