Reopening the Economy: Public Health Advice

I thank Dr. Cillian De Gascun, director of the National Virus Reference Laboratory, NVRL, and Professor Philip Nolan, president of NUI Maynooth, for joining us.

I advise the witnesses that by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to this committee. If they are directed by the committee to cease giving evidence in relation to a particular matter and continue to do so, they are entitled thereafter only to a qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, 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.

Members are reminded of the provisions in Standing Order 186 that the committee should refrain from inquiring into the merits of a policy or policies of the Government or a Minister of the Government or the merits of the objectives of such policies. We expect witnesses to answer questions asked by the committee clearly and with candour. Nevertheless, witnesses should expect to be treated fairly and with respect and consideration at all times. If they have an issue in that regard or feel that they are not being treated fairly, I ask them to bring that to the attention of the committee immediately.

I invite Dr. De Gascun to make his opening statement. The written version has been circulated in advance. I ask that he limit his statement to five minutes, please.

Dr. Cillian De Gascun

I thank the Chairman and the members of the committee for the invitation to appear today. I wish them well with the important work they are undertaking on behalf of the Oireachtas. The invitation I received indicated that the committee wishes to focus in particular on two issues this morning: first, on the specific issue of minimising the risk of Covid-19 in the context of the phased lifting of restrictions, and second, with regard to the current understanding of the behaviour of the virus and the prospects of a second wave of the pandemic occurring. I am, of course, happy to assist committee members by answering any other queries they may have, insofar as I can.

I wish to take this opportunity to acknowledge the immense grief that many people will have experienced in recent months due to Covid-19. I wish to express my deepest condolences to all those who have lost friends and family during this pandemic.

I will first explain my own background as that may be helpful in gaining an understanding of my role in respect of the response that has been mounted to Covid-19 in Ireland. I am a medical virologist by training and have been the director of the National Virus Reference Laboratory at UCD since December 2013. It provides a clinical, diagnostic and reference virology service for hospital and community-based clinicians throughout Ireland. Indeed, it has been doing so since 1963 when it was established at the behest of the Department of Health to carry out surveillance for poliovirus following the introduction of the polio vaccine into Ireland. In that regard, the NVRL remains the World Health Organization, WHO, accredited national polio laboratory for the country. It is also the WHO national laboratory for measles and rubella and the WHO national influenza centre, contributing data annually to the global influenza surveillance and response system. In fact, Ireland was one of the founding members of the global influenza surveillance network, as it was then called, which was established in 1952. The NVRL is accredited by the Irish National Accreditation Board to ISO standard 15189. In a normal year, it performs more than 950,000 tests on more than 350,000 samples.

When SARS-CoV-2, the virus that causes Covid-19, first emerged, the NVRL was the laboratory designated to undertake testing nationally. As the pandemic progressed, the number of labs with the ability to perform testing increased, and there are now more than 40 sites at which testing is performed. With specific reference to Covid-19, I am a member of the National Public Health Emergency Team, NPHET, and chair the expert advisory group which provides technical recommendations on specific issues to NPHET and the HSE.

In the context of the current pandemic, I note that SARS-CoV-2 is a novel virus and there remains much that we simply do not know. In the first instance, we do not know the precise origin of the virus itself. SARS-CoV-2 is the seventh coronavirus known to infect humans and is a member of the sarbecovirus subgenus of the coronaviridae family. Although bats are regarded as the most likely natural host for the virus, the recombinogenic nature of coronaviruses means it can be difficult to identify the ultimate source because different parts of the genome can have different origins. This is in contrast to influenza viruses, for example, which reassort but do not typically undergo homologous recombination within ribonucleic acid, RNA, segments. As such, ascertaining the source of a novel influenza virus such as the pandemic virus of 2009 can be reduced to a question of where each of its segments originated.

We believe the likely source of SARS-CoV-2 to be bats because, following surveillance carried out after the SARS pandemic of 2003, we know there are hundreds of coronaviruses circulating in bats. In addition, the most closely related virus to SARS-CoV-2 to date is a coronavirus that was identified in a rhinolophus affinis bat sampled in the Yunnan province of China in 2013. The interesting thing about the 2013 virus is that despite being almost 96% identical to SARS-CoV-2 across the genome, the part of the genome that encodes for the protein that would allow the virus to infect humans efficiently and enter into human cells is quite different.

It is this receptor-binding domain part of SARS-CoV-2 that is, in fact, more similar to coronaviruses that have been identified in Malayan pangolins, which initially led to speculation that a pangolin could have been an intermediate host for SARS-CoV-2. However, analysis of the available sequence data suggests that the most likely divergence date of SARS-CoV-2 from its most closely related bat coronavirus ranges from 1948 to 1982. This would indicate that the SARS-CoV-2 lineage is not a recent recombinant and that, despite intensified characterisation of sarbecoviruses since SARS, viruses closely related to SARS-CoV-2 have been circulating unnoticed in horseshoe bats for many decades. The occurrence of a third significant coronavirus emergence in 17 years, together with the high prevalence of these viruses in bats that was alluded to earlier, means that these viruses are likely to cross species boundaries again.

As the committee carries out its important work on Covid-19, I ask it to do so with one eye on the future to ensure that Ireland can learn lessons from this experience and be better prepared, across all sections of society and the health service, when the next pandemic occurs. I am happy to answer any questions.

Thank you Dr. De Gascun. I invite Professor Nolan to make his opening statement and ask him to also limit it to five minutes please.

Professor Philip Nolan

Conscious that we, as individuals and as a society, have faced difficulty, tragedy and loss over the past 100 days, and knowing, as Dr. De Gascun said, that significant challenges remain ahead for all of us, it is useful to take an opportunity to examine our collective response to Covid-19 and to learn what lessons there are to be learned. In that spirit, I welcome the opportunity to be with the committee today, welcome the work it is doing and thank members for the invitation.

The emergency response to a pandemic can be supported and informed by the expert advice of epidemiologists, statisticians and disease modellers, whose analyses and insights can help us understand the spread of the disease, model and forecast possible scenarios, and monitor the effects of different interventions. The process of mobilising a specific Irish epidemiological modelling advisory group, IEMAG, began on 8 March 2020, it was formally established on 11 March and it first met on 12 March. The group comprises almost 50 researchers, academics and practitioners, with a very wide range of expertise, forming an interdisciplinary team with the required competencies to analyse, monitor and model the spread of Covid-19. The terms of reference of the group include gathering evidence on the epidemiology of Covid-19 - essentially, how the virus is transmitted and how people become ill; using statistical approaches to monitor and understand the outbreak in the Republic of Ireland; developing epidemiological models to forecast probable scenarios for numbers of new cases of Covid-19 over time and to monitor the impact of public health interventions; developing a healthcare capacity, demand and resource model to assist the health sector plan for the possible impact of each of these scenarios; and developing analysis on the geospatial characteristics of the outbreak in Ireland.

