Joint Committee on Health debate -
Wednesday, 12 Oct 2022

Long Covid and Monkeypox: Discussion

Chairman

The purpose of the meeting today is to discuss the issues of long Covid and monkeypox. To enable the committee to consider this matter, I am pleased to welcome from the HSE, Dr. Siobhán Ní Bhriain, national clinical director for integrated care, and Dr. Derval Igoe, specialist in public health medicine. I am informed that Dr. Ciaran Bannan, consultant in infectious diseases at St. James's Hospital, will be filling in for Dr. Catherine Fleming, consultant in infectious diseases and co-lead on the infectious diseases clinical programme. I also welcome from the HSE, Dr. Ciaran Browne, national crisis management team lead for monkeypox, and Professor Fiona Lyons, medical director, clinical lead, sexual health and crisis pregnancy programme.

I welcome everyone to the meeting. All those in the committee room are asked to exercise personal responsibility to protect themselves and others from the risk of contracting Covid-19. All witnesses are reminded of the long-standing parliamentary practice that they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable or otherwise engage in speech that might be regarded as damaging to the good name of the person or entity. Therefore, if any of their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that they comply with any such direction.

Members are also reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against persons outside the Houses or an official either by name or in such a way as to make him or her identifiable. I remind members of the constitutional requirement that they must be physically present within the confines of the Leinster House complex in order to participate in public meetings. I will not permit a member to participate where they are not adhering to this constitutional requirement. Therefore, any member who attempts to participate from outside the precincts will be asked to leave the meeting. In this regard, I ask members partaking via Microsoft Teams that, prior to making their contributions, they confirm that they are on the grounds of the Leinster House campus.

I invite Dr. Siobhán Ní Bhriain to make her opening remarks on behalf of the HSE.

Dr. Siobhán Ní Bhriain

Good morning. I thank the Joint Committee on Health for its invitation to discuss long Covid and monkeypox. The Chairman has already mentioned who I am joined by. I send Professor Fleming's apologies and thank Dr. Bannon for joining us at short notice. I will talk first about long Covid. The HSE launched its interim model of care for long Covid in September 2021. The model provides a framework for the provision of supports and services for those experiencing prolonged symptoms of Covid-19. The model is being implemented in a phased approach with each hospital group having access to both a post-acute and long-Covid service. This will deliver eight post-acute Covid clinics and six long-Covid clinics around the country. The following sites have post-acute Covid clinics: Mater Misericordiae University Hospital; Connolly Hospital Blanchardstown; St. James's University Hospital; Tallaght University Hospital; Cork University Hospital; University Hospital Limerick; University Hospital Galway; and Letterkenny University Hospital. Long-Covid clinics are established in Beaumont University Hospital; St. James's University Hospital; St. Vincent's University Hospital; Cork University Hospital; University Hospital Limerick; and Galway University Hospital. Both Tallaght University Hospital and St. James's University Hospital are operating combined post-acute and long-Covid clinics. Some of these clinics have been established in response to local population needs using existing resources and capacity. The HSE is working closely with each of the hospital sites to expand the existing clinics, where needed, to provide a full range of care. The HSE is also examining how existing services in the community can support those with post-Covid or long-Covid symptoms. The number of people that are affected with acute Covid and long Covid remains unknown, but published reports indicate that approximately 10% to 20% of Covid-19 patients experience lingering symptoms for weeks to months following acute SARS-CoV-2 infection. An epidemiological survey is being planned to provide insight and understanding into the prevalence of long Covid in the Irish population and risk factors for developing long Covid. It will also help to forecast future demand for services and will inform the direction of the model of care. The HSE has commissioned HIQA to review the evidence regarding long Covid, including models of care in other jurisdictions. This, along with additional research that will be conducted by the HSE, will inform the development of services and a review of the current interim model of care.

I will now move on to monkeypox. Monkeypox virus is found naturally in certain African countries. Prior to May 2022, monkeypox infection was rarely seen outside those endemic countries. Infection with the virus responsible for the current outbreak manifests as a mild illness and most people recover within weeks. However, it can occasionally cause severe complications, including death. Severe illness is more likely to occur in people with a weakened immune system, pregnant people and children. Following reports of cases of monkeypox infection in gay, bisexual and other men who have sex with men in Europe, a multisectoral, public health-led national incident management team was established to prepare for cases being identified in Ireland. This was the first time chains of transmission were reported in Europe without known epidemiological links to endemic countries in Africa. The HSE rapidly put in place laboratory diagnostic capacity; clinical patient assessment capacity; transport pathways; clinical and public health guidance documents; and channels for sourcing vaccine and anti-viral medication. Patient information resources and a communication campaign to ensure that individuals with suspected or confirmed monkeypox infection had timely access to the appropriate information and assessment were also put in place to ensure that the public and the workforce responding to monkeypox were protected. Contact tracing guidance was also developed, including the offer of post-exposure vaccination to close contacts deemed at significant risk of an infection. Mobile vaccination teams were deployed to administer vaccines to close contacts in the community.

In Ireland, the first case of monkeypox infection was confirmed on 27 May 2022. Since then, 194 cases have been identified, with 11 hospitalised. Cases are predominantly male and the mean age is 35. In July, the current global outbreak of monkeypox infection was declared a public health emergency of international concern by the WHO. The HSE focus is the roll-out of primary prevention vaccination to individuals likely to benefit most, in line with national immunisation advisory committee, NIAC recommendations. There are estimates that between 6,000 to 13,000 people will benefit from primary prevention vaccination. The HSE has commenced vaccinations of high-priority groups. In the context of limited vaccine availability, the chief clinical officer established a clinical advisory group to advise on the prioritisation categories for vaccination. Working with the Department of Health, to date over 2,000 vials of monkeypox vaccination have been secured. In August, the European Medicines Agency, EMA, advised that countries could administer the vaccine intradermally. This increases our ability to provide vaccination to identified priority groups. The HSE has provided primary vaccination to more than 300 people and post-exposure vaccinations to 160 people. On Monday, 17 October, the HSE will commence offering vaccinations through 11 designated centres across the country. Individuals will be asked to self-identify their risk for infection and, where they deem appropriate, to self-book a vaccine appointment. The aim is to complete vaccinations for high-priority groups between now and December. Two doses of monkeypox vaccinations are administered at least 28 days apart. The Department of Health and the HSE continue to procure additional vaccine stocks and are hopeful that further stocks will become available.

Communication to gay and bisexual men who have sex with men remains a critical part of our response, working in close relation with community organisations. Community partners developed an extensive communication campaign including washroom posters across Ireland; social media advertising; online and print advertisements in the LGBTQ+ press; video content to include monkeypox testing care; and a number of public and community leader meetings with members of the national crisis management team. The HSE has also funded HIV Ireland to provide a counselling and psychological support service for those affected. This concludes my opening statement. Go raibh míle maith agaibh.

Chairman

Go raibh maith agat Dr. Ní Bhriain. We are going to discuss monkeypox first. You said the EMA advised that countries would administer the vaccine intradermally. What does that mean?

Dr. Siobhán Ní Bhriain

It is the way it is administered. Administration of medication can be under the skin or into a muscle. Generally, if you can give it intradermally, you can get more doses. I will ask one of my colleagues, Professor Lyons, to comment on that.

Chairman

It is a technical term. I have not come across it before.

Professor Fiona Lyons

It is delivering the vaccine between the layers of the skin. If anyone has ever had a Mantoux test for tuberculosis in the past, they may remember. It is like a little bee sting. As we do not use Mantoux testing any more, the skills for doing intradermal administration are not as widespread within the health service as they were previously, because they are not used that often. The EMA advised that it would give us the opportunity, in the context of limited supply of vaccine, to administer vaccine to more people. We gained the possibility of administering vaccine to more people, as opposed to giving it under the skin. Subcutaneous administration involves a small needle under the skin, usually up in the arm. Intradermally is in the forearm, in the volar aspect of the forearm, in between the layers of the skin.

Chairman

That is great. I thank Dr. Lyons for the explanation for the layman, including me. I welcome Senator Buttimer, who is substituting for Senator Kyne.

Senator Jerry Buttimer

I thank Senator Conway for allowing me to contribute first and the committee for its indulgence. I thank Dr. Ní Bhriain for coming before the committee this morning.

I am a member of the lesbian, gay, bisexual and transgender, LGBT, community and am involved with our group in the Oireachtas as well. I welcome a number of points, including that the category of people who will be vaccinated will be broadened, as well as the intradermal route of administration.

I am disappointed with the overall reaction of the HSE and the Department of Health to this crisis for a number of reasons. First, the roll-out of the primary prevention vaccination has been far too slow. Second, I do not see any evidence we have increased our availability of supply. Compared to other European countries, we lag behind in supply. I have three questions about the decision to start on 17 October 2022. Why wait until that date to begin? I raised a Commencement matter in the Seanad with the Minister on 20 September. I received almost the same reply today as I did then regarding what we are doing as a country. We do not seem to have increased the supply. Can Dr. Ní Bhriain answer the point first and then explain the start date of 17 October? As regards the risk group, has the HSE considered using the pre-exposure prophylaxis, PrEP, list for example?

Dr. Siobhán Ní Bhriain

I thank the Senator for his comments. I will ask a number of my colleagues to respond. I ask Dr. Igoe and anyone else who wishes to contribute to talk about primary prevention. I ask Dr. Browne to answer the question about the lack of evidence of increased availability. I ask Dr. Lyons to comment on why we are waiting until 17 October and if Dr. Igoe also wants to contribute on that, that will be fine. I ask Dr. Browne to discuss the issue of supply chains and Dr. Lyons to comment on PrEP. I will hand over to Dr. Igoe first to comment on primary prevention.

Dr. Derval Igoe

I will speak about two aspects of primary prevention, namely, behaviour change and harm reduction and pre-exposure vaccination or prophylaxis. Regarding primary prevention and communicating risk, this disease has been overwhelmingly within the gay, bisexual and men who have sex with men, gbMSM, community. We have worked hard from the beginning to work in partnership with gbMSM representatives, including the Gay Health Network, GHN, and the MPOWER programme. Initially the focus was awareness of this disease, the symptoms and the need to present early for treatment. The next step focused not only providing treatment for the patients, in terms of care, but also identifying others who may be at risk having been exposed to them and providing post-exposure vaccination. That has been happening for quite a while.

More recently the focus is not only on awareness of the disease but also on some changes in behaviour that people might make to reduce their personal risk of infection pending vaccination. Quite a systematic campaign was outlined in the opening statement, using a variety of media channels, outreach in venues etc. employing an approach adopted from America which is like a traffic light approach that indicates behaviours according to higher or lower risk in order for people to be able to avoid certain behaviours that might put them at increased risk. That has been rolled out comprehensively within the community.

The second part is pre-exposure prophylactic vaccination that is now the focus of the vaccination programme. There are two focuses: the post-exposure vaccination which started as soon as was possible when we first got cases in Ireland and we are now planning for the roll-out of the pre-exposure vaccination. It has been taken in a couple of phases. First, we focused on people with a history of early infectious syphilis, identified them quickly and tried to vaccinate them and now we have widened the criteria. With regard to-----

Senator Jerry Buttimer

Could Dr. Igoe explain what will be done in respect of widening the criteria? Who will be vaccinated or what criteria will be applied? At the moment it is syphilis and then we do not seem to know where we are going as regards the communication. I welcome the extension to the 11 designated centres. Where will they be located?

Dr. Siobhán Ní Bhriain

I will ask Dr. Igoe to address the first part of the Senator's question and then I will ask Dr. Browne to answer the second part.

Dr. Derval Igoe

As my colleague mentioned, a clinical advisory group was convened to determine who the criteria should be widened to include. The group we are calling 1B comprises those who are determined to be at highest risk of exposure. They are defined as non-monogamous gay, bisexual and other men who have sex with men and transgender women who have sex with men who self-report one or more of the following: bacterial sexually transmitted infection or primary genital herpes within the past six months; sex in a sex-on-premises venue such as a sauna, dark room, sex club etc. within the past six months; a person who has had group sex within the past six months; or a person who has had three or more sexual partners in the past three months. People can self-refer if they feel they have had those exposures and therefore are at high risk of exposure to the disease.

Senator Jerry Buttimer

Can Dr. Browne answer on the locations and communication?

Chairman

I am conscious of time but I will allow as much information as possible to be shared as it is important for this morning's meeting that we get as much information out to the public so the witness might share where the clinics will be located and I will move on.

Dr. Siobhán Ní Bhriain

I will hand over to Dr. Ciaran Browne who will talk about the supply issue the Senator raised and the location of the clinics.

Dr. Ciaran Browne

I will answer specifically on the centres. There will be 11 centres in Ireland to include three sexual health services in Dublin, in addition to Citywest and Croke Park as our CVCs. Wexford, Portlaoise, Cork, Galway-----

Deputy Róisín Shortall

What are CVCs?

Dr. Ciaran Browne

I apologise, CVCs are Community Vaccination Centres. We are putting the capacity in place both through our sexual health services and our community vaccination centres. The three sexual health services in Dublin are in the Mater, St. Vincent's hospital and St. James's Hospital. The CVCs include those in Croke Park, Citywest, Wexford, Portlaoise, Cork, Galway and Limerick. There will be 11 centres nationally.

In respect of the supply issue, at the start of this, the HSE working with the Department of Health tried to secure as much stock as we could. We immediately procured 660 vials of the vaccine and then a further 1,400 arrived. We were trying to procure stocks in the context of a global outbreak and many different jurisdictions were trying to procure stock at the same time. The Department of Health and the EU did a lot of work to try to procure additional stock and we are hopeful it will arrive in the future.

When we commenced the first phase of vaccinating the early infectious syphilis group, the administration of the vaccine had to be done subcutaneously, which meant we used up the stock very quickly. In late August when we were planning this, the intradermal application of the vaccine became available and that was an opportunity to spread the vaccine but it necessitated us stepping back and trying to plan. Previous to that, we would not have been able to use the CVCs as much. Hence we had done a lot of operational planning. The Senator can appreciate administering a vaccine like this safely to a large cohort necessitates a huge amount of operational planning about how we will provide it, the information we will give out, how people will book and importantly, how the dose will be recorded because it is a two-dose regimen. It is therefore important to track who has received the first dose and who has received the second dose. We are as anxious as everyone to ensure we start vaccinating the community as quickly as possible and we have done a lot of work in partnership with them and to keep them updated on our plans.

Senator Jerry Buttimer

I thank the Chair for his indulgence and I thank the committee for letting me go first.

Deputy David Cullinane

I thank the Cathaoirleach and I welcome the witnesses. My questions are quite specific so I do not wish everybody to answer them just the relevant person. If it is Dr. Ni Bhriain, that is fine. I am looking for information in the first instance. Dr. Ni Bhriain stated that 194 cases of the monkeypox virus have been notified so far and that there have been 11 hospitalisations. Is the position likely to have been understated? Would it be the case that there may be some people who are infected and about whom the HSE may not have been notified? Is it likely that number is at the lower end of how many are actually infected?

Dr. Siobhán Ní Bhriain

I will ask Professor Lyons to answer that question.

Professor Fiona Lyons

I thank Deputy Cullinane. From the outset, Ireland adopted, very appropriately, an approach of having a sensitive case definition. By that we mean that the criteria to have testing were set at a low bar in order to enable good, sensitive case ascertainment. The case definition was set at a level that should allow us to identify people to come forward for testing. I do not believe that the case definition has had an impact on our ability to have cases undiagnosed. There is no denying that at the beginning of this outbreak some of the stuff seen on social media would have probably made it very scary for individuals to come forward. There was some pretty nasty stuff put forward on social media. We worked with our community colleagues in the context of getting a very robust communication plan out to the LGBTQ-----

Deputy David Cullinane

Is Professor Lyons confident the figure is fairly accurate?

Professor Fiona Lyons

I am, yes.

Deputy David Cullinane

Very good. Have projections been done to establish what the best- and worst-case scenarios might be in the context of this outbreak?

Dr. Siobhán Ní Bhriain

Is Dr. Igoe happy to answer that question?

Dr. Derval Igoe

Yes. What we are finding in Ireland is that the number of cases in August was higher than the number of cases in September. We are on a slight downward trajectory. That is similar to what has been found in the United States, in Canada and in Europe overall. As to why that is happening, the view is that it is a combination of approaches. It is a combination of vaccination and changes in behaviour. If it is the case that there are smallish dense networks, people might have developed some natural immunity. Those are the three theories as to why it is decreasing. That is not to say that this will continue in the future. Our understanding is that this is overwhelmingly within the gbMSM community. If that continues within the community and there is no spread outside it - and there is no evidence of that - then we would not see cases in other populations.

In America they had the opportunity to look at people's behaviours systematically and they found that 50% of people had changed their behaviour as a result of monkeypox. Behaviour change is also a factor. If behaviour change is sustained, if the vaccination programme progresses and goes well and if the outbreak stays within the gbMSM community, I do not see a big escalation.

Deputy David Cullinane

That answers the question. In terms of the vaccination roll-out, when the witnesses say there are 2,000 vials. Is that 2,000 doses, or how many doses would that figure represent?

Dr. Ciaran Browne

If we use the subcutaneous method, as we explained previously, that would be 2,000 doses. Is it a two-dose regimen, however, so that would be 1,000 courses-----

Deputy David Cullinane

It would be 1,000 people.

Dr. Ciaran Browne

Exactly.

Deputy David Cullinane

Only 1,000.

Dr. Ciaran Browne

If we can exploit the intradermal route, we sometimes see three, four or five doses out of one vial.

Deputy David Cullinane

There is stock for 1,000 people to be vaccinated. How many have been vaccinated up to now?

Dr. Ciaran Browne

From yesterday's figures, there has been 400-----

Deputy David Cullinane

Was it 300?

Dr. Ciaran Browne

According to our latest information, it is 415.

Deputy David Cullinane

And it is estimated that between 6,000 and 13,000 people would benefit.

Dr. Ciaran Browne

Yes.

Deputy David Cullinane

So we are a long way away from that.

Dr. Ciaran Browne

If I might explain, using the intradermal route and the stock of 1,400 we have allows us to offer vaccines to many more people. We are hopeful that more stock will arrive in the near future. At the moment, we are commencing on the basis of vaccinating through the self-booking portal.

Deputy David Cullinane

We cannot plan on the basis of hope. We can only plan on the basis of what we will actually have.

Dr. Ciaran Browne

Yes.

Deputy David Cullinane

When Dr. Browne says that it is hoped to increase the stock and secure more doses, what is the anticipated pipeline?

Dr. Ciaran Browne

We anticipate to hopefully vaccinate 2,200 people over the next few months. If additional stocks come in, that will allow us to extend vaccination to other-----

Deputy David Cullinane

Dr. Ni Bhriain stated that the estimate is that between 6,000 and 13,000 people will benefit. Even if the target of 2,200 is reached, it is a long way from that. Is it purely down to availability and the fact that we simply cannot get enough?

Dr. Ciaran Browne

Yes, and our approach is to then offer the vaccination to the risk groups we have identified. Deputy Cullinane is correct-----

Deputy David Cullinane

Within that community of 13,000 individuals who are at risk, even at the maximum, only a fraction of those people will be offered a vaccine in the short to medium term.

Dr. Ciaran Browne

Yes, unless we get additional stocks, which we are hopeful will happen.

Deputy David Cullinane

Even with the hope, we are talking about 2,200.

Dr. Ciaran Browne

It is up to 6,000. Do not forget that if we get additional stocks in, we will use the intradermal application. That allows for an expansion of the actual number of vials into a larger cohort of the population. We hope that if we get those additional stocks, we could be vaccinating up to 6,000 people.

Deputy David Cullinane

Okay.

Dr. Ciaran Browne

That is not the 13,000, but we do not know what the uptake rate will be.

Deputy David Cullinane

I thank the witnesses and wish them well with their work.

Chairman

Are we getting the stock through the EU or separately?

Dr. Ciaran Browne

It is through the EU.

Deputy Róisín Shortall

I thank the Chair. I the witnesses for coming in and for their presentation. I echo points made earlier by the first speaker in relation to us being slow to gear up to meet the need in this area. The first case here was identified in May. A public health emergency was declared in July. There was not a lot happening after July, publicly anyway, whatever about what was going on behind the scenes. However, I welcome the information in the opening statement about people being able to self-identify as being at risk, the opening up of facilities and the apparent gearing up that is happening. All of this is determined by availability of vaccines. I was somewhat confused by Dr. Browne's comments regarding the possibility of getting three, four our five doses from a vial. Why is there a variable in this regard?

Dr. Siobhán Ní Bhriain

There are a lot of important points here. I would like to bring Professor Lyons in on the issue of communications.

Deputy Róisín Shortall

I am sorry, my time is very limited.

Dr. Siobhán Ní Bhriain

Apologies.

Deputy Róisín Shortall

I want an answer to my question on why it is not a definite number.

Professor Fiona Lyons

As Dr. Browne already alluded to, they come in a 1 ml vial. It is ordinarily used by means of a subcutaneous route where you extract the entire 1 ml.

Deputy Róisín Shortall

Yes, I know.

Professor Fiona Lyons

In order to get 0.5 ml to try to get five doses out of a vial, a particular needle and syringe has to be used, which we had to source and have been sourced. There is not a guarantee of actually getting five out. It is a fiddley thing is the best way to describe it. The experience has been that people are mostly getting about four doses out per via,l but there are some circumstances where there were it may be three. In some circumstances, it may be up to five. It is literally that we are using a vial that was only ever meant to be for extracting one dose, dividing its contents into five and trying to get as many as possible out of it. That is why there is the range of around three to five.

Deputy Róisín Shortall

Is the vaccine mixed with any other substance to-----

Professor Fiona Lyons

No, not at all.

Deputy Róisín Shortall

It never is.

Professor Fiona Lyons

No.

Deputy Róisín Shortall

That is okay. I was just wondering.

Professor Fiona Lyons

No, absolutely not.

Deputy Róisín Shortall

Is that best practice?

Professor Fiona Lyons

That is what-----

Deputy Róisín Shortall

Professor Lyons has said that it is fiddley. Has nobody come up with a solution for that?

Professor Fiona Lyons

We were very lucky that from the very beginning of this outbreak we have been able to work collaboratively, nationally and internationally. We would sit on many international groups to try to learn from the experience of others and learn from each other. It is best practice in the European Medicines Agency has indicated that in the context of limited supply of vaccines, we should consider adopting this route. The Chief Medical Officer has instructed a review on that following NIAC's recommendation on that.

Deputy Róisín Shortall

Okay.

Professor Fiona Lyons

At this time, in the context of limited vaccine supplies, it is best practice.

Deputy Róisín Shortall

I thank Professor Lyons. She said that there are currently 11 people in hospital. Typically how long does a hospital-----

Professor Fiona Lyons

No, 11 people have been hospitalised.

Deputy Róisín Shortall

Have been hospitalised.

Professor Fiona Lyons

Yes, have been hospitalised since the beginning.

Deputy Róisín Shortall

Okay, 11 people have been hospitalised. Typically, how long is a hospital stay?

Professor Fiona Lyons

There is no typical stay because some of the individuals involved have not had a medical requirement for hospitalisation. It has been primarily because they have not been able to safely isolate within their homes. We have been able to manage most of the individuals who have been infected in their homes.

The admission could be very short and range from a number of days up to a couple of weeks. We have had a couple of patients who have been in hospital with us for a number of weeks.

Deputy Róisín Shortall

Okay, but the HSE now has a facility for people to isolate.

Professor Fiona Lyons

Yes.

Deputy Róisín Shortall

Okay. What is the capacity of that facility?

Dr. Ciaran Browne

That is 45 beds, as far as I am aware. The Deputy is right. It is a community isolation facility that is already operational.

Deputy Róisín Shortall

How many of those 11 people would have been in for other reasons apart from isolation?

Dr. Derval Igoe

Would it be okay if I came in on that? To clarify, basically, 11 people have been admitted to hospital for reasons of their medical care. There have been 19 people hospitalised, two of whom we know were admitted for isolation purposes only.

Deputy Róisín Shortall

There was a bit of noise. I missed the first point Dr. Igoe made.

Dr. Derval Igoe

I beg your pardon. I will repeat it again.

Deputy Róisín Shortall

Just the numbers.

Dr. Derval Igoe

To date, 19 people have been hospitalised. Of those, seven were admitted for clinical care related to monkeypox. We know two were admitted for isolation purposes only. This would have happened very early on in the evolution of this epidemic. We do not have information on the other six yet. For our knowledge, however, 11 people have been hospitalised requiring clinical care. We do not have information on the duration of hospitalisation at the moment.

Deputy Róisín Shortall

That is surprising given the numbers are so low. I would have thought there would have been information on that. I want to move on to the membership of the strategic advisory group. There are 16 people on it, 15 of whom are doctors, along with one press and communications person. What is surprising is that there are no nurses on that advisory group. Why is that the case?

Dr. Ciaran Browne

The Department of Health is the leader of the strategic advisory group. It put the composition of the strategic advisory group together. Is the Deputy referring to the national crisis management team?

Deputy Róisín Shortall

No, I am not. I am referring to the membership of the strategic advisory group.

Dr. Ciaran Browne

That is led by the Chief Medical Officer. The HSE obviously participates in that committee but the composition of that group was put together by the Chief Medical Officer and the Department of Health.

Deputy Róisín Shortall

Okay. Does Dr. Browne think it would it benefit from the presence of nurses?

Dr. Ciaran Browne

I do not know if anyone has a comment in that regard.

Deputy Róisín Shortall

Okay. I want to get back to the question of the number of doses that are available. As I said, I welcome the fact that people can now self-identify their risk. What happens then when the current availability runs out? The HSE is saying it has 6,000 doses, at best, at the moment, and that the target is up to 13,000. What happens then? When does the HSE expect that to happen in the absence of additional doses being available?

Professor Fiona Lyons

That will depend on a number of factors. When we will run out depends on what the uptake is like. Based on a survey in which people in Ireland participated, there was an anticipated acceptance of offer of approximately 85%, which is a very high uptake rate. Our experience thus far within people who have been invited forward for vaccines as opposed to self-booking for a vaccine is that it has not been that high. It has been between 50% and 70%, varying over certain clinic times.

The acceptance rate in terms of how many people will accept the offer of vaccination is one thing that will determine how quickly we will run out of vaccines. The important thing is to communicate. As Dr. Igoe indicated, we have already seen a change in the trajectory of the numbers with the combined prevention health promotion and health protection approach that has been adopted and communicated to people who may be at risk of infection. That will need to continue in the setting of limited access to vaccines.