We present our analyses, through the chair, to NPHET, at least weekly, and key conclusions are also shared weekly with the public through the Department of Health briefings. We need to be aware at all times that statistical analyses and mathematical models provide very useful insights but also have important limitations, so our input has always been contextualised within the wider public health expertise available within IEMAG itself and NPHET. The work of the advisory group has offered special insight into the management of the outbreak in Ireland. We provided early evidence from international studies on the particular characteristics of how SARS-CoV-2 is spread, complementing and reinforcing the work of the expert advisory group, chaired by Dr. De Gascun, and the Health Information and Quality Authority, HIQA. Our early modelling work demonstrated that the strategy of mitigation or "flattening the curve" alone would not be an appropriate or sufficient response; rather, in the early stages of this epidemic, it became clear that we must suppress transmission of the virus to very low levels to protect public health. Colleagues have also been able to provide NPHET and Government with important insights into the effectiveness of public health interventions in reducing the number of cases, the force of infection and the reproduction number. Our focus is now shifting to monitoring and early warning of and rapid response to any significant resurgence of disease into the future.

This pandemic has allowed me to see up close and independently the different elements of our response to a public health crisis.

I want to conclude speaking as a citizen and witness to this by recording my admiration, first, for the people of this country, for their fortitude in the face of this crisis and the diligence and care with which they have attended to public health advice; second, for healthcare workers, including and in particular those working in public health, among whose number I count colleagues, friends and family members for their courage, dedication and professionalism; third, for the very many public servants I have encountered across the Department of Health, the HSE and other agencies who have impressed me deeply with their ability, collegiality, humanity, work ethic and effectiveness; and, finally, for the 50 or so members of the Irish Epidemiological Modelling Advisory Group who, in addition to their normal duties, have through their expertise and sheer hard work made a modest but important contribution to our response to Covid-19. I am more than happy to answer any questions that the committee might have about the nature of our work.

I thank Professor Nolan. I call on the first Fianna Fáil speaker who is Deputy Stephen Donnelly and he has ten minutes.

I welcome Dr. De Gascun and Professor Nolan. I thank them for attending and for their ongoing work. I know they have both been very busy in different ways supporting the work of the National Public Health Emergency Team, the Department and the various healthcare officials working on our response.

I would like to get the response of the witnesses to the open letter to Government signed by more than 1,000 scientists in Ireland, which was published yesterday. I am sure they have both read the letter. It states: "Our current policy is to live with the virus under a long-term mitigation strategy, with the risk of future surges and lockdowns until when, or if, a vaccine becomes available." We have all heard scientists over the last number of weeks, including microbiologists, immunologists and virologists saying that under the current approach a second wave of this virus is highly likely and some say it is inevitable. If a second wave comes we are looking at closing the schools down again, possibly in the same month that they open. We are looking at businesses being closed down. We are looking at very serious restrictions on people's civil liberties. We would be looking at the almost complete shutdown of the healthcare system for a second time. Given the starkness of their warning, that more than 1,000 scientists have signed the letter, if they are right we need to do things differently. In the expert opinion of the witnesses are they right? Is the strategy to live with the virus, albeit at a suppressed level, accepting that there is a decent chance that there will be a second wave, and we have all lived through what happens when a wave of this virus arrives, right?

Professor Philip Nolan

I will answer and I am sure Dr. De Gascun will also have views. This is not simply a question of being right or wrong. As Dr. De Gascun has pointed out, this is a novel virus. There is a lot we do not know about the virus. There is a lot we do not know about the effectiveness of different public health interventions. So, in any such context one is going to have different scientists who will have different judgments based on the incomplete evidence available to them. That is the first thing I would say. It is not unusual for scientific knowledge to be contested. The people involved in that, I know many of them-----

I do not need the caveats. I just seek the opinion of the professor who is leading the entire modelling work for the State; are they right?

Professor Philip Nolan

We are supporting NPHET in it and the Deputy will have heard the views of the Chief Medical Officer on those assertions. My view is that taking all of the evidence available to NPHET, and let me clear, the strategy is not one of mitigation. I have made that clear in my opening statement and NPHET has made that clear in public. It is not a question of living with an ongoing significant level of transmission of the virus. The strategy is one of suppression, suppressing the virus to very low levels.

Again, in the interest of time, I just want the opinion of the professor as to whether the scientists are right.

Professor Philip Nolan

My opinion is that the strategy as laid out - as recommended by NPHET to Government and adopted by Government - is the right strategy for this country at this time.

To be clear, the professor has answered a different question.

Please allow a response.

Chair, it is okay.

It is not really. Professor Nolan needs to be allowed to answer his question and then the Deputy can come back in.

Professor Philip Nolan

What I am telling the Deputy is that in the face of incomplete information different scientists will have different views.

NPHET and the Government are charged with putting in place a response that is timely, proportionate-----

We know all of that. What is Professor Nolan's opinion? Am I safe in saying that he disagrees with them?

Professor Philip Nolan

I am giving my view. My view is that the recommendations of NPHET for how Ireland should manage this pandemic are the correct recommendations. I support them. They accord with my own judgment and the judgment of my team. The point that I want to make is no strategy utterly insulates us from the risk of the virus re-emerging in our society.

We all understand that. I thank Professor Nolan. How likely is a second wave in his opinion?

Professor Philip Nolan

It is probable that at some point in the future the incidence of this disease will increase again in Irish society. How big that increase will be, when it will happen and how difficult it will be to manage are very hard to predict. There is something I can tell the Deputy, which is one output of a modelling study. If we had changed our regime on 18 May and the reproduction number on that date had increased to 1.6, we would have been looking at approximately 500 cases by the 19th.

I know that but, in the interests of time - and I am not trying to be rude - I also know that there is a lot of uncertainty and that scientists have different views. However, Professor Nolan is the guy leading the modelling work and I am asking, in his opinion-----

Professor Philip Nolan

And I was about to give the Deputy-----

-----how likely is a second wave and when might we expect it.

Professor Philip Nolan

I want to be very careful with the term "second wave" because it gives the public the impression that some overwhelming recurrence of the disease will wash over them in future. What we do know is that throughout Europe there will be renewed outbreaks of the disease of varying size. They could be described as small second waves or they could be described as manageable outbreaks. My view is that throughout Europe, perhaps somewhat randomly, we will see new outbreaks of disease, which we will be required to monitor and make sure that they do not become significant second waves, and which public health colleagues will be required to intervene and control in order that the disease does not spread beyond that manageable outbreak.

I thank Professor Nolan. How likely does he think we are to see a second wave of sufficient scale that we would have to look at closing down schools and businesses again and restricting civil liberties again? That really is the question many people want an answer to. I know there is no perfect answer. I am just looking for Professor Nolan's opinion.