Like with any outbreak response, the vaccines are not the only part of the response. They are an important component of the response but not the only part of it. Therefore, an important thing will be to support individuals, and this has been stated within the communications plan, who may be at risk and who do not have access to vaccines in mitigating their risk of acquiring-----

Deputy Róisín Shortall

The HSE's estimate is that up to 13,000 people would benefit.

Professor Fiona Lyons

They are just estimates.

Deputy Gino Kenny

I thank everybody for their presentation this morning. I have a number of questions, the first of which is with regard to deaths globally in respect of the virus. Do the witnesses have any figures to hand regarding those who have succumbed to this virus?

Dr. Derval Igoe

I thank the Deputy. Yes, with regard to the number of deaths, the WHO only yesterday reported on the total number of cases, which is more than 71,000. In that context, there have been 26 deaths in the current year.

Deputy Gino Kenny

There have been 26 deaths globally this year.

Dr. Derval Igoe

That is globally, yes.

Deputy Gino Kenny

Incrementally, what were the figures globally for the number of people who got infected with monkeypox this time last year?

Dr. Derval Igoe

Basically, within the non-endemic countries, we would not really have had any cases at all to speak of. I will give the Deputy the figures. There were approximately 626 cases in endemic countries this year. It is perhaps important to say the deaths have been disproportionately in the endemic countries as opposed to the non-endemic countries, even as part of this outbreak this year. In non-endemic countries, there have been 26 deaths but in endemic countries, there have been-----

Deputy Gino Kenny

Endemic countries are where it is-----

Dr. Derval Igoe

This is where the disease can be found generally. For example, this would generally be countries in central or western Africa.

Deputy Gino Kenny

Okay. Incrementally, the virus and the number of those who have been infected has increased.

Dr. Derval Igoe

Yes, definitely. What happened in May of this year was very unexpected in that there has been in recent years the sporadic imported case from somebody who was in a country where the disease occurs, and who maybe travelled to England or America and became ill and was then identified. That had happened. What was extraordinary this year was that, in May, people were identified with monkeypox who had no travel links to the country in which it occurred and where it does happen. This was extraordinary in that it was not associated with a country that has occasionally gotten cases of monkeypox.

Deputy Gino Kenny

Why does Dr. Igoe think that is the case?

Dr. Derval Igoe

Nobody knows for sure. What possibly happened was that a person had a link to an endemic country and then, within a smallish population where there are quite a lot of links, a seeding event or several seeding events happened whereby that person was in touch with other people within that community who then became infected. There were probably what we would call chains of transmission that were undetected at that time. The second thing that was unusual in May of this year was that the clinical manifestation and severity of the disease was milder than what would have been recognised in Africa.

Deputy Gino Kenny

I am guessing that beforehand, those who presented with monkeypox may generally have come from that particular area-----

Dr. Derval Igoe

Exactly.

Deputy Gino Kenny

-----and that dynamic has now slightly changed in that they did not visit that part of the world.

Dr. Derval Igoe

Exactly. The vast majority of cases and all the cases in the current outbreak we have now do not have any link with the countries in which this disease is found regularly.

Deputy Gino Kenny

Okay. In what way does Dr. Igoe think stigma is a factors with regard to people coming forward and possibly getting the vaccine, in some cases, having perhaps been infected with monkeypox? Is this a factor? Obviously, this was a major factor during the 1980s and 1990s with regard to HIV, and still is, to a certain extent. What kind of effect does that have?

Dr. Derval Igoe

Obviously, stigma could be a factor.

We recognised that it is very important to work in partnership with colleagues and workers within NGOs that actually work with the gbMSM community to make sure that there is good awareness of exactly what the disease is, how people can be helped and what the benefits of the vaccine are. Colleagues have been part of the response right form the very beginning, and are a key part of the response now in encouraging their peers to get vaccinated, and in knowing who should come forward now that this new phase has been announced. We recognise nationally that there is a risk of stigma. Indeed, it has also been recognised by the WHO and other colleagues internationally. It is most important that we work together to avoid that. We can avoid that by ensuring that the key population that is currently affected is fully part of the response, which I think it is, in fairness.

Deputy Neasa Hourigan

Apologies for being slightly late. I was doing the school run. I would like to return to the isolation issue. I am aware that the isolation requirement for monkeypox is different from that of Covid. Can the witnesses outline the isolation time periods?

Professor Fiona Lyons

The time period is variable depending on the presentation that the person has. Generally, speaking, if a person has skin lesions they need to separate themselves from their household and sexual contacts until all the skin lesions have healed. A bit like in the case of somebody who has chicken pox, until the lesions have healed, scabbed and the scabs have fallen off, they must isolate from household contacts during that time. If a person has lesions on a part of the body that is covered, he or she may be able to come out of isolation when no new lesions are appearing, before everything has healed over. If an individual has lesions on the face or hands that could come into contact with somebody in normal social interactions such as shaking hands or having a cup of coffee together, he or she must wait. The point I am trying to make is that it is quite variable. By the time some individuals have their diagnosis of monkeypox, they may be very close to resolution. The range of symptoms that people present with is quite variable. Some people may just have one lesion, whereas some individuals may have very extensive lesions involving many parts of their body.

Deputy Neasa Hourigan

Is guidance on a number of days' isolation being provided?

Professor Fiona Lyons

Absolutely.

Deputy Neasa Hourigan

What number of days is specified in the guidance?

Professor Fiona Lyons

It is very individualised. It is an indiviualised guidance. From the beginning, most patients who have unfortunately been infected with the virus have been able to stay at home and have been able to be managed at home in the community with support from the clinician who is looking after them at home. That discussion around when they come out of isolation is made in conjunction with the clinician who is providing them with support at home.

Deputy Neasa Hourigan

I suppose what I am trying to get at-----

Professor Fiona Lyons

It is not black and white.

Deputy Neasa Hourigan

-----is that it is not like Covid,-----

Professor Fiona Lyons

No.

Deputy Neasa Hourigan

-----where we were telling people that if they tested positive they should isolate for seven days or 14 days.

Professor Fiona Lyons

That is correct.

Deputy Neasa Hourigan

So, individuals are not being told to isolate for 28 days or anything like that?

Professor Fiona Lyons

That is correct.

Deputy Neasa Hourigan

So it requires medical guidance?

Professor Fiona Lyons

It requires an interaction between the patient and his or her clinician.

Deputy Neasa Hourigan

Are people being provided with sick certificates for that?

Professor Fiona Lyons

Yes.

Deputy Neasa Hourigan

I do not want to use the word "struggling", but considering that we are negotiating the procurement of vaccines, is isolation particularly important in terms of prevention?

Professor Fiona Lyons

It is am important part of the jigsaw puzzle in prevention. Therefore, we need to support people to be able to safely isolate.

Deputy Neasa Hourigan

Could Professor Lyons expand on that? How would she characterise supporting people so that they can isolate?

Professor Fiona Lyons

Deputy Kenny talked about stigma just before Deputy Hourigan came in. There is no doubt that there is potentially quite a big stigma associated with having this infection for individuals in the gbMSM community. In looking after people who are at home, we phone them. In the beginning, we were phoning them every day to see how they were physically, and depending on how they were doing, we would phone them more frequently or less frequently. What became apparent very early on was that they had quite a lot of psychosocial support needs as well. That is why the HSE has funded psychosocial and psychological support for individuals who are experiencing monkeypox infection and the stigma or the social isolation associated with that. Through the MPOWER programme, individuals can provide their phone number and they will be contacted to avail of the service which is now funded by the HSE and run by peers within the community.

Deputy Neasa Hourigan

Would it be fair to say that because of the group that this affects, patients might be more likely to be living in shared housing or might be part of a younger cohort?

Professor Fiona Lyons

That has certainly been the case for a number of individuals who have been infected with monkeypox thus far, which is why, in the very early days, we recognised this as a challenge. That is why the isolation facility has been established, so that people can safely isolate in an appropriate setting to protect other individuals in their household from being infected.

Deputy Neasa Hourigan

I know that it is not really the Professor's area, but it is worth saying for the record that there are financial barriers to people isolating if they are in precarious work as well. We are not supporting people financially the way we did during Covid.

Professor Fiona Lyons

Yes, and we have raised that with the Department of Health.

Deputy Neasa Hourigan

That has been raised.

Professor Fiona Lyons

Yes.

Deputy Neasa Hourigan

I have raised that and will continue to do so. It does not seem very clever to me not to be supporting people in every way that we can. Financial barriers for people in precarious work is a major issue. I want to get one more question in before my time runs out. What funding package is in place for the next round of communications in which people will be asked to self-identify for vaccination? Has the HSE received a new funding package for that? It is a new strategy that the HSE is undertaking in asking people to self-identify for vaccination.

Dr. Siobhán Ní Bhriain

I think it is important to mention that the communications process is very much peer-led with this community. There are already very strong links with the community.

Deputy Neasa Hourigan

I am aware. I am aware that the representatives of the HSE have met with stakeholders, because I have also been talking to them. It is not the job of those NGOs to communicate with their peer group. It is the job of the HSE to make sure that all of the information is out there. I am asking if the Government has provided the HSE with a separate funding package for this new round of communications.

Dr. Ciaran Browne

We have funded those organisations to support us in the communications process.

Deputy Neasa Hourigan

What is that funding package?

Dr. Ciaran Browne

I will come back to the Deputy on that. I do not know the figure off the top of my head.

Deputy Neasa Hourigan

I would love to know that number. I thank the witnesses.

Deputy Colm Burke

I thank the witnesses for attending. Apologies for not being here for the presentation. Unfortunately, I was speaking in the Dáil at the same time that the witnesses were presenting, but I have gone through the notes. On long Covid, the witnesses mentioned in the presentation that between 10% and 20% of people have ongoing problems for a number of months after getting Covid.

Chairman

Sorry, Deputy, we are discussing monkeypox.

Deputy Colm Burke

My apologies. Can the Chairman move to the next speaker?

Chairman

Yes. I call Senator Conway.

Senator Martin Conway

Briefly, do the witnesses accept that the HSE was somewhat behind the curve in comparison to other countries? For example, in France, individuals can book a vaccine appointment through an app and can even get vaccinated in a pharmacy. Here, it seems that the service has been delayed, is cumbersome and the HSE has been slow to react. Do the witnesses accept that in hindsight, that is the case?

Dr. Siobhán Ní Bhriain

I would have to say that I think our response was actually very swift and rapid. The vaccine is readily available to the community.

Dr. Ciaran Browne

When we initially started, we had a very limited supply of vaccine. Part of the issue for us in rolling out a vaccination programme was direct access to stock. We commenced vaccinations in early September-----

Senator Martin Conway

Do the witnesses accept that the HSE response was slow, because of circumstances beyond its control?

Dr. Ciaran Browne

Yes, we accept that we would have rolled out the vaccination programme sooner if we had available stocks.

Senator Martin Conway

Good. I am just trying to get my head around this. What is the difference between Ireland and France, a country in the EU, where individuals can book vaccination appointments on an app and avail of them through the pharmacy? It is a member of the EU, as we are. Where is the missing link? How come its service is so swift, ready and accessible, but in this country it seems to be slow, cumbersome and delayed?

Dr. Ciaran Browne

I cannot speak to what the French jurisdiction had in terms of access to vaccines. We have been working very closely with the Department of Health to secure as much stock as quickly as possible in the procurement of the vaccines that we have obtained.

Senator Martin Conway

Following on from Deputy Hourigan's point on communications, I think it is very worrying that the HSE is looking for new streams of funding for communications. Surely, the communications and health messaging for monkeypox is so important that the HSE should not have to look for new streams of funding. Surely it should be readily available and the HSE should be proactive as opposed to somewhat reactive?

Dr. Siobhán Ní Bhriain

I will bring my colleague, Professor Lyons, in on this, but I think it is very important to state that there is a very strong communications system with the community that is already extant, which has already been used to support communications for monkeypox. Perhaps Professor Lyons would like to comment on that.

Senator Martin Conway

Before she does, in hindsight, again, would the witnesses accept that the HSE's communications to date on this issue have been off the mark?

Dr. Siobhán Ní Bhriain

Our communications have been very focused on the affected community from very early on. I ask my colleague, Professor Lyons, to comment on that.

Professor Fiona Lyons

Having had experience of dealing with outbreaks of other infections over the years, what works best is when there is multi-sectoral involvement. Under Dr. Igoe, who chaired the incident management team, and subsequently under Mr. Browne's direction of the national crisis management team, the community has been involved from day one. The WHO has acknowledged the efforts Ireland has made to ensure communication is sensitive and responsive. As an example of that responsiveness, in the context of stigma and the concern about individuals coming forward for testing, one of the things we heard in feedback from the community, which we got because we have been so engaged with the community since the beginning of this, was that people were scared to come forward for testing. In response, we got two doctors, one who speaks Brazilian Portuguese and one who speaks English, to make a video that went up on YouTube to debunk some of the myths that may have been out there among the community and inform individuals on what to expect. The communication to the community has been very targeted, nuanced and responsive. We have very much engaged in a collaborative team approach.

Dr. Igoe may wish to add to that.

Dr. Derval Igoe

Key to our approach is that it did not just begin on day one. There have been very strong relationships between public health, sexual health services and the relevant NGOs. We communicate around sexual health issues on a regular basis. When it came to communicating about monkeypox, it was not a question of starting from zero. That is all I would add to what Professor Lyons said.