Professor Philip Nolan

The management of any second wave will be different from the management of the first wave. The wave is likely to be different and we know an awful lot more about how to manage the virus than we did the last time. One might imagine that there could be more targeted measures introduced to control future outbreaks before the type of blanket measures we have seen in this context. I am not evading the question; I simply cannot give the Deputy a probability as to how likely or unlikely a second wave is.

I am not looking for a number and I appreciate that would be an impossible question for Professor Nolan to answer. Does he think it is extremely unlikely? Does he think it is highly likely? Does he have absolutely no sense of how likely it is?

Professor Philip Nolan

Honestly, I think it is possible but it would be arrogant of me. We cannot predict the future and people who do my type of work and the type of work Dr. De Gascun does need to be humble. There is lots we do not know. Right now, on a precautionary basis, we need to plan as if it is possible and ensure that we have all of the contingency plans in place to deal with a tough scenario should it eventuate in the future.

I thank Professor Nolan. The letter also states that those who run public transport are planning for 20% of normal capacity, pub and restaurant owners are planning for 30% and school authorities for 50%. The healthcare system is planning and operating at a reduced rate 20% to 50% throughout the system. Is it the understanding of our guests that these will be ongoing reductions in operational capacity due to an ongoing level of the virus in our society? Does he see the virus being reduced in the coming months to a point where, essentially, society, public services and businesses can fully open up to full capacity as before?

Professor Philip Nolan

I will make a comment and perhaps Dr. De Gascun might want to expand on it. Yes, the strategy for this country, which in time will become a European Union-wide strategy, is to suppress transmission of the virus and maintain the levels of disease at very low levels.

Any significant level of disease represents a risk to people and their health and also represents a risk of a second catastrophic outbreak. We will learn a lot then about what risks are possible and about what behaviours carry low risk in the context of that low community transmission. I return to the fact that we do not know everything about this virus yet and some things we are assuming are high risk may not actually be as high risk as we think they are.

Would Professor Nolan foresee society getting back to full capacity by the end of this year?

Professor Philip Nolan

I think our behaviours will continue to be modified by this virus for some time to come.

Would Professor Nolan foresee schools, restaurants and businesses opening up to full capacity by the end of the year, along with the healthcare system?

Professor Philip Nolan

I honestly do not have a crystal ball to answer that question. I do not know what we will learn about this virus over the next six months. I do not know what we will learn that we can and cannot do. It is impossible for me to say precisely what the impact of this virus will be in six months time. I am sure the Deputy will get lots of people to offer an opinion on that but my view, having looked at this, is that a lot of uncertainty remains about the future of us living with low levels of this virus somewhere in the European Union.

Cuirim fáilte roimh na finnéithe. Can the witnesses give us a sense of where we are at with the planning? I thank the witnesses again for being here. I know they are incredibly busy men. I will start by asking Dr. De Gascun to give us a sense of how good our information is to date. Yesterday, the Department confirmed that we had nine new Covid-19 cases. That is a great number in that it is incredibly low compared to the numbers we have had in the past. Is it fair to say that Dr. De Gascun would have been able to guess where those nine cases would emerge before they happened? In other words, is our information good enough now that we can know that if there will be new cases next week, we can guess where they will potentially emerge?

Dr. Cillian De Gascun

The number yesterday was positive. We have often seen low numbers on a Monday so there may be a slight weekend lag in the figures. It is important that we do not get too carried away.

The number of new cases from yesterday is almost irrelevant to my question. I am asking if we now know where there are clusters and can we be fairly confident that clusters will not emerge somewhere that the National Virus Reference Laboratory does not know about at the moment?

Dr. Cillian De Gascun

It is difficult to say. We have an idea but we do not know. What we have achieved is that we have driven the infection out of the community to a large extent. It was reported yesterday at the press briefing that we are seeing some household clusters now because people are staying at home and they are transmitting to household contacts. We have also seen a number of employment and work settings that have characteristics that facilitate transmission of the virus such as people working together in shifts, travelling together or living together.

Meat factories.

Dr. Cillian De Gascun

That is one of the examples. If we reopen-----

Is there any other particular sector? We have seen the evidence that was released in recent weeks on the meat factories. Is there any other sector or particular type of workplace that is raising concerns with the National Virus Reference Laboratory?

Dr. Cillian De Gascun

Not that I am aware of at this point in time.

I gather that whatever number of reported and confirmed cases there are, there is an X number of other likely cases. At one stage there was a suggestion that there could be as many as four times the number of cases as those that had been confirmed. Do we have a sense of what the X number is now? In other words, how many cases of Covid-19 have there been that we do not know about but that we can make assumptions on or that the evidence would point towards?

Dr. Cillian De Gascun

I might let Professor Nolan come in on that point as well but one of the reassuring things we have seen from a testing perspective is that as we have increased the amount of testing we have been doing in the last two to three weeks, the positivity rate has continued to decline.

That would suggest there is not a huge wealth of undiagnosed or undetected infections out in the community but, as I said, Professor Nolan may have something to add to that.

Before I allow Professor Nolan to add something, if he wishes to do so, there are some anomalies in terms of outbreaks. The counties of Cavan and Monaghan have had fairly high instances, proportionally. I think Cavan has the highest, Monaghan the third highest. The reason many people find this unusual is that, internationally, it appears that the greatest concentrations of cases are generally in large urban centres. I think that in most countries the epicentres are generally in large cities. Cavan and Monaghan are two predominantly rural counties. Does Dr. De Gascun have any understanding or reasoning as to why these counties have had such high instances?

Dr. Cillian De Gascun

My understanding is that public health has been heavily involved in investigating those clusters and increased activity. As a virologist, I have not been directly involved in that so I cannot give the Deputy an answer to that question, I am afraid.

Does Professor Nolan have any information in this regard?

Professor Philip Nolan

There are two things. First, we still estimate that for each symptomatic case we detect - we are detecting the vast majority of symptomatic cases - there is probably somebody out there without symptoms but who is carrying the disease-----

One other person.

Professor Philip Nolan

Yes. Some early serology work suggested there might be several others, but the later work and careful detective epidemiological work suggests that is the ratio. As for county variation, and in fact international variations, it is very difficult to dissect out why one county is hit more than another. If the outbreaks and clusters of cases are taken out, one still sees county-by-county variation. We need to remember that Cavan and Monaghan are very close to Dublin by European standards, so it is not anomalous for the disease to be seeded in the capital, which is also the transportation hub, and then to spread out somewhat randomly in different directions from the capital.

Louth and Meath stand between us, though.

Professor Philip Nolan

Yes. We may never find a fully satisfactory explanation for why some counties have high incidence of this disease and other counties have low incidence.

Is it something Professor Nolan is examining?

Professor Philip Nolan

It will take a long time to tell. We are still only 101 days into this. One learns the full story of a pandemic when it is over. People will look back through the records constantly to see if we can get any clue as to why there are these variations.