Senator Martin Conway

Am I right to conclude from what the witnesses are saying that they would do nothing different if they were doing it all over again?

Professor Fiona Lyons

Is the Senator referring to the communications perspective?

Senator Martin Conway

Yes.

Professor Fiona Lyons

I think our communication has been good.

Senator Martin Conway

I thank the witnesses.

Senator Frances Black

I thank the witnesses for their presentation. I am sorry for being late to the meeting, which happened because I had some technical problems. I hope my questions do not repeat points that have already been covered.

As I am sure the witnesses are aware, news of the monkeypox virus has really triggered fear in a large number of people, many of whom are still trying to overcome the anxieties of the Covid-19 pandemic. There probably are many false narratives circulating in regard to monkeypox. What steps will the witnesses take to dispel those rumours and false narratives?

Dr. Siobhán Ní Bhriain

Professor Lyons and Dr. Igoe have answered some of the questions on the communications issue. We have emphasised the importance of direct communication with the community, part of the purpose of which was to help reduce stigma. The Senator is absolutely right that this is a sensitive area and we have been very focused on reducing stigma. I ask Professor Lyons and Dr. Igoe to come in with any additional comments they wish to make on how we are managing that issue.

Professor Fiona Lyons

We have sought to be proactive, responsive and nuanced to the needs of the affected community and we have taken a team approach to that. This has involved getting feedback from the community around where the needs are, what the questions and fears are and trying to ensure we get messages out to people that debunk the myths and ensure individuals are not afraid to come forward for assessment and testing as they need it. A really important part of the communication has been to get the message across that when people have an opportunity to self-book for vaccination, they will not be asked to declare their risks. This will be a self-identification process and those risks will be captured nowhere. That is a really important part of ensuring people do not feel stigmatised in this regard.

We have developed community well-being assessments and services and are providing care for individuals with monkeypox infection who are isolating at home. The HSE-funded empower psychological supports provide individuals with a number to contact if they are experiencing a lot of distress, which is something that we all, as clinicians, have identified if we have been calling people over a weekend, say, to see how they are doing from a clinical perspective. We have noticed they are struggling sometimes with the social isolation and perhaps some stigma they are experiencing by virtue of having the infection. That is why the community and psychological supports were put in place for those individuals.

I have nothing further to add other than to reiterate our approach has been very nuanced, responsive and proactive.

Dr. Derval Igoe

Working within the community, using many channels of communication and availing of the different ways in which people hear messages, is one important aspect of our outreach. People are in venues speaking to individuals where they are at and allaying their fears. Using a variety of channels for communication within the community is important.

Professor Fiona Lyons

An important point is that for some individuals who have been infected with monkeypox, English is not their first language. Ensuring the information is available to people in other languages has been an important part of our communication. We are fortunate to have within our teams individuals who speak Brazilian Portuguese, which has been invaluable to our communication campaign.

Senator Frances Black

That is good to hear. If there are people listening to this discussion today who suspect or are fearful they might have monkeypox, what advice would the witnesses give them and what would they tell them is the first thing they should do?

Dr. Siobhán Ní Bhriain

I ask Professor Lyons, who is our clinical expert on this, to respond.

Professor Fiona Lyons

There is a lot of information available to people in a variety of languages on the hpsc.ie website. A link to information on monkeypox is one of the scrolling items on the homepage and if users click into it, they will find a variety of information sources about the infection, a list of symptoms people may experience, what vaccination involves and what may happen to individuals who are vaccinated. If people are unwell and require emergency care, they need to call the emergency services. If they think they may be at risk of infection, they should contact either their GP, who will refer them for testing, or, if they are already engaged with sexual health services, they should contact those services. As has been seen thus far, many of the individuals who have been diagnosed with monkeypox infection already have an established relationship with one of the sexual health services.

Senator Frances Black

I thank the witnesses for their replies and for their work.

Deputy Colm Burke

In regard to the 6,000 to 13,000 people who would benefit from primary prevention vaccination, what is the process for trying to identify them or is there any such process? What stage are we at in the sense of talking about numbers?

Dr. Siobhán Ní Bhriain

I will hand that question over to Dr. Igoe.

Dr. Derval Igoe

The first thing to highlight is that these are estimates of the numbers we believe would benefit from vaccination. We used available data we have in the system to get our estimate. We used two different methods, both of which came up with a similar number. The first method was looking at the current numbers of people who are on the medicine PrEP to prevent HIV infection. We did not just take that number; we also looked at a potentially unmet need, which would include people who are waiting to get on that programme. We identified 4,000 people who are on PrEP and an additional 30% who may have an unmet need, which gave us 5,120 people. As well as that, we looked at people living with HIV who are gay, bisexual or men who have sex with men, gbMSM. Based on some information we have on behavioural surveillance, involving self-reported bacterial infection in the previous 12 months, which was available from an Internet-based survey we were involved in, we identified another 28% who reported such an infection. However, we know from Internet-based surveys that one may get an overestimate of the situation, so we halved that number. From that estimate, we came up with a number between 5,610 and 6,100, depending on whether or not we halved the number reporting bacterial infection via the Internet survey.

Deputy Colm Burke

Will we have a better idea of the numbers in six months or will it be an ongoing rolling situation?

Dr. Derval Igoe

The estimate we have applies before the vaccination programme starts. It is the number we anticipate will present. Once the vaccination starts, we will know the number of people who actually come forward. For now, we are working on an estimate.

We have two different ways to do that. These are not perfect but they are the estimates that we have.

The second way was not to look at whether a person is either on treatment to prevent HIV or is living with HIV. The second way is just looking at the gbMSM community who have reported bacterial sexually transmitted infection in the last year.

Deputy Colm Burke

Is there information that the GPs would be able to feed back to the HSE that would be of assistance to it?

Dr. Derval Igoe

In terms of estimating the numbers, no. I would just say that GPs refer anybody who they think might have monkeypox to a sexual health service. The numbers are usually notified. It is a notifiable disease now, so we get all the numbers and they usually come from sexual health clinics. GPs would not really be inputting the numbers reporting with sexually transmitted infection here. It would not be our main way that we would get that information.

Deputy Colm Burke

On the availability of the vaccine, what is that likely to be over the next six months? Is the position regarding access likely to change?

Dr. Ciaran Browne

On the Deputy’s previous question, depending on uptake, we have plans for the development of the capacity for the next two or three months. If uptake remains high, we will continue that vaccination for as long as supplies are available. On the current plans for vaccine supply, we are expecting additional doses in the fourth quarter four and significant stocks in the second quarter of 2023. Again, our roll-out of the vaccine is dependant on those vaccine supplies coming through.

Deputy Colm Burke

Say by the end of the March of the coming year, what numbers do the witnesses think that they will be able to make available vaccines available to? We were talking about 6,000-----

Dr. Ciaran Browne

We are hoping to cover the 6,000 depending on whether stocks arrive in the near future. If people want to continue to avail in our priority groups-----

Deputy Colm Burke

Do they think that they may have been able to access sufficient vaccines to vaccinate the 6,000 by March of the coming year? Are you talking about maybe-----

Dr. Ciaran Browne

That is our plan, but it will hopefully be even before March of the next year. We will keep emphasising that we do not have 100% confirmation that those stocks will be coming in. However, if those stocks do come in, we will be able to offer vaccines to those 6,000 people.

Chairman

I have two questions for the HSE before we move back to the topic of long Covid. Is there a contact tracing programme in effect for monkeypox?

Dr. Derval Igoe

Yes, there is. It is an important component of the response. When a person is diagnosed with monkeypox then they are interviewed by public health. They speak to the person and they identify sexual and other contacts who may be at risk of having been exposed to monkeypox. Then there is specific advice and vaccination, where appropriate, or post-exposure vaccination for them. This has been an active component right from the very beginning. For each individual, their illness is treated, but also the contacts that they have identified are contacted by public health. They are advised about the risk of exposure and of what they need to do. If they have developed any symptoms, they are advised about them and about what they need to do. They are also offered post-exposure vaccination to try to reduce the likelihood that they will develop monkeypox. It is a very active component, and it needs to remain so.

Chairman

Dr. Igoe stated that it is a mild illness and that most people recover within weeks. However, again, there are people whose immune systems are down, pregnant women, children, etc. Are there any long-term side effects in relation to it?

Professor Fiona Lyons

It is too early to say, to be honest. Scarring at the site of the skin lesions is something people report. For individuals who have a large burden of scars on their faces, that can be difficult. Scarring at the site of skin lesions is an issue.

Chairman

I would have thought that while this is relatively new to Europe, it has been around for a long time in Africa and elsewhere. I wonder if there are side effects involved. Professor Lyons is saying that there are none aside from the scarring.

On public information, how do people contract the virus? Is it through secretions or is it through the passing of fluid? I ask them to not go into too much detail in respect of it because I am conscious that it is early in the morning.

Professor Fiona Lyons

Primarily skin-to-skin contact is a very important mode of transmission.

Chairman

I thank Professor Lyons. That was really helpful. The positive message is that the HSE is saying that it is on a downward spiral. Hopefully, that will continue. It is about people changing their behaviour. That was the strong message that came out. There are supports available. With the vaccine and the increased use of it, we can hopefully deal with the crisis that exists. There is a 45-bed isolation facility in place. I think we have covered that.

We will now move onto the topic of long Covid. I will kick off with questions from Senator Conway, who will have five minutes and I ask that he please try to keep to that.

Senator Martin Conway

Totally; 100%. I thank the HSE for that useful engagement earlier on. Long Covid is a very serious issue. I am sure the HSE will agree with me on that. From looking through the statements, what concerns me are words to the effect that “the HSE will deliver” and “we expect to expand the service”. Those phrases relate to the provision of services. How many clinics are fully operational?

Dr. Siobhán Ní Bhriain

We absolutely agree with the Senator that this is a very important issue. We have a number of clinics that are operational, but they are not fully operational because this is a new illness and because we are building up our resources in order to respond to it. I will pull up the exact information. Does Mr. Browne have that information-----

Senator Martin Conway

Just before the we do that, I want to hear now about clear timelines. I raised this in the Seanad as a Commencement matter only approximately two or three weeks ago, and the reply that I got was very clear. The phrases used were “we plan to deliver” and “we expect to deliver” and “it is our intention to deliver”. What I want to know is when the delivery is going to happen. What I want from the HSE is a clear timeline, if I can have one.

Dr. Siobhán Ní Bhriain

What I might just say on that is that we are recruiting to those sites. I cannot give a definitive timeline on delivery because it is dependent on recruitment and because we are continuing to build up our recruitment at all sites for post-acute Covid and for long Covid. We are certainly-----

Senator Martin Conway

Can the HSE give us the figure in terms of who and what precisely they are recruiting and where they are in that recruitment process?

Dr. Siobhán Ní Bhriain

What I can do is send the Senator a good deal more detail on who we are recruiting to each team, if that would be helpful, and where the recruitment process stands. I would certainly be happy to supply that.

Senator Martin Conway

And then timeline on it please.

Dr. Siobhán Ní Bhriain

We can certainly supply that as best we can.

Senator Martin Conway

The problem is that while all this planning and upscaling is going on, there are people who are very sick with Covid. I cannot for the life of me understand why this planning did not take place a year ago, because it was fairly clear in the early days of the pandemic that there were people who had lingering symptoms that were far beyond the period of ten days or two weeks. I have engaged with people who have not yet gone back to work after two years because of Covid. I engaged over the summer with a senior consultant who had to reduce his working hours because of the long-term effects of Covid. To think that the HSE still does have not a fully operational clinic to deal with long Covid anywhere in the country is totally unacceptable.

Dr. Siobhán Ní Bhriain

I thank the Senator. As I say, we have been building on our services since September 2021, when we launched our interim model of care for long Covid. I would just like to bring Dr. Bannan in on the clinical management of some of the symptoms of long Covid.

Dr. Ciaran Bannan

Post-acute Covid or long Covid is a very challenging condition, as the Senator identified. There are significant numbers of people who are not right many weeks after infection. We see a variety of symptoms, including neurological, cardiovascular, respiratory, aches and pains and musculoskeletal. In terms of our model of care, what we aim to offer, because we see such a variety of symptoms, is a one-stop shop for patients. When patients present to one of the long Covid clinics, pretty much all of their needs be met under one roof. We will have input from allied health professionals, including from occupational health, which will often run things such as boutique programmes and physiotherapy, which will also run exercise programmes for patients who may benefit from that. We will do the battery of investigations to out rule any-----

Senator Martin Conway

That centre of excellence is exactly what we want. People should expect all of those services from the centre of excellence. When are we going to have the first centre up and running, fully staffed and fully operational? When are we going to have the eight that have been committed to fully up and running, staffed and operational?

Dr. Siobhán Ní Bhriain

As I said, we will certainly supply the Senator with all the information about the current recruitment status. I would like to say that the science remains relatively unclear as to the specific treatments for some of the symptoms of long Covid. The best evidence we have available at this time points to supportive therapy. While we are waiting for our clinics to be up and running, we have done a lot of communication works with our colleagues in general practice to-----

Senator Martin Conway

I fully understand the difficulties and challenges with recruitment but as of now, Dr. Ní Bhriain cannot give me a date for when there will be at least one fully operational long Covid clinic in this country?

Dr. Siobhán Ní Bhriain

A number of our clinics are operational. They may not be fully staffed but they are fully operational.