Professor Nolan has spoken about the second wave. I think he has used the word "probable" or "possible". Would both Dr. De Gascun and Professor Nolan agree - I would like a yes-no answer - that the success of ensuring such a second wave does not become overwhelming will be in large part reliant on our ability to have a sufficient test, trace and isolate regime in place?

Dr. Cillian De Gascun

I will say just one thing about the second wave and then answer the Deputy's question. There is a problem with this new virus. When we have studied previous pandemics, they have all been influenza viruses and have all come with second and third waves. This virus is not influenza. SARS did not really get to a second wave; MERS has not got to a second wave. That is the challenge for us in trying to anticipate what will happen with this virus. The other human coronaviruses tend to be seasonal and to peak in the first month or two of the calendar year. From a virology perspective, we are concerned about winter but-----

Accepting that, and almost leaving that aside, does Dr. De Gascun agree that testing and tracing will be important moving forward?

Dr. Cillian De Gascun

Absolutely, but only in conjunction with physical distancing, hand hygiene and respiratory etiquette. They are the control measures. Testing is not a control measure in and of itself. It is one component of a public health response.

Is Dr. De Gascun satisfied that the current testing and tracing system that is in place is sufficient for whatever might come down the line?

Dr. Cillian De Gascun

The current testing system was set up in the context of a pandemic, and my understanding is that the HSE is working on a more sustainable, longer-term solution for the coming winter season. At the moment what we have has worked incredibly well and a huge amount of work has gone into getting it up to where it needs to be. However, given the way it has been established, with the number of volunteer staff and staff seconded from elsewhere, I believe a longer-term solution is required.

I have two questions. I will try to be as brief as possible. Perhaps Professor Nolan might be the best person to answer whether we have any reliable data on excess deaths for the period since March. In Britain they have released those figures in recent days. Do we have a sense of what they are for Ireland yet?

Professor Philip Nolan

We do. Careful work has been done on mortality. I am not doing it, so it would be better if I asked the Department of Health to pass that on to Deputy Carthy. The one thing I do know is that we are well able to account for the excess mortality we are seeing in terms of the mortality we are detecting due to Covid-19. There is no discrepancy between our excess mortality data and the ongoing monitoring of the epidemic. That is a good position to be in - if I can put it that way - because it means we are seeing things as they are happening and we are not missing something.

My final question is to both speakers. Reference was made to the letter that scientists wrote to Government yesterday. Many people have taken an interest in it. One notable thing from that letter was its stark call for an all-Ireland approach to be adopted in whatever measures are adopted. We have seen some rhetoric to that end. Are Dr. De Gascun and Professor Nolan satisfied that the North-South co-operation, interaction and integration of strategies have been sufficient? Do they see areas where there is room for improvement?

Professor Philip Nolan

Certainly, there is an effective liaison mechanism at our level in terms of the sharing of data. The overall national strategy is not for me to comment on.

Dr. Cillian De Gascun

Similarly, I have not been involved in the North-South strategy, but I know the engagement has been there.

Do they think it is a little mad not to have an integrated strategy on such a small island?

Thank you, Deputy Carthy. I think they answered the question. They say there is interaction between their agencies.

Interaction is different from integration.

I am going to move on to the next Fine Gael speaker. Do you intend to take ten minutes, Deputy Burke?

Yes. I thank Professor Nolan and Dr. De Gascun for their presentations this morning and for the work they have done. I join them in thanking all the people who have worked on the front line and behind the scenes to ensure we have dealt with this in a proactive way in trying to reduce the number of deaths.

Yesterday, New Zealand announced changes. The authorities there were highly successful in locking down at an early stage. They now have no cases. What time period will we have to travel before we are in a situation where we will have no cases? Are we talking about months or weeks? Is it too early yet to speculate on that?

Professor Philip Nolan

The good news we are seeing is that the disease continues to decline even as the Government slowly lifts some of the harder restrictions that we are under. Again, I am keen to avoid groundless predictions but the positive news we are seeing is that the number of cases continues to decline as we progressively open up. The international experience is that, as yet, with some exceptions, many countries have managed to maintain low prevalence of the disease and begin to go about their business, literately and figuratively, more completely.

If we have no new surge - and I hope we will not have any new surge in the coming weeks - are we still talking about three months before we are in a situation where we are totally out of the woods on this?

Professor Philip Nolan

We are not totally out of the woods on this until there is a vaccine.

I accept that. I mean in the sense of keeping it suppressed.

Professor Philip Nolan

The comment many of us have made about living with the virus has been misinterpreted. The best prediction we can make at the moment is set out in the national plan. It was called a "living document" when it was launched and has become a living document because it has found itself amenable to some acceleration as our progress in suppressing the disease has gone well. Again, I am not being cagey; I am simply facing the fact that predictions under such levels of uncertainty are dangerous. All I can say is that we have made very positive progress. We are looking at a progressive and careful lifting of the very strict interventions while watching very carefully for any resurgence or reintroduction of the disease. If I can be blunt about it, we are growing in confidence and knowing more as time goes by. We are 100 days into this and in another 30 days we will know at least 30% more and will probably know twice as much about how to handle this. It is incumbent upon me to be very careful not to pretend to know more than I know.

I wish to go back to the very start, when the committee was set up on 8 March and it followed on from there. The people we seem to have missed out on were those in nursing homes and mental health facilities and I am interested in learning from that. I note that this committee got a copy of letter recently, dated 2 April, to HIQA asking it to set out and deal with particular issues. Are there issues now that we need to plan for into the future? I refer in particular to what occurred with regard to nursing homes, whereby we do not appear to have taken action at an early enough stage. Nursing homes themselves do not appear to have taken action and the agencies involved with nursing homes do not appear to have looked at what was happening in other countries, including Italy, with regard to care facilities and nursing homes. There was a four-week gap when action was not taken. Is there something that we need to highlight now and for which we need to be ready?

Professor Philip Nolan

There are two parts to that question. There is the very broad public health support for nursing homes which is not my area of expertise. Within my area of expertise, one of the things to be learned from this, and we still do not have clarity on it, is the extent to which people can transmit the disease before they have symptoms of the disease. It is perfectly reasonable in the outbreak of a new infectious disease to isolate people who have symptoms. In mid to late March it began to become a concern that people could transmit the disease before they developed symptoms. Within mine and Dr. De Gascun's area of expertise, our aim is bottoming that out and really understanding how this disease is transmitted outside those classic settings of having symptoms, shedding the virus and transmitting the disease.

As a member of NPHET, my experience was that suppression of the virus in the community as the primary means of protecting vulnerable and then specific steps to protect vulnerable people was a core concern. NPHET was looking at information from Italy, the United States of America and the European Centre for Disease Prevention and Control, ECDC as it was coming in and working hard to make what we could of it in terms actionable outcomes.