Senator Martin Conway

Can we stick to the point? Can Dr. Ní Bhriain give this committee a date, or at least an expected date, as to when there will be one fully operational long Covid clinic in this country?

Dr. Siobhán Ní Bhriain

May I just give an example? In St. James's------

Senator Martin Conway

Can Dr. Ní Bhriain give me a date?

Chairman

Hold on, Senator. The Senator is asking the witness a question.

Senator Martin Conway

She is not answering it, Chairman.

Chairman

The Senator keeps putting her off every time she tries to answer. Will the Senator please allow her to answer?

Dr. Siobhán Ní Bhriain

In St. James's Hospital, we plan to appoint 6.3 whole-time equivalents to run the clinic. We currently have four in place. In other clinics, we may not have a full complement of staff in place but the patients are being seen through, for example, other clinics within that hospital. The Senator asked about an operational clinic. I would like to distinguish between a clinic that is up and running and a clinic that is appropriately staffed. We are seeing patients although we may not have the full complement of staffing for a clinic. I am more than happy to provide the Senator with the precise information. It does not mean a service is not being supplied in those areas.

Senator Martin Conway

I accept that. However, at this time, Dr. Ní Bhriain cannot give me a definitive date three, six or nine months hence.

Dr. Siobhán Ní Bhriain

As to what?

Senator Martin Conway

As to when a clinic will be fully operational.

Dr. Siobhán Ní Bhriain

We have fully operational clinics. They may not be fully staffed but they are operational.

Senator Martin Conway

They are not fully operational unless they are fully staffed. Let us be honest. We will leave it at that.

Deputy David Cullinane

I think the Senator asked reasonable questions and it is not good enough that we cannot get an answer as to when we will have a fully staffed and fully operational clinic. All of us have raised issues around when these clinics are going to be up and running. In fact, some parts of the country, including where I come from in the south east, do not have a clinic. That is my understanding. There are regional variations.

I have a number of direct questions. Unfortunately, I cannot allow each of our guests to come in. Who will be dealing with the model of care for long Covid? Who is the best person to field those questions?

Dr. Siobhán Ní Bhriain

A number of us have dealt with the model of care. Professor Fleming-----

Deputy David Cullinane

To whom should I put my questions? I have a short period of time.

Dr. Siobhán Ní Bhriain

The Deputy can put his questions to Dr. Bannan and me.

Deputy David Cullinane

I will start with Dr. Ní Bhriain. Dr. John Lambert was before the committee some time ago. He made the point that the research he has done, and others internationally have done, points to residual harm being caused by brain damage. He suggested neurological factors were at play and said that should be the number one priority. Is that built into the model of care at the moment?

Dr. Siobhán Ní Bhriain

It is.

Deputy David Cullinane

When I asked Dr. Lambert if he believed the current model of care was fit for purpose, he said:

No, it is not. As I said, of the 1,000 patients that I have seen, I would say that probably 20 of them need pulmonary support in the short term, but 1,000 of them needed neurological support. I am not saying that there is not a need for cardiac and pulmonary physicians in some cases, I am saying that looking at the document [meaning the HSE plan], it states that tertiary-level care for neurorehabilitation is going to be part of the plan. That should be prioritised as the number one issue.

Dr. Lambert's contention is that it is not being prioritised.

Dr. Siobhán Ní Bhriain

I emphasise that the model of care is an interim model of care. What that means is that we built it on the available evidence at the time. We are now seeking additional evidence from HIQA and doing a study with our own health protection surveillance colleagues, looking at the epidemiology or the predicted numbers of people who may suffer from long Covid in an Irish context. Our model of care is interim. We will absolutely be updating that as more evidence becomes available. I am meeting with Dr. Lambert next week to have further discussions in that regard. We are very keen to develop-----

Deputy David Cullinane

That was one of the points that Dr. Lambert raised with us. He said he found it difficult to get a meeting with the Minister and senior HSE officials. My understanding is that he is running a long Covid clinic at the Mater hospital. Is that right? He is at least part of a team in that hospital.

Dr. Siobhán Ní Bhriain

Sorry?

Deputy David Cullinane

Dr. Lambert is involved in research and work in the Mater hospital.

Dr. Siobhán Ní Bhriain

He is, as far as I know.

Deputy David Cullinane

He has submitted a business case and a plan in the hope that will become a properly resourced Covid clinic. Has that materialised?

Dr. Siobhán Ní Bhriain

The long Covid clinic for Ireland East Hospital Group is currently located in S. Vincent's hospital.

Deputy David Cullinane

I understand that. Has the Mater hospital produced a business case to the HSE looking for funding?

Dr. Siobhán Ní Bhriain

I have not seen a business case from the Mater.

Deputy David Cullinane

That is very surprising. When he was before this committee, that was one of the issues Dr. Lambert raised. He said he submitted a business case and a plan, which has been with the Department since July 2021.

Dr. Siobhán Ní Bhriain

His business case would be very much a matter for Ireland East Hospital Group. I will certainly bring up that issue with him next week.

Deputy David Cullinane

I would have hoped that senior people in the HSE would be aware of the plans, views and business case of somebody of his stature. I am sure he will not consider that a great start to his meeting with Dr. Ní Bhriain next week but we will see how that meeting goes.

What has changed? What has evolved in recent months, given the research, which is evolving all the time? What is the biggest change Dr. Ní Bhriain has seen? It is not good that we do not have a fully staffed, fully operational long Covid clinic open yet but given what we have in place and the evolving evidence and research, what has been the biggest shift in the model of care for patients with long Covid?

Dr. Siobhán Ní Bhriain

The model of care, as written, is now as it was in September 2021. When we look to updating a model of care, we rely on current evidence. We do not update our models of care every few weeks. It takes a lot of work to develop a model of care. A very large team developed that model of care.

Deputy David Cullinane

I suggest it needs to be addressed again.

Dr. Siobhán Ní Bhriain

I agree with the Deputy.

Deputy David Cullinane

I do not know what value the HSE puts on the work of Dr. Lambert or anybody else, but Dr. Lambert seems to be a specialist in this area. He seems to have expertise. If I were in Dr. Ní Bhriain's position, he would be somebody I would want to listen to and engage with. There has been no shift or change in the model of care since September 2021 while the international research is evolving all the time. It is evolving by the week, let alone how it has evolved since September 2021. That is not good.

I wish to ask about immunocompromised patients, who are a very important cohort of people who have been largely forgotten. I spoke to a blood cancer patient yesterday who said that she remains in the same situation we all entered when we went into lockdown in March 2020. That is still her life at this time. Many of those who contracted Covid also have long Covid. I know there are issues around the Evusheld antibody drug. What additional supports or plans are in place for patients who are immunocompromised? What access is available to those antiviral and antibody medications such as Evusheld? As Senator Conway said earlier, France and other countries seem to be well ahead of us and we seem to be well behind the curve. Why is that the case?

Dr. Siobhán Ní Bhriain

I will first respond to the Deputy's question about Evusheld, if that is okay. Evusheld is currently undergoing a health technology assessment, HTA. It is still an investigational medication internationally. The evidence in its favour does not yet fully support its use in this country. It is undergoing that HTA and we expect the results of that in due course. That has been advised by the medicines management programme. There is a recently emerging body of evidence that it may not be so effective for patients who have more recent variants. We are waiting for results before we subject our patients to medication that may cause other risks and damages. I could not agree more with the Deputy that immunocompromised patients have had an enormously difficult time during the pandemic.

Deputy David Cullinane

What is the plan for them?

Dr. Siobhán Ní Bhriain

The biggest plan for immunocompromised patients is to ensure their vaccination status is up to date. As the Deputy knows, the national immunisation advisory committee, NIAC, has issued additional guidance for immunocompromised patients over the age of 12.

Deputy Róisín Shortall

I wish to return to the interim guidelines from September 2021 on the management of long Covid. Who was responsible for drawing those up?

Dr. Siobhán Ní Bhriain

It comes under the governance of the chief clinical officer and it was led by me. I chaired the group that led the drawing up of the guidelines.

Deputy Róisín Shortall

Okay. What kind of specialties do those guidelines cover and what is the relative importance of each of those?

Dr. Siobhán Ní Bhriain

At the time, as I said, we were relying on contemporary evidence. We had a multi-specialty, multidisciplinary group to set up to develop the interim model of care.

We had colleagues such as Professor Fleming who works in the field of infectious diseases She has taken a very strong leadership role with her expertise. We had multiple specialties and disciplines, including psychiatry, psychology and neurology, as well as respiratory and infectious diseases.

Deputy Róisín Shortall

Would the witnesses accept that pulmonary complications have largely gone now as a result of the Omicron variant taking over and people being vaccinated?

Dr. Siobhán Ní Bhriain

I will ask my colleague Dr. Bannan, who is an infectious diseases expert, to comment on the clinical and respiratory side.

Dr. Ciaran Bannan

At present, while the admissions with pulmonary complications have definitely decreased and we are seeing fewer patients going into ICU, patients are still coming into our clinics with significant issues, such as shortness of breath, and with identified pathology. The pulmonary manifestations have not gone away as of yet.

Deputy Róisín Shortall

Arising from the events of the last year, a decision was taken to establish six long Covid clinics. What consultants are attached to those clinics? I refer to both the number and the specialty.

Dr. Siobhán Ní Bhriain

The long Covid clinics are being led by infectious diseases consultants. For example, Dr. Bannan will be leading it in St. James's Hospital and has been leading-----

Deputy Róisín Shortall

How many of those are there?

Dr. Siobhán Ní Bhriain

It is one consultant per clinic.

Deputy Róisín Shortall

Okay. What other specialists are there?

Dr. Siobhán Ní Bhriain

There would be a trainee in infectious diseases, occupational therapists and administrative support and staff nurses. There would also be strong links in each of those clinics with the local psychiatry services. We have done that very specifically to provide psychological and psychiatric support for patients who may have those complications, which have been relatively common in long Covid, as well as other complications. Each of those pathways will be able to refer on to the neurology pathway-----

Deputy Róisín Shortall

I am talking about the specific long Covid clinics. I am not talking about other services in the hospitals. Dr. Ní Bhriain says each clinic has an infectious diseases expert. What is the situation with cardiologists, for example?

Dr. Siobhán Ní Bhriain

As the Deputy alluded to, the cardiology complications have been less complicated than we had expected but-----

Deputy Róisín Shortall

How many cardiologists are there?

Dr. Siobhán Ní Bhriain

There are no specific cardiologists in those clinics.

Deputy Róisín Shortall

What about neurologists?

Dr. Siobhán Ní Bhriain

There is no neurology clinic attached to each service. There is a tertiary referral neurology service in St. James's Hospital to which all clinics can refer. That is for post acute Covid clinics and long Covid clinics.

Deputy Róisín Shortall

How many consultants?

Dr. Siobhán Ní Bhriain

At the moment we have one consultant there who is a neurocognitive specialist.

Deputy Róisín Shortall

Who was responsible for selecting those locations?

Dr. Siobhán Ní Bhriain

We would have worked nationally with our colleagues in operations to develop those locations, the principle being to have one available to each hospital group.

Deputy Róisín Shortall

It is very hard to understand what has happened with the Mater hospital, which opened the first long Covid clinic and has been operating it since June 2020, has published several articles about Covid and did a very detailed study on long Covid that involved 155 patients. That clinic has built up extraordinary expertise - much more expertise, it could be argued, than any other hospital - and yet that clinic is now being forced to close. What is the rationale behind that?

Dr. Siobhán Ní Bhriain

Each hospital group has a long Covid clinic. Ireland east chose to locate that in St. Vincent's University Hospital. There is expertise around the country on long Covid. It is a matter for each hospital group to decide where it wants to locate its long Covid clinic.

Deputy Róisín Shortall

I thought Dr. Ní Bhriain said her team selected the sites.

Dr. Siobhán Ní Bhriain

We advised hospital groups and we worked with the teams to select the sites.

Deputy Róisín Shortall

How much importance does her team attach to neurological complications as a result of long Covid?

Dr. Siobhán Ní Bhriain

We attach a lot of importance to it. Neurological complications have a broad spectrum across neurocognitive, psychological and psychiatric aspects. Would Dr. Bannan have any comments on those neurological, psychological or psychiatric complications?

Dr. Ciaran Bannan

We are seeing emerging potential patterns of pathology with long Covid. As Deputy Cullinane said, a lot of research is going on into long Covid and new papers are coming out all the time. There is a number of theories around what is causing it. It may be an autoimmune phenomenon or it may be related to changes in the blood vessels where the blood vessels have not returned to normal after a Covid infection. It may also be related to neurological issues at present. To date, studies have not shown much in the way of structural abnormalities to the brain. Further research is needed into that and further research is needed into all the other potential pathological mechanisms explaining long Covid. It is quite an exciting time for-----

Deputy Róisín Shortall

Would the witnesses accept that the existing guidelines are primarily based on heart and lung problems and not brain problems?

Dr. Siobhán Ní Bhriain

No. My clinical background is neurocognitive and psychiatric. We were very aware and very concerned about these-----

Deputy Róisín Shortall

What are the current waiting list for those clinics?

Dr. Siobhán Ní Bhriain

Unfortunately, the waiting list is up to five months for some of the clinics. That is because we are recruiting and it is taking us time to get the staff.

Deputy Róisín Shortall

That is the waiting time. How many people are on the waiting list?

Dr. Siobhán Ní Bhriain

I have that information here and I can provide it to the Deputy.

Deputy Róisín Shortall

Is there a figure?

Dr. Siobhán Ní Bhriain

Different clinics have different waiting lists.

Deputy Róisín Shortall

What kind of quantum is it?

Dr. Siobhán Ní Bhriain

In Blanchardstown, for example, at the end of August there were 135 people on the waiting list. There were 60 in Beaumont, three in the Mater and 286 in Tallaght.

Deputy Róisín Shortall

The Mater is not a centre for long Covid any more. The HSE has not selected it.

Dr. Siobhán Ní Bhriain

It was not selected but some sites, including Tallaght, have set up additional long Covid clinics and we are working with those sites to help develop them as well.

Deputy Róisín Shortall

Is Dr. Ní Bhriain aware of the business case that has been submitted by Dr. Lambert?

Dr. Siobhán Ní Bhriain

I am aware that he has submitted one. We are meeting with him next week and we will discuss that further. I am happy to do that.

Deputy Neasa Hourigan

I want to ask about something specific but I will add a comment first. This is in my constituency so I will call it out. Given the cohort and the demographics, I am also amazed that we have not funded the long Covid clinic at the Mater. It seems like a no-brainer. It is absolutely required in that area and it seems there is huge wealth of knowledge there.

I want to talk about children and long Covid. What is the HSE's position around that?

Dr. Siobhán Ní Bhriain

Our information to date is that children are not that severely affected by Covid and tend to recover fairly quickly. The best clinical advice we have had is that they are best dealt with by general practitioners, who are very experienced in dealing with post viral illnesses in children, or general paediatricians. We have commissioned a review from HIQA looking at models of care and that will include children and how other jurisdictions are looking after children. That is our approach to children at this point in time.

Deputy Neasa Hourigan

At the moment, if a parent feels their child is experiencing long Covid, they bring them to the GP. What exactly does the HSE expect the GP to do?

Dr. Siobhán Ní Bhriain

The GP will take a clinical history, see how the child is doing and make a judgment on whether or not that child needs further-----

Deputy Neasa Hourigan

I have been looking at what they do in other jurisdictions. Let us say there are 12 weeks of persistent symptoms. What does the GP do then?

Dr. Siobhán Ní Bhriain

The GP may decide that the child needs further referral to a general paediatrician. If that is the case-----

Deputy Neasa Hourigan

It would be a general paediatrician. It is not specified. The child is not sent to a long Covid clinic. The paediatrician may not have particular expertise in post-viral illnesses or infections.

Dr. Siobhán Ní Bhriain

Paediatricians have quite a lot of expertise in post-viral illness in children.

Deputy Neasa Hourigan

They are not being sent to the long Covid clinics.

Dr. Siobhán Ní Bhriain

We do not have a long Covid clinic for children.

Deputy Neasa Hourigan

Is there no expectation that we would do that?

Dr. Siobhán Ní Bhriain

That will depend on the review by HIQA and how we are informed by evidence as we go forward.

Deputy Neasa Hourigan

Some of the parents I have spoken to are looking for things like physiotherapists, occupational therapists, psychologists and dieticians. I do not think you can even get on the list for a dietician in Crumlin hospital at the moment. The fact that we are also not offering them care at a long Covid clinic seems out of step, certainly with the UK at least. University College London hospitals have launched a service for children and young people. It goes from zero to 18 years and is for those who have been suffering symptoms for 12 weeks or more. They can access the same type of care as adults.

Dr. Siobhán Ní Bhriain

Any child referred to a general paediatrician will have access to a multidisciplinary team that can provide that level of care. I assure the Deputy that if we discover in the evidence base that we need a long Covid clinic for children, we will be looking at that.

Deputy Neasa Hourigan

Just to be clear, we are saying that adults need specialised care and need people who have particular experience long Covid but when it comes to children, we are sending them through a referral pathway that is more generalised.

Dr. Siobhán Ní Bhriain

That is the appropriate clinical advice we have had.

Deputy Neasa Hourigan

Is that the appropriate legal advice?

Dr. Siobhán Ní Bhriain

It is the appropriate clinical advice. It is absolutely clinical.

Deputy Neasa Hourigan

There are no plans to do as the NHS has done in the UK and explore the idea of children's long Covid clinics.

Dr. Siobhán Ní Bhriain

As I have said, we have commissioned a review from HIQA.

Deputy Neasa Hourigan

When are we expecting that review?

Dr. Siobhán Ní Bhriain

It is expected by mid-November.

Deputy Neasa Hourigan

Will action be taken?

Dr. Siobhán Ní Bhriain

Absolutely.

Deputy Gino Kenny

I have a number of questions. How many people are suffering from long Covid? Do the witnesses have the number of cases in the State to hand?

Dr. Siobhán Ní Bhriain

I will hand over to Dr. Bannan to address that question.

Dr. Ciaran Bannan

One of the difficulties in determining this figure is that the denominator, the number of people in the State who have had Covid, is difficult to determine. It is very difficult to monitor. Based on international evidence, we expect that 10% to 15% of people will have persistent symptoms at 12 weeks and that a small minority of patients will continue to have symptoms at one year and up to two years afterwards.

Deputy Gino Kenny

What is the medical definition of long Covid?

Dr. Ciaran Bannan

There have been a lot of difficulties with the definition but the generally accepted definition, which we are using in Ireland, is persistent symptoms following possible or confirmed Covid-19 infection 12 weeks after infection.

Deputy Gino Kenny

In the medical field, is there a difference of opinion on the diagnosis and treatment of long Covid?

Dr. Ciaran Bannan

There is an emerging body of evidence. This is a very new infection. We have experience with many other viruses such as glandular fever and the initial SARS outbreak, in which we saw a lot of post-infection sickness, malaise, tiredness and fatigue. It is quite exciting that we have a specific diagnosis in a lot of individuals here. We often see patients in clinics who have significant post-viral fatigue. We primarily manage them holistically, try to get them on the road to recovery and support them in that.

Deputy Gino Kenny

Is it the case that the classic symptoms of long Covid are chronic fatigue and respiratory issues? Are there any classic symptoms?

Dr. Ciaran Bannan

This is the difficulty. We see patients with a constellation of symptoms. A very wide variety of symptoms have been reported by patients to date. Work has been done which shows that patients fall into particular clusters. Many patients may be quite achy and have muscular pains while others will be tormented by brain fog and difficulties with memory, concentration and finding words. Other patients have significant pulmonary issues either following admission to hospital or even without admission. These symptoms fluctuate over time. For some people, they will go away and be replaced by new symptoms. For the most part, people will recover over time but that recovery is very difficult to anticipate.

Deputy Gino Kenny

With regard to gender, is there a kind of equilibrium?

Dr. Ciaran Bannan

There are a number of risk factors for developing long Covid. It seems to be particularly common in the age group from 35 to 69. Females seem to be more affected. People who have underlying medical conditions seem to have a higher risk of developing long Covid. People who have been hospitalised with severe Covid will also often have persistent symptoms.

Dr. Siobhán Ní Bhriain

If I may interject, there is a small body of evidence that suggests people who are vaccinated are at a slightly lower risk. Does Dr. Bannan agree that is fair to say?

Dr. Ciaran Bannan

There is an evidence base to suggest that vaccination-----

Deputy Gino Kenny

There is a lower risk of developing long Covid.

Dr. Siobhán Ní Bhriain

There is slightly less risk rather than a lower risk. It is slightly lower.

Deputy Gino Kenny

The presence of underlying conditions is obviously a factor in developing long Covid. I know it is very difficult but can the witnesses say whether those who develop long Covid had an underlying condition beforehand?

Dr. Ciaran Bannan

They often have. If a patient has chronic obstructive pulmonary disease and his or her lung capacity is not great at baseline but he or she is just managing, developing Covid and ongoing symptoms can tip the balance away from being quite functional and getting around. That can be very frustrating for patients.

Deputy Gino Kenny

People listening in may have had symptoms of long Covid. I got Covid recently and I would not wish my worst enemy to constantly have those symptoms every day. It is your worst nightmare. Having it for a week or two is bad enough but I really would not wish my worst enemy to have it all of the time. It is obviously very serious because it affects people's mental health and overall well-being. People want to hear what provision has been put in place for the treatment of people who have long Covid. There is a budget and so forth but what can people expect when they are suffering from long Covid? What kind of services can they get to treat their symptoms?

Dr. Siobhán Ní Bhriain

As we have said, the science is only emerging. There is no evidence of a definitive treatment for the condition yet. Dr. Bannan will say that some sort of supportive therapy works but there is no evidence for any definitive medication or any other particularly definitive treatment. It is very important that we recognise other symptoms people might have, co-morbid symptoms such as anxiety or depression, and that those are treated appropriately. However, internationally, there is not specific treatment for long Covid. Is that fair to say?

Dr. Ciaran Bannan

I wholeheartedly agree. It is about acknowledging patients' symptoms and that what they are going through is very important. Early on in the pandemic, many patients felt they were being shut down and just told to get on with it. It is really about acknowledging the condition and making sure that we are not missing anything else because patients may have heart failure that has been worsened by the Covid. We are optimising underlying medical conditions, making sure that nothing new is emergent and supporting the patients on a path to recovery through holistic methods.

Deputy Gino Kenny

In situations where people have had the symptoms of long Covid for a good period of time, have Dr. Bannan and Dr. Ní Bhriain come across symptoms somehow subsiding, whether with or without treatment?

Dr. Ciaran Bannan

Yes.

Deputy Gino Kenny

That is obviously what people want to hear. Somebody was saying that this could go on for a long, long time. That would plague your mind.

Dr. Ciaran Bannan

For the most part, what we are seeing in clinic is a trajectory towards improvement, which is reassuring. In saying that, there are still a minority of patients who are still quite badly affected by their initial infection in March or April 2020.

Deputy Colm Burke

On long Covid, in her opening statement, Dr. Ní Bhriain said that between 10% and 20% of people had continuing symptoms for a number of months thereafter. What percentage are we down to six months after getting Covid? Do we have any idea at this stage of the percentage of people who continue to have symptoms six months after first getting Covid? Has any kind of analysis been done as regards the numbers?

Dr. Siobhán Ní Bhriain

Dr. Bannan will be able to come in on that. He has already said that the overall trajectory is towards improvement. To really estimate the effect of long Covid in Ireland, we are planning an epidemiological study. The field work for that is starting now. The point of that is to determine the current health status of people who have been infected with Covid-19. I can give the Deputy a much more detailed briefing on that and on our plan outside of this meeting but it is very hard to estimate. There have been multiple studies but they have been done in multiple populations including people who have been hospitalised, people who were in ICU and people who were not hospitalised. It is very hard to say.

Deputy Colm Burke

Have any international studies been done?

Dr. Siobhán Ní Bhriain

Multiple international studies have been done.

Deputy Colm Burke

Are they coming up with any percentages as to those who still have symptoms, for example, six months after initial infection?

Dr. Siobhán Ní Bhriain

Do we have a sense of the percentage at six months?

Dr. Ciaran Bannan

As I have said, a lot of data tends to be taken a year following infection but there seems to be ongoing improvement and many people have returned to normality at that stage. This is complicated by the fact that we are seeing new variants, with which we are seeing different patterns of illness. We also have to factor in the effect of vaccination and previous infection on the severity of disease in patients and on their subsequent recovery.

Deputy Colm Burke

On the issue of the age profile, I know that many older people contracted Covid. However, with regard to the age group under 20, I have recently come across a number of families, including the family of a child of 11, who have had serious problems with long Covid.

Have we any idea of the number of people aged under say, 20 years, who are suffering long-term effects as a result of contracting Covid?

Dr. Siobhán Ní Bhriain

We do not have that data immediately to hand but as I said to Deputy Hourigan, when we have the HIQA study we will at least have a slightly better sense of that. The advice we have had from our paediatric colleges, which we work very closely with, is that a very small number of children suffer from either post-viral illness or long Covid. That said, the Deputy is right that we have all been approached by somebody whose child has been unwell but they are very small numbers from what we are of.

Deputy Colm Burke

What kind of numbers have the six clinics that are up and running dealt with to date? Have we any idea of the weekly numbers they are dealing with? That would give us an idea of the referral rate as well.

Dr. Siobhán Ní Bhriain

We have some sense of it and we are continuing to collect the data. We do have a sense of the numbers that are being seen and we are continuing to collate the data on that.

Deputy Colm Burke

What kind of overall number would the six clinics be seeing per week?

Dr. Siobhán Ní Bhriain

I do not know how many there are per week.

Deputy Colm Burke

That kind of figure would give us an idea of what we are talking about. The last thing we need is for there to be a waiting period to access those clinics. We must ensure we do not build up a waiting list as is happening in many other areas. We must be able to respond to the demand. Are we satisfied the six clinics that are set up are dealing with the demand that is currently there?

Dr. Siobhán Ní Bhriain

As I say, part of the problem is some of the clinics are not fully operational. It is taking time to build them up and unfortunately we have a waiting list. We know there were 90 patients seen in March, for example. There were 146 seen in August. Has Dr. Bannan got a sense of how many people would be seen? I think people are seen once or twice at a clinic.

Dr. Ciaran Bannan

People will typically have between one and multiple visits to the clinic. We have a three-tiered approach to management. Many patients will be suitable for self care, their symptoms will recover over time and they will continue their lives. A number of people will need GP intervention and the GP service is a gateway into the clinics as well. The clinics-----

Deputy Colm Burke

On the GP issue, are we keeping them up to date on what they can access and where the services that are available are? Have GPs been fully briefed on all this and are they being kept up to date on new developments?