I am concerned about the letter from the Department of Health to HIQA, dated 2 April, which reads: "I would be grateful if as a matter of urgency, you would commence the progression of this action and provide an update at the NPHET meeting on Friday 3rd April." There was a gap of four weeks before HIQA was asked to do something.

Was there a presumption that this was being done? I ask Dr. De Gascun to comment on that. Was there an impression that work was already being done in this area when it was not?

Professor Philip Nolan

The Deputy would have to ask HIQA and others about that.

The Department wrote to HIQA on 2 April, so it must have been concerned that the work was not being done. Based on Dr. De Gascun's view from being involved in the committee, was an impression given that work was being done to deal with nursing homes at a very early stage? We now have a letter from the Department to HIQA on 2 April that clearly indicates that the Department was concerned that work was not being done. What is Dr. De Gascun's view on that from his own involvement in the committee?

Dr. Cillian De Gascun

From a NPHET perspective, my recollection is that the vulnerable persons subgroup was established in early March and would have been working across Government with the various organisations and agencies to implement plans for nursing homes and other vulnerable groups. Speaking from a virology perspective, and Professor Nolan has alluded to this, the virus tends to cause the symptoms it needs in order to transmit. That is what the virus wants to do. For example, chickenpox causes lesions that are full of virus. We typically associate this kind of situation with symptomatic transmission. We have learned recently that the elderly may be asymptomatic or may have atypical symptoms. People will remember the fever, cough and shortness of breath that came out from China, and the WHO mission report to China gave us our first real insight into what this disease looked like. What is interesting, from a virology or medical perspective, is that the disease we are seeing now seems to have evolved and appears slightly different to the classical presentation in China. That made it more challenging to control outbreaks in certain situations. Ultimately, in order to protect the most vulnerable we had to suppress virus transmission in the community and I think we have been very successful in doing that.

There was a period of four weeks when perhaps something more proactive should have been done by working with the nursing homes, HIQA and the Department. What is Dr. De Gascun's view on that? Was there a presumption within the committee that this was already being done?

Dr. Cillian De Gascun

Based on our meetings at the time, the work was ongoing. I cannot speak to the correspondence to which the Deputy is alluding as I have not seen it but the understanding at NPHET was that the focus was on vulnerable groups from a very early stage.

This letter indicates that the Department was concerned that there was not a focus on those vulnerable groups.

I thank Deputy Colm Burke. I call Deputy Noonan.

I thank Professor Nolan and Dr. De Gascun. A number of Deputies have referred to crushing the curve and the 1,000 academics from the science community who put forward a compelling argument to look at going the distance and eliminating the virus from the community. Given that we are an island, they make a very compelling case and we have seen the progress made in New Zealand. I propose that we might invite some representatives from that group to the committee to tease out these issues further and see where we could make progress. It is worth debating further.

Testing plays a fundamental role in how we exit restrictions and effectively crush the virus on the island. My first question, for both Professor Nolan and Dr. De Gascun, relates to timelines for testing. We need clear and deliverable timelines on testing, and to go from the emergence of symptoms to swabbing, testing, tracing and contact quarantine within 72 hours when at capacity. I ask the witnesses to comment on the current state of testing within the country.

Dr. Cillian De Gascun

This comes under the auspices of the HSE so I do not have oversight of the entire pathway. However, my understanding is that the target was for 90% of tests to be completed within three days and I think Paul Reid said it was at 82% or 83% earlier in the week.

Again, the testing in and of itself does not control the infection. If people develop symptoms and have had a test they have to self-isolate and not transmit the infection onwards.

In essence, while three days is important and is a very good target, the reason we want to get to that timeline is because we want to prevent the contacts of the index case transmitting the virus onwards. If I have the infection today, there is no saving me. My immediate contacts from yesterday and today are the group we are trying to contain. We want to prevent my contacts from transmitting the virus and that is where the three to four days comes from. We know the average incubation period for this virus is in or around five days. Some will be shorter and some will be longer - it can be up to two weeks.

It is important that we get results quickly, but the primary way people can prevent themselves from transmitting infection is by self-isolating and not having contact with others. If I am symptomatic, I need to present quickly. I need to contact my GP today and get tested. A lot of the sampling today is a same-day or next-day process. That means I can let the people with whom I have been in contact know that I have had a swab taken and that they should consider themselves potential close contacts, and that they should self-isolate for a couple of days until I get my result. The testing in and of itself does not control the infection. We need to try to get the message out to people that ultimately it is the physical distancing, self-isolation and identifying symptoms early which are important.

The reason we want people to contact their GP and be sampled early is purely because they are eating into the days when contacts have not been informed. If I sit at home for three days waiting for this to get better, my contacts could potentially be transmitting the virus onwards. That is what we are trying to address with a very short turnaround time. We need people, once they are symptomatic, to present for care as early as possible.

I have a second question on the testing of healthcare workers. It is currently only for suspected cases, but routine testing has been shown to reduce community transmission significantly. I would like to ask the witnesses to comment on the current guidelines for the testing of healthcare workers in the country.

Dr. Cillian De Gascun

It is a really good question. A significant amount of work has been done in this area. I appreciate that, in many respects, it probably seems straightforward to test all healthcare workers. The challenge is that negative results, that is, virus not detected results, at a single point in time do not give us a huge amount of information. We are very concerned about healthcare workers because they have accounted for 30% or more of all the cases we have seen. They are on the front line. Obviously, we had challenges in the early days from a PPE perspective. It is really important that we look after our front-line healthcare workers.

Part of the reason our proportion is so high is because they were always prioritised for testing, even when we had testing challenges with global supply chain issues in the early stages. The actual prevalence of infection in healthcare workers now is very low. We want to try to ensure we put in place a surveillance system that targets those healthcare workers who are at greatest risk so we can identify pockets of infection early on and contain them rather than doing mass testing. The problem with a mass testing approach as the prevalence becomes very low is that we may start to generate incorrect false positive results. We need to be careful about how we use the testing capacity we have.

I thank Dr. De Gascun and Professor Nolan for all their work over the past few weeks and wish them the best of luck for the weeks ahead. Obviously, this has not been beaten yet. I would like to get the views of the witnesses on face masks. I have had many contacts over the past couple of days, in particular yesterday, from people who are very concerned about the messaging on face masks. To sum up, people feel it is rather woolly. What are their thoughts on the utility of wearing face masks and the directives from the Government on them? Do they have any thoughts or recommendations in that regard?

Dr. Cillian De Gascun

I can start and will then pass over to Professor Nolan. We looked at this in the EAG from an evidence perspective.

There is certainly very good evidence that medical grade face masks work very well in people who are symptomatic and in the healthcare setting. We gave that advice to NPHET a number of weeks ago. The challenge with masks in the community is that we believe that appropriate mask use is beneficial, but it is only as an add-on - an additional measure - to good hand hygiene, physical distancing, good respiratory etiquette and all that.

The challenge is that inappropriate mask use can be potentially harmful and can increase the risk of transmission. We know that the evidence on cloth masks and non-medical grade masks is not fantastic. People use the nice plausible hypothesis that because it stops the particles it is trapping the virus as well. We do not actually have great evidence in that area. As a barrier, it certainly prevents some particulate matter from spreading. Where people are symptomatic and coughing and sneezing, the mask will prevent onward transmission of particles that, we presume, contain virus.

However, many of the experiments that have been done to date have really been to demonstrate a proof of principle rather than actually demonstrating that virus is not transmitted. Obviously, based on the population-based studies from countries that have instigated universal mask usage from an early stage, I think it has worked. It is not the only measure that they have implemented so I think there certainly is a role for it and that is why our advice is that people in areas where they cannot physically distance should be wearing masks.

At one point in this country a number of years ago we sent iodine pills to everyone with instructions on how to use, and that was for a totally different thing. I have taken from what Dr. De Gascun said earlier that SARS has a seasonal element to it.

Dr. Cillian De Gascun

Sorry, it may do. The other human coronaviruses have a seasonality to them.

Going into winter 2020-21 we may need to tool up our testing and tracing again. Would Dr. De Gascun recommend that every household in the country should have appropriate face masks with instructions on how to use them? Would that be a good investment of resources as we enter winter 2020-21?

Dr. Cillian De Gascun

From a personal perspective, I think that is a very good suggestion because we know there is an inequity where some people cannot afford to purchase their own face masks or are not in a position to make their own face masks. In the context of trying to plan for something coming down the tracks, we know there are significant global shortages of PPE and masks, and obviously the priority is to preserve our medical grade masks for our healthcare workers in the healthcare setting. Absolutely, there is time now to scale up manufacturing capacity. Therefore, I think the suggestion the Deputy has made has considerable merit.

Personally, I think the make-and-do links on the Government website are not appropriate and not something we should be sustaining. We need to be very strong on this because there is big concern over it.

When things reached a peak in April and into May, the testing capacity was 15,000 tests per day. Do we still have a number per day target or have we moved on from that? If we still have, what number is NPHET recommending?

Dr. Cillian De Gascun

I kind of never want to hear the 15,000 a day thing for a long time, to be honest. Obviously, we need capacity. The 15,000 was based on looking at an influenza-like illness, ILI, rate from previous seasons and from viruses to see what the actual demand might be. The NVRL was receiving 7,000, 8,000 or 9,000 samples per day in late March or early April and we did not have the capacity on the island to do that testing. That is where the plan for 15,000 came from. Ultimately, we wanted to have the capacity to implement the public health strategy that was there at the time so that everybody who needed a test could have a test. Again it comes back to what we were discussing earlier about not being able to predict exactly what that number would be. We wanted to be able to test everybody who needed a test, and certainly there was a period in late March and the first half of April where we were not able to do that. Now that we have significant spare capacity, we are in that position and we want to stay in that position.

I thank both witnesses for their presentations and their ongoing work. I have questions on two specific areas.

The first is on data and the second is on strategy.

On the first point, I contest that we have not been transparent enough about the data surrounding the virus. For that reason, I ask Dr. De Gascun his opinion on, for example, the model relating to the R number. Why has that not been published by now? There is a very strong case for being absolutely open and transparent about all data. There is a great amount of data being collected, processed and analysed by the Health Protection Surveillance Centre, HPSC, but, unfortunately, it is not been made publicly available. There are three areas I wish to inquire about. The model for the R number needs to be published. We need daily numbers for testing and tracing, which we have never received. Prevalence is a factor of the rate of testing. Can we have those numbers? Finally, can we have details on the location of the virus, its prevalence and the death rate relating to it? I know that all of that data is there on a small area basis. Can it be published?

The strategy adopted in this country has been to test, trace and isolate. That strategy has not ever been really operated because the testing and tracing system was always playing catch-up. The success in flattening the curve revolved around closing down society and the economy. What is the strategy now? Is there not a strong case and, in light of the probability of a second wave, a need to change the strategy, especially as we come into the winter months? It is not sufficient to stick with the test, trace and isolate strategy. Is there not a strong case to change that strategy to include the measures outlined in the document from the 1,000 scientists?

Professor Philip Nolan

I will comment on a few of those matters. I cannot accept the characterisation relating to a lack of transparency. The basic data is published every day by the HPSC.

I am concerned about the three particular areas I listed.

Professor Philip Nolan

There was also a blanket assertion, however, about not being sufficiently transparent. At our daily briefing, we are going to come to the point that the Deputy raised, through supporting work on a new dashboard to make more data, which is there but is very complex to present in a digestible way, available to the public.

There has been a general theme here which I want to address in the context of additional measures, such as test, trace, isolate and face masks. What we do know is the mechanism by which we suppress the transmission of this virus is avoiding unnecessary contacts, maintaining reasonable physical distance, and rigorous hygiene. All of the other things are supplements to that.

I accept the points Professor Nolan is making. We have been successful largely because society and the economy were closed down. In the context of it being potentially two years before there is a vaccine, the probability of us having a second wave - and moving into the second half of the year with the threat of flu etc., which would hugely complicate matters - is there surely not a need now to change the strategy that we are using in order to make it more targeted-----

Professor Philip Nolan

With respect-----

-----and to limit the movement of people, especially into the country, and also to be stricter about the wearing of masks?

Professor Philip Nolan

We are talking about two different things. At one point, we were approaching 1,000 new cases a day. These very strict measures were required to suppress a level of transmission.

I accept that. What is the strategy for the future?

Professor Philip Nolan

The strategy for the future has been set out in the public plan.

Is it still mitigation as opposed to elimination?

Professor Philip Nolan

It never was mitigation. It was suppression. One of the questions that needs to be asked about the letter that is alluded to is what is the difference really between the stated strategy, which is to keep numbers at a very low level, and this somewhat more ambitious strategy to eliminate it? When talking about eliminating, in other words going from five, six, seven or ten cases a day to zero cases, one must think of the cost of that versus the benefits and ask what it would really buy us.

When we get to zero cases a day and the rest of the world is at some modest number of cases per day, how does one then prevent a resurgence of the virus? Do we completely, hermetically seal the country?

A different strategy is to suppress the virus to very low levels and then engage with our European Union colleagues to see how all of Europe is going to suppress the virus to very low levels. Some countries that have had enormous outbreaks have succeeded in bringing the disease under control and some countries with modest outbreaks have succeeded in bringing the disease to very low levels. While New Zealand is an island of 4 million people, from a geospatial perspective it is utterly distinct from the island of Ireland. The strategy in New Zealand was fine for New Zealand but it may not be the optimum strategy for Ireland. I come back to my fundamental point.

I thank the witnesses for all their work. Undoubtedly it has been a pressured time for them and their colleagues. I am a big supporter of science. Will the witnesses comment on one lesson from all of this, which is the need to invest more in scientific research in this area? Do they feel that the level of Government investment in that area is satisfactory?