Dr. Siobhán Ní Bhriain

Yes, and we plan to issue further memorandums to them. We are relating to our general practitioner colleagues in a number of ways on the clinical management of the symptoms by means of seminars organised by the Irish College of General Practitioners, ICGP, where experts give advice. We are also keeping them up to date on the development of clinics and will continue to do so.

Deputy Colm Burke

I thank our guests.

Senator Frances Black

I thank our guests for coming in. I want to follow on from Deputy Hourigan's question around children. I am aware of a couple of cases. I totally agree with what Deputy Gino Kenny said because I had it is as well and there is exhaustion as well as sickness. If you had that exhaustion for a long time it really impacts you in every way and particularly your mental health. For young people who suffer with long Covid it is not just about the loss of their health, which applies to everybody who has it, but their loss of time at school and the loss of their childhood, which is something they can never get back. It takes a toll on their mental health. I am concerned because we already know about the poor state of children's mental health services and the lack of help available for children. I want to check whether our guests experienced any cases themselves or heard of any cases and if anything is being done at all about long Covid for children.

Dr. Siobhán Ní Bhriain

Just to say, there is nobody here who is a paediatrician so I cannot say we have had direct clinical experience of it. We have certainly been contacted by families of children and we advise them on the most appropriate direction of travel for them in their particular area and that particular child. People of course contact us about that. We have a national clinical adviser for children, Dr. Ciara Martin, and I keep in regular contact with her on how we manage it. We are reviewing the evidence first. The incidence of long Covid in children has been very small. I have to be honest that the studies have also been very small, so it is difficult to extrapolate from that. As I said to Deputy Hourigan and others, we are reliant on some of the information that comes to us from HIQA, which goes from newborns all the way up; there is no age limit. We have heard of symptoms such as brain fog and other difficulties in children. The clinical evidence we have - again I am reliant on my paediatric colleagues but I work closely with them - is children recover faster than adults and their symptoms tend to resolve quickly. The Senator is right that we have experience of this in other areas, like glandular fever, as Dr. Bannan has mentioned. Children and adolescents have prolonged symptoms from those conditions. The recommended pathway developed by my clinical colleagues for children is that if they require specialist care after being seen by a general paediatrician, they can be referred on to the appropriate consultant - respiratory, cardiology and so on.

Senator Frances Black

Okay.

Dr. Siobhán Ní Bhriain

But it is difficult, absolutely.

Senator Frances Black

Yes. The elderly are a group considered especially vulnerable to this virus and its lasting effects. Given all 14 post-acute and long Covid clinics are located in larger towns and cities, how does the HSE plan to deliver care to those who live in more rural environments?

Dr. Siobhán Ní Bhriain

Is the Senator asking about older people specifically or just generally?

Senator Frances Black

Generally, but really older people because they are so vulnerable. It must be awful for them to be living far away and having to travel. That is the concern.

Dr. Siobhán Ní Bhriain

It is a good question. When we were developing the model of care we had much input from our colleagues in geriatric medicine. That is my own specialty. The Senator is probably aware of the development of the enhanced community care for older persons programme. Many older people who have prolonged symptoms of Covid have other co-morbid conditions. These could include respiratory disease, heart disease and frailty. Those older people, especially those aged over 65 years, are far better dealt with in the enhanced community care geriatric programmes that have a multidisciplinary specialty team available to them, and we are rolling those out around the country. The focus of those enhanced community care programmes for chronic disease in older persons is to provide an outreach-type service and to have it very widely available. For most older people - and again I am speaking from my clinical background here - we generally advise referral to a geriatrician who would have a very wide scope of practice and be well able to manage the co-morbid conditions that may exist with long Covid.

I might ask Dr. Bannan about this. Would it be fair to say we are not having a huge issue with persons aged over 65 years or 85 years presenting to the long Covid clinics, because we have the older persons clinic?

Dr. Ciaran Bannan

No, our initial demographics highlight that this is a condition that seems to affect middle-aged individuals.

Senator Frances Black

Okay. Dr. Ní Bhriain mentioned the 14 clinics have already been established. The healthcare service is already really stretched. There is no doubt about it. We see that in a lot of the presentations that come in. Is there any way our guests can ensure the efficiency and longevity of the service?

Dr. Siobhán Ní Bhriain

I am glad to say the funding we have got for it is permanent so our plan is to ensure its longevity and also to continue researching the service as we develop it to ensure we are responding to the need that is out there.

Senator Frances Black

Okay. I thank our guests.

Chairman

Before I let Deputy Shortall in I have a couple of questions of my own.

In the lead-up to this meeting, I spoke to several people who have long Covid. Most of those people have a sense of frustration. They feel there is a lack of awareness of their situation. Some are fairly critical of their GPs, that they are at a loss and do not really know what to do with these patients. Medication has been provided that is unsuitable. One person told me codeine was prescribed. This person has had long Covid for the past two years. It does not seem to be going away, and that person was concerned about the medication being recommended. Another person with long Covid that I spoke to ended up getting clots on the lungs. There was also an impact on the heart and muscle loss. This person was told to avoid overexertion, because that could bring on a stroke or a heart attack. We have, therefore, many people with different types of long Covid. All of them are frustrated, though, by the lack of urgency. In the context of some of the questions asked, it will have been heard that the clinics have been set up, but that they are not fully staffed. This is one of the issues in this regard.

Another thing people were initially complaining about was that those with heart complaints were sent to heart specialists and those with lung complaints were sent to lung specialists, and the same happened with those with neurological complaints. People were being sent to different specialists. When Professor Jack Lambert appeared before the committee, he spoke about having a one-stop shop. This would make sense, and I think this is what we are trying to do. He was very complimentary of the British system which had brought all these elements together within a clinic setting. The frustration expressed by Professor Lambert, and it is also expressed by other clinicians, concerns the fact that the British system has not developed from its initial positive start. It has not learned from international practice since. I refer again to the fact that we are still waiting on this report. We do not know the extent of the challenge faced.

Is there more of a chance that people who have had Covid-19 multiple times will develop long Covid? I know some people have had Covid-19 four times. Is there more of a chance, therefore, of developing long Covid from having more infections? The concern around other variants was mentioned. For many of the people I spoke to, though, Omicron seemed to be the variant that had brought on long Covid in most cases where people had contacted me. Some of the other variants are much milder, or, rather, the experience can be mild for one person, but strangely that does not necessarily mean the same thing will happen to another person. Is there any evidence available in this regard?

Dr. Siobhán Ní Bhriain

I think what the Chair is asking is what are the risk factors for developing long Covid. He described some situations where people seem to have had some pretty horrific symptoms, including pain, if they require codeine. I ask Dr. Bannan to comment on the evidence base for risk factors for developing long Covid-19.

Dr. Ciaran Bannan

This is very much an evolving area. The Omicron strain has only been with us for this year really and we do have people who have had multiple infections. Ongoing research will help to determine whether subsequent infections pose a higher risk of contracting long Covid. From what I have seen in the clinic to date, I feel that, for the majority of patients, subsequent episodes of Covid-19 tend to be milder than the initial symptoms and people often recover much faster than before. It may be associated with a setback in their long Covid symptoms, but recovery is usually experienced quite quickly and those patients get back to their baseline faster. This is, however, very much new evidence. Time and ongoing experience will tell, from this perspective.

Chairman

A colleague spoke about his and his family's situation. His wife and daughter have long Covid. This is just one household. The father-in-law ended up in ICU, but he does not have long Covid. I presume there is some link in this regard. Would it be unusual to have a case where a whole family has been impacted to some extent in this regard? People are looking for answers. Could this come down to the strain of the variant?

Dr. Ciaran Bannan

This still needs to be teased out. One thing we recognised early on in our clinic was that many of the pateints coming to us were not the patients who had gone through ICU. Plenty of patients came back from the ICU some six to eight weeks later and told us they felt like new people and were 100% back to normal. Other people then, who had mild Covid-19 infections, were hit hard by subsequent symptoms. The severity of the initial infection, therefore, does not appear to be a major risk factor for the development of long Covid symptoms. We are trying, as I said, to tease out what risk factors, be those genetic, gender or underlying conditions, are associated with the development of long Covid. We know some of these already, and they include age, gender and underlying comorbidities.

Chairman

Would it be unusual for people to be referred to clinics abroad in respect of long Covid?

Dr. Ciaran Bannan

It would.

Chairman

They would be the exception-----

Dr. Siobhán Ní Bhriain

Any referrals abroad, unless they happen privately, would happen through the treatment abroad scheme, TAS. I have not heard of cases in this regard, but we can certainly look into it. I have not heard any information in respect of TAS concerning people being referred to a long Covid clinic outside Ireland.

Chairman

I am aware of a case, and these are individual cases where this information is coming from, of someone who has had clots on the lungs. An attempt was made to try to drain those clots, and this, in itself, had an impact. This person is taking about 20 different tablets daily. It is frightening that someone who did not experience any initial symptoms has now had their heart and lungs affected. In this unusual situation, the experts here do not seem to be able to come up with solutions and people look abroad for expertise. I get the sense that some countries are probably more advanced regarding this issue. We are still trying to compile a report regarding symptoms and the number of people affected. Other countries seem to be much more advanced. People listening to us at home, and some may not be at the extreme end of this experience, will be hoping there will be a stream to cater for individuals in this situation. We heard earlier there is no such stream for children. As a layperson, I would imagine we would have had a stream for children if this condition is impacting them as well. This is also probably a recommendation that will arise.

To return to what I said at the start, frustration seems to arise because many people impacted have been in this situation for two years and we are only now getting around to producing a report and to putting the clinic together. This is the frustration I am trying to express. It is not a criticism of the witnesses. I understand the delays in respect of trying to recruit people, etc. I am highlighting the frustration felt by the patients in this situation, in this limbo. They are going to their GPs or trying to get to specialists, and so on, but they seem to be getting moved around. Not only are they getting a sense that they are not being listened to, but no one seems to have the answers and these answers may not exist.

Dr. Siobhán Ní Bhriain

The Chair has raised many issues. The single most important message we would like to get out as clinicians, as most of us here are, is that most people do recover over time. This is the single most important message. Several experts in long Covid and infectious diseases around the country have advised, including Dr. Bannan, that this is the single most important aspect. A second point is that the small numbers of people with those specific symptoms, such as lung clotting, for example, would need a combination of specialist treatments from a haematology specialist and possibly a lung specialist. We do have experts here who can provide this care. Thankfully, these cases are rare, although we have heard of them, and specialist care is available.

It is important to return to the point regarding long Covid clinics being staffed by infectious diseases consultants. Within hospital settings, if patients need care from another specialist, that is available. These pathways are there. If Dr. Bannan, for example, feels he needs the advice of a cardiologist or respiratory consultant, he will pick up the phone and say he is going to refer a patient. We do, therefore, have these pathways within hospital settings for people with these complex, but rare, complications.

Chairman

Again, looking at cancer care, for example, there is a team around a person. I suppose people are looking for that team, whether it be neurology, lungs or heart. The team comes together and one gets a better sense of the care path for that individual. That is what the ideal will be in the future. I have probably talked enough.

Deputy Róisín Shortall

I completely agree with the Chair. He is absolutely right on this. It is a matter of concern that with a condition that is so new, we are working to guidelines that are 13 months old. I accept what was said on HIQA being commissioned to do a study. There is a vast amount of research that has been done internationally. What is the mechanism for learning from that research and adjusting the approach? For example, what country has demonstrated best practice in relation to the treatment of long Covid?

Dr. Siobhán Ní Bhriain

I would be fairly reluctant to comment on who is demonstrating best practice until I have the HIQA review because it will do a review by jurisdiction. In individual clinical practice, we are continually informed by best evidence. Our interim model of care is to set up a service. That does not change the fact that individual clinicians who are operating at the coalface will not use the best available evidence to treat somebody. It is important that a model looks at what we are trying to do from a service-wide point of view, however, a clinical guideline will be continually looked at. The clinical evidence-----

Deputy Róisín Shortall

That is assuming that the right clinicians are working in this area.

Dr. Siobhán Ní Bhriain

We have infectious disease experts appointed to these areas within the HSE.

Deputy Róisín Shortall

Okay. What is the typical healing period of long Covid for the three main areas of heart, lungs and brain?

Dr. Siobhán Ní Bhriain

On the recovery period, we have tried to address that and it is very difficult to say what the recovery is. Does Dr. Bannan want to comment?

Dr. Ciaran Bannan

Again, it is very difficult question to answer. We are only two years into the disease. From a pulmonary point of view, we have people who have scarring in their lungs as a result of ICU admissions and being on a ventilator for a prolonged period. They have significantly reduced lung function and that will be a legacy for those patients.

Deputy Róisín Shortall

That is not long Covid though, is it? That is acute Covid.

Dr. Ciaran Bannan

Once the symptoms go beyond 12 weeks, that would be considered in the realm of long Covid.

Deputy Róisín Shortall

What does the international evidence tell us about the relative recovery periods from those three different areas?

Dr. Ciaran Bannan

That it is variable and it will depend on the individual as well. We do not have good data on that at present.

Deputy Róisín Shortall

There are not good data available.

Dr. Ciaran Bannan

No.