The issue of transparency and the governance in our response to Covid-19 is important. Right from the beginning we have been told we were being led by science and I want to dig into that a little bit. Since early March I have asked for the minutes of the expert advisory group to be published, along with the group's recommendations and advices to NPHET. To date, and only as of last week, we got the first two months of those minutes but with none of the recommendations or advices. We are two months behind on the publication of the expert advisory group's minutes and there are no recommendations or advices. This is important with regard to the past and the present. We want to hear, and I certainly want to hear, what the scientists are saying to NPHET, and then evaluate the decisions that are made by NPHET and the Government on the scientific advice. I believe there is a lack of transparency in that. Will the representatives explain why the minutes, with the advices and recommendations, are way behind or are not being delivered at all?

When I looked at the two months of minutes, three of them were significantly redacted. I do not have the time to go into the instances in great detail, but I do not see why they have been redacted. In the minutes of 25 March 2020, for example, under the heading "Mask use by healthcare workers in clinical areas", there are comments from some people asking if something can be recommended if the supplies are not there. Other comments acknowledge that this is happening in other hospitals too. We, however, do not know what is being referred to because the critical section is redacted. It clearly relates to personal protective equipment, PPE, health workers and exposure to Covid-19. Why would that be redacted? Who redacted it? When one considers the high level of infection rates among healthcare workers, which seemed to be significantly high, perhaps the witnesses will comment on this. A lot of the advisory group's deliberations in the published minutes focus on the issue of the exposure of healthcare workers, testing of healthcare workers, PPE for healthcare workers, self-isolation of healthcare workers who have been exposed, and so on. Why would these issues be redacted when they are so terribly important?

I will give another example. On 18 March 2020, a report to the expert advisory group showed that 7% of cases could be accounted for by asymptomatic transmission, and there was a recommendation from one meeting that passengers coming from northern Italy should be quarantined for two weeks. At the meeting it was said that this suggestion would be relayed to NPHET. It was not. From what I can see, because we have not received the recommendations or advices, it was never relayed to NPHET and it does not appear again at the next NPHET meeting. Why the secrecy around the deliberations of the scientists and experts? Why is there a delay? Why are there redactions if transparency should be key?

Dr. Cillian De Gascun

Certainly, transparency is very important to us. There was no intention of withholding the minutes and the advices. They were shared, albeit lately, this week.

With regard to the redaction, the request came in for the minutes. We always anticipated they would be published. In the context of the request, we felt the group should have an opportunity to review things where specific individuals or institutions had been alluded to and in that situation we removed that information. As to the advices, we have gone through up to two months of minutes now. April is currently ongoing and should be ready in the next week or so, and the advices have been provided. However, it is important-----

No advices were provided. No advices were published at all.

Dr. Cillian De Gascun

I will follow up on that, because they have been signed off by the EAG and my understanding was that they were going to go up online this week. I can follow up on that for the Deputy. We have no problem about our discussions being aired in public. As I said, the only things we have removed is where specific individuals or institutions might have been referenced in the context of a discussion around, as the Deputy said, PPE. Whether that was due to, say, the number of healthcare workers infected or the number of outbreaks, we felt that information, which would not necessarily otherwise have been in the public domain, should not come out through a discussion from the EAG. However, as I said, other than that, everything else has been left in.

I thank the Deputy.

Yes. Deputy Shortall had a very specific question about the methodology of determining the R-nought rate, and asked it of Dr. Holohan. He said that it was being peer-reviewed for publication. We have not heard anything since. Can the witnesses enlighten us, because it is a question that has been asked again?

Dr. Cillian De Gascun

I will refer this question to Professor Nolan.

Professor Philip Nolan

The Chairman is right. We got involved in a discussion on the rest of the matters. That has been published, and I think it was on 21 May, so the work was done and then it was written up. The methodology for the estimation of time-dependent R and the model structure that gives us the other estimation-----

Could Professor Nolan send that in to us, if it has been published?

Professor Philip Nolan

It is on the departmental website.

That is great, thank you.

Is Professor Nolan saying it was published prior to the CMO's comments?

Professor Philip Nolan

No. We were writing it up, I think, while he was here. The date I have that it went up was 21 May, if that is the Thursday-----

That is the full model for how the R-nought is calculated.

Professor Philip Nolan

Correct.

Thank you. Maybe we will have time for some questions at the end. I thank Professor Nolan.

I call Deputy Shanahan for the Regional Group.

I thank Dr. De Gascun and Professor Nolan for their incredible work. Certainly the State recognises that they have given us service.

I ask Dr. De Gascun to comment on a couple of things and to leave me a bit of time to come back to Professor Nolan on a further issue. With respect to the wet markets in China, I know it is not definite that this coronavirus has come from them, but a significant risk has been identified in the Far East. Does Dr. De Gascun know if Government or the European Union are going to make any representations, in terms of trying to regulate what is going on there, or to close them down?

I know it was discussed earlier but I refer to some of the confusing messages from the ECDC and the WHO, specifically with respect to masks, distancing, and flattening the curve versus what came out in the open letter yesterday. Is there any opportunity to try to reach consensus among the senior medical and policymakers? There has been much confusion. I, as a member of the Regional Group, asked back in March for masks to be made mandatory where social distancing was not possible, and at the time that was rubbished. Now here we are talking to people about making their own masks, so one of the issues that has come up in recent days is this confusion in messaging, and we all have a responsibility to try to get behind a single messaging strategy and promote it.

With respect to testing and tracing, what is the latest on the app development? We have not heard about it, or I have not heard anything about it in recent weeks. Are we close to a phone app and something that might help us prevent a second surge?

Dr. Cillian De Gascun

On the wet markets, it is a really interesting question because that is the problem, to which I alluded in my opening statement. We still do not know where this virus came from. This highlights one very significant challenge in trying to eliminate anything. The only things we have been able to eliminate or eradicate are those agents for which we have a vaccine, and for which we are the natural host reservoir. That does not apply to SARS-CoV-2.

I am not aware of any planned representation from the Government to the EU but the Deputy highlights an important point. There were cases reported retrospectively from November with no link to the wet markets so there is still a lot of work to be done in that respect.

We touched on the issue of masks earlier and it comes down to context. The evidence base depends on the type of mask being used and the setting in which it is used. That is the problem with the cloth or home-made masks the Deputy alluded to. The strength of evidence for those is not fantastic but we still recommend them in a setting where physical distancing and good respiratory etiquette cannot be maintained. It is still advised. There is always a reluctance to make things mandatory as a first port of call but I accept the observation that the uptake in the last couple of weeks has not been as large as we would have expected.

Could I ask about the app development with regard to testing and tracing?

Dr. Cillian De Gascun

I am not involved in the app development so I cannot give the Deputy any update.

Professor Nolan might know.

Professor Philip Nolan

It is the same answer, I am afraid, on that one.

I want to make a quick comment on face masks and testing and tracing. They are really important parts of the strategy. What worries me a little is the narrative that they can replace other elements of the strategy. It has been suggested that if only we had testing and tracing in a couple of hours and everybody wore face masks, we could do all the things we used to do. Unfortunately, that is not the case. The evidence remains that reducing contacts, being very careful with handwashing and maintaining some distance, simply not being as intimate as we used to be in our normal ways of going about business, are essential.

I thank Professor Nolan and apologise for cutting across him. As a member of NPHET, he may be able to answer a question on the deal on private hospitals. Everybody accepts it was very important to get capacity for a surge. We had Mr. Breslin in here last week and he spoke about the potential for revisiting that deal. One of the things he described was that he was bound under a mandate which the Government had described previously where there was not an opportunity for doctors who were working privately full-time to continue working in that way without signing a type A contract. I understand this contract is being revisited. Has Professor Nolan any insight into what the position will be regarding full-time private doctors in this review?

Professor Philip Nolan

No. That is not in my remit.

I presume NPHET is giving guidance to the Government and the Department of Health on this.

Professor Philip Nolan

Maybe I missed something but not that I was aware of. NPHET advises on the public health situation.

I thank Dr. De Gascun and Professor Nolan for being before us today.

Our country has been in lockdown for many months, which has led to many businesses going to the wall. While good political work has been done on many fronts, do the witnesses think it was a mistake to allow the Italian rugby fans into Ireland after their match was called off? Do they think it was a mistake that we did not fully advise those going to Cheltenham from Ireland of the dangers of going over there and coming back?

Professor Philip Nolan

I think Dr. De Gascun should answer first about specific evidence as to whether those travel-related events actually introduced disease.

Dr. Cillian De Gascun

At the moment we do not have specific evidence that the virus was particularly associated with either of those two groups of individuals. We are an island nation with significant transport to many European countries on a daily basis. I do not think we have evidence to support the assertion that they were the only points of introduction for the virus.

If we have a second wave of Covid, which nobody can be sure of but the worry is there, is the country prepared for such a wave? Are our nursing homes and community hospitals prepared for a second wave of Covid-19 if it strikes?

Professor Philip Nolan

We need to be careful about use of the term "second wave". I wish we did not use it. I would prefer we thought about the possibility, rather than probability, of a significant resurgence of the disease at some point. It is possible that we might have a significant resurgence of the disease at some point. We must prepare for that eventuality.

It may not happen and we should work to prevent it happening. We have learned a great deal during the past 100 days which would have us better prepared for any second resurgence. The strategies would, perforce, be different. They will be different in nature from the first time out and we will have more knowledge and experience which we would apply to any second significant development.

Are the witnesses aware that some laboratories in Ireland can give same-day Covid-19 results and should the HSE concentrate on those laboratories so we can speed up same-day testing and results?

Dr. Cillian De Gascun

The plan for the second half of March and the start of April was to build up capacity for large-scale testing. We had a significant number of samples that could not be tested in real time. They were exported for testing and we were very grateful for that.

As the Deputy stated, demand for testing has dropped significantly and there is capacity on the island to do that. I am not familiar with the technicalities of the arrangement with all of our commercial partners, but we certainly want to reduce the turnaround times insofar as we can. Ultimately, however, what we need people to do is to get themselves tested quickly if they develop symptoms and then self-isolate. Self-isolation is the control measure that is really important. Testing is just one element of the whole suite of public health measures. We want people, therefore, to identify themselves quickly if they have symptoms and then self-isolate and not transmit the virus onwards.

Should our doctors and nurses be testing for Covid-19 to speed up detection in hospitals, nursing homes and clinics?

Dr. Cillian De Gascun

We touched on this earlier. It is an interesting discussion because we know the prevalence level is very low now. It is a question, therefore, of how best to target individuals in the healthcare setting and to obtain usable and helpful information. If we test everybody on a Monday morning and the virus is not detected in any of them, that does not tell us anything about the rest of the week. It is important that testing, in and of itself, does not come to be seen as a shield against infection. What we really want to do in our hospitals is ensure we have sufficient staffing, PPE, infection prevention control training and support for all our healthcare workers because they are at the front line. Testing, in and of itself, however, is just one component. As I stated, work is ongoing to identify the best way to use testing to support our measures over the coming weeks and months.

I thank Dr. De Gascun and Deputy Collins. The next speaker is Deputy Butler.

I could not agree with Dr. De Gascun more when he stated that we need to keep one eye on the future to ensure Ireland can learn lessons. Recent data are encouraging, but we must be wary of a possible resurgence of the virus.

South Korea endured SARS in 2002, influenza in 2009, MERS in 2015 and now Covid-19. The country, with ten times the population of Ireland, has had great success in suppressing the virus. Test, trace and isolate is the three-legged stool of South Korean health policy, as I am sure Dr. De Gascun is well aware. Have we reached an adequate level of testing and tracing here? Does he believe that the public is buying in? Public buy-in is crucial. As we have moved to phase 2 in recent days, it is now more essential than ever that public buy-in continues.

Dr. Cillian De Gascun

I agree with that sentiment and this comes back to something that Deputy Boyd Barrett said earlier concerning investment in research. South Korea was in a position to act in the way it did very early on because investment had been put in place after the country's experience with SARS in 2002 and MERS in 2012. From our perspective, we had to react in an emergency setting to the emergence of SARS-CoV-2. We had to put in place what Paul Reid termed a wartime structure of sampling and public health contact tracing. We had to put that in place, in part, for a variety of reasons and, not apportioning criticism, there has been underinvestment in our public structures over several years.

Are we at an adequate level of testing and tracing in light of the current numbers?

Dr. Cillian De Gascun

We certainly have significant capacity for testing and tracing, but it is based on a system that has seconded staff from other sections of the public sector who, all going well as we reopen Ireland through the coming phases, will have to go back to their day jobs. We will still need to have a structure in place. As stated, my understanding is that the HSE is working on that proposal.

Obviously, public buy-in is crucial.

Does Professor Nolan wish to contribute on that point?

I have a separate question for Professor Nolan. South Korea utilised contact and tracing data very effectively. It was very forthcoming in providing information on the location of clusters. Do the witnesses accept that better knowledge of clusters and their locations might have led to a better outcome here? I am referring specifically to meat factories and residential care homes. The authorities here were very slow to discuss anything relating to clusters. That issue has been raised several times at this committee.

Dr. Cillian De Gascun

Professor Nolan may wish to address that question.

Professor Philip Nolan

I will make some general comments on the issue. First, test, trace and isolate is only part of the strategy in South Korea. There is also extreme social distancing and significant use of barriers. Second, South Korea is a different country with a different view on issues relating to privacy and data protection from the view that might be prevalent