Deputy Róisín Shortall

Okay. I have ongoing concerns about the approach that has been taken. The other issue, of course, is capacity. If somebody goes to a clinic and that person has a particular, say, heart problem or brain fog or whatever, there is a referral pathway. That may well be the case, but they will join a waiting list to see a neurologist or a cardiologist. Is that not the case?

Dr. Siobhán Ní Bhriain

That is the case for any condition.

Deputy Róisín Shortall

Those waiting lists are very long. In theory, there is a referral pathway. However, the reality for many people is that they will be left suffering from a long Covid condition for a very long time because of lack of capacity. Presumably, it kind of three or four months post Covid before somebody goes to or is referred to a clinic.

Dr. Siobhán Ní Bhriain

No. That would depend on the severity of the symptoms. If somebody was very acutely unwell, for example, as in the blood-clotting situation, they would be seen as an emergency.

Deputy Róisín Shortall

However, there is a five-month waiting list to be seen in a clinic.

Dr. Siobhán Ní Bhriain

Yes, overall.

Deputy Róisín Shortall

That is what concerns me, because that is on top of several weeks, let us say. In the meantime, a person’s life is completely put on hold and there are huge costs involved in that. People are out of work and all of that, apart from the personal distress and health issues. There is a big question about capacity there.

I asked Dr. Ní Bhriain earlier about waiting times and numbers. She told me the waiting time is five months on average. Can she clarify how many are on the waiting lists for the six long Covid clinics?

Dr. Siobhán Ní Bhriain

On the wait list at month end, it depends on the clinic.

Deputy Róisín Shortall

Perhaps Dr. Ní Bhriain can just tell us what they are.

Dr. Siobhán Ní Bhriain

The data that I have are not complete and they are only up to the end of August. At the moment, for Connolly, 135 people are on the wait list. In the Mater it is three people, in Beaumont it is 60 people and in Tallaght it is 286 people.

Deputy Róisín Shortall

Dr. Ní Bhriain told me about the Mater and Connolly. Neither of those have long Covid clinics. I am asking about the six long Covid clinics that have been established.

Dr. Siobhán Ní Bhriain

Does the Deputy mind if I come back to her on that so I can get the precise information?

Deputy Róisín Shortall

Can Dr. Ní Bhriain come back to us with details with the number of people who have been seen in the clinics and the number of people on the waiting lists?

Dr. Siobhán Ní Bhriain

Yes, absolutely.

Deputy Róisín Shortall

The indications are that there is a huge issue about lack of capacity. We know that 1.6 million people in Ireland have had Covid. That is just the diagnosed people, so it is presumably an underestimate. Even if the percentage suffering from long Covid is small, we are still talking about very big numbers. I do not have the confidence from what I am hearing today that there is the capacity there to address that issue. Obviously, if there are waiting lists of five months, there is not an adequate capacity.

Dr. Ní Bhriain said their funding is secured. Is that secured for the existing service or is there is a stretch in that, if they have to gear up and recruit significant numbers of additional health professionals?

Dr. Siobhán Ní Bhriain

The funding is secured for existing planned services. We secured some funding for 2022 and we have secured in the region of €6.6 million for 2023 onwards. As the Deputy knows, budgeting is an annual thing. That certainly will not preclude us from making a business case if we need further services in the national service plan next year – absolutely not. The current funding that is secured is for the planned existing clinics. As I said, we will certainly be applying for further funding if we need to.

Deputy Róisín Shortall

As well as data on the numbers of patients seen and the number on waiting lists, could we also have the data on what the current planned services are?

Dr. Siobhán Ní Bhriain

Absolutely.

Deputy Róisín Shortall

Including the different specialties that are or will be included in those six long Covid clinics.

Dr. Siobhán Ní Bhriain

Yes.

Deputy Gino Kenny

I have one question. We have touched on recovery and obviously, that is what it is all about. People who are suffering from long Covid want to recover. That is evident. On medical intervention and medication, in the opening statement it was touched on that there is not a huge amount of evidence as such on medication intervention in that way. Is there ongoing research on how people can be treated medically for long Covid with, for example, a medication?

Dr. Ciaran Bannan

Absolutely. We are in a good position in Ireland in that we have a national model of care. We have a collective group that meets on a regular basis to discuss what is happening in the world, what the new research is and research avenues that we can go down to look at potential new treatments. One of the major caveats of medicine is to first, do no harm. Any new treatments will need to be in the context of a controlled clinical trial basis and we would be looking to collaborate internationally with organisations on that. There is much research ongoing in the field of long Covid. We are all hopeful for a magic bullet at some stage.

Deputy Gino Kenny

Am I correct in saying that one of the main symptoms of long Covid is chronic fatigue?

Dr. Ciaran Bannan

Absolutely.

Deputy Gino Kenny

That has been the main factor in anybody who has got Covid. Obviously, there are other issues. However, chronic fatigue-----

Dr. Ciaran Bannan

Very much so.

That would be the number one symptom.

Deputy Gino Kenny

And someone who has long Covid-19 has that on a constant basis.

Dr. Ciaran Bannan

Yes.

Deputy Gino Kenny

That is-----

Dr. Ciaran Bannan

With fluctuations as well, which makes it difficult. Some patients will have post-exertional worsening of their symptoms so if they do try to get back to what they were doing, they can feel like they were hit by a train and be set back quite significantly. It is really about recognising that and managing that for patients.

Deputy Gino Kenny

There are obviously some parallels between fibromyalgia which has certain symptoms that are familiar with long Covid-19. There is research on the treatment of fibromyalgia. Is that research being used in some ways to mitigate long Covid-19, particularly around chronic fatigue?

Dr. Ciaran Bannan

A lot of the strategies we use in supportive care around fibromyalgia and chronic fatigue syndrome also would be applicable in what we use in the management of Covid-19.

Chairman

I thank Dr. Bannan.

Deputy Róisín Shortall

What is the treatment for chronic fatigue syndrome from clinics?

Dr. Ciaran Bannan

A lot of it is just supportive, we do not have a magic bullet. We do not have a particular drug that works against it. A lot of it is ruling out other medical conditions that we are missing, such as thyroid disease or anaemia or something that would explain the patient's symptoms. It is one of the frustrating medical entities that we do not have a definitive answer for as yet.

Deputy Róisín Shortall

Is it generally accompanied by brain fog?

Dr. Ciaran Bannan

It can be.

Deputy Róisín Shortall

What percentage of people with long Covid-19 would Dr. Bannan say have those particular type of symptoms?

Dr. Ciaran Bannan

We see a high proportion of patients with neurological symptoms, fatigue and with symptoms of brain fog, such as word finding difficulties. Again over time a lot of patients do recover but we do have patients who are left with ongoing symptoms.

Deputy Róisín Shortall

That is part of the reason it is hard to understand why only one neurologist has been appointed to the clinics. I think that is the main condition that we hear about because it does drag on over a very long time and is massively debilitating.

Dr. Ciaran Bannan

A lot of the international evidence to date and the research done in it, from a structural point of view when brain scans were done, were finding very little in the way of pathology. This is quite frustrating. There is a huge amount of research ongoing and we are looking to determine what is responsible for the ongoing symptoms.

Dr. Siobhán Ní Bhriain

If I might add to that, the person appointed to the post at St. James's Hospital is highly specialised in the area of neuro-cognitive disorders. Her research is at the cutting edge of identifying, first the existence of neuro-cognitive disorder and then the management of it. I have to go back to what Dr. Bannan said when he said no structural abnormalities, that refers to when one does a brain scan very frequently and there is nothing on the brain scan to say what exactly the problem is. We think from emerging evidence that neuro-cognitive strategies are probably going to be the best in managing some of those symptoms. This is very cutting edge and very early research and we are fortunate that the person we have is actually the most qualified person in the country for that post. But it is very early stages in the management of that.

Chairman

I do not think anyone has criticised the people in post and if that is the impression that was given, it is the wrong one. I think that people are saying there are key elements of the teams that are missing and maybe some need to be beefed up more than others. The brain fog would not be unusual for anyone who comes out of a serious operation. It is quite common in that sense. The scary thing for a lot of people is that we all know someone in that situation. The anecdotal evidence is that a lot of people seem to be suffering from it. I know people who lost their sense of taste or smell and it has never really come back. If you lose your sense of taste, it is a huge thing.

As for the other elements, the psychological fatigue, the number of people who are front-line workers who are now out sick, we are talking about people, some of whom have not been able to go back to work. There is a huge cost involved to being sick in Ireland. Are there any recommendations on medical card access? Do the witnesses expect that to come out of the HIQA report on this issue? If you are looking to avail of all this expertise, it is quite expensive and just being in hospital is quite expensive in Ireland.

Dr. Siobhán Ní Bhriain

I will mostly respond on the clinical side. The review we have commissioned is on what are existing models of care in other jurisdictions and how our models of care align with those models of care. Consequently, it is very clinically oriented. But the principle behind developing any of the services is that it is in line with Sláintecare and that people are entitled to this access. I would be going outside my area of expertise as a clinician to talk too much about other recommendations. My job is very much focused on the clinical side. We can certainly ask those questions for the Cathaoirleach.

Chairman

I do not think anyone would disagree that there is a huge expense involved in this and a good possible recommendation coming from today's meeting could be that people are being challenged by their illness and there is no-one saying otherwise. Could we get figures as to how many dedicated staff there are in the long Covid-19 system from witnesses at some stage? This is their homework. Where they are based and how many we hope to see working in total? Lastly, what is the clinical definition of long Covid that allows healthcare professionals to diagnose and refer people? There is acute Covid-19 and long Covid-19. Anecdotal evidence from some GPs is that they have difficulty as they are not familiar enough with it. Our guests might also give additional information on how GPs are being kept abreast of developments in the field. That also would be useful.

Deputy Crowe might note the meeting is coming to an end.

Deputy Cathal Crowe

I wish to profusely apologise. Perhaps I could contribute for two or three minutes. We had a transport-----

Chairman

We dealt with the monkeypox virus first and we are now discussing long Covid-19.

Deputy Cathal Crowe

That suits me fine and I was following some of the meeting in the office but I had two other committee meetings. I have two essential questions. I had a meeting yesterday with Colette Cowan, chief executive of the University Limerick Hospitals Group. I understand there will be some capacity-building in that hospital group in terms of long Covid-19 and treatment of same. I hope the witnesses can give some detail on that if it is available. The Chairman has just asked about quantifying long Covid and its symptoms. As it is such a broad spectrum, has the HSE had much engagement with Medmark or other similar workplace health screening bodies? I ask because it has been an issue for some people whose employer wanted to know how it was they cannot present back to work. As Covid-19 manifests itself and is symptomatic in many different ways, has the HSE given clear guidance and does it have communication lines open? I have just named one body but it could be any referral body like that.

Dr. Siobhán Ní Bhriain

I thank the Deputy and if I could answer the first question on the UL situation. That has been a particular challenge to recruit to. There was initially a challenge in recruiting a general infectious diseases post there. We were looking to recruit to that and to the specialist long Covid-19 clinic. Talking to Ms Cowan and our colleagues, we are planning to run that service - I think through a newly-appointed person - but there is a plan to run it through the infectious diseases clinic while awaiting the appointment of the infectious specialist consultant in long Covid.

Deputy Cathal Crowe

Does Dr. Ní Bhriain have timelines for that?

Dr. Siobhán Ní Bhriain

I do not have that at the moment.

Deputy Cathal Crowe

Okay, I thank Dr. Ní Bhriain.

Dr. Siobhán Ní Bhriain

Going on to Medmark, they are a private occupational health organisation. I know of them obviously and if they would approach us I would be happy to work with them but I would like to come back to the Deputy specifically on that.

Deputy Cathal Crowe

Maybe I should not have named them but we became very familiar to the hierarchy during the Covid-19 pandemic including the Chief Medical Officer, the National Public Health Emergency Team, NPHET, and the HSE and that is fine. They certainly led the public response to Covid-19 but now a lot of people in the workplace find themselves being referred on to private health screening bodies.

It was important that we had very clear, centralised advice all the way through the pandemic. It is important also that whatever information we have centrally in Ireland, or, indeed, from colleagues overseas, particularly in Europe, would be shared with any such body that would be screening employees returning to the workplace or remaining out of the workplace as the case may be. It is a struggle for some people and it manifests itself in different ways. It could be a sniffle for one person but it could floor another person for months and months. This is the problem with long Covid. Sometimes what cannot be seen is not always understood, measured or signed off on. That is something that people are struggling with.

Dr. Siobhán Ní Bhriain

The Deputy is absolutely right. We developed a huge amount of guidance during the pandemic. All of that is publicly available through our various websites. We certainly have specific occupational health advice within the HSE and then other organisations would develop their own occupational health advice.

Chairman

Thank you very much. Is there anything else the witnesses would like to add?

Dr. Siobhán Ní Bhriain

No, thank you.

Chairman

I really appreciate the witnesses coming in this morning. It has been very informative. Hopefully, it has been helpful for people who are watching at home. The committee looks forward to the HIQA survey on this issue and to any other developments in relation to it. Perhaps at some stage in the near future, if we have the time, we could return to the issue, or when the report comes out, to see how the development of the various clinical models progresses. I appreciate the witnesses' time and assistance in relation to long Covid and monkeypox. The committee will keep these matters under review. We will meet in private session at 4 p.m. on Tuesday, 18 October.

The joint committee adjourned at 12.02 p.m. until 9.30 a.m. on Wednesday, 19 October 2022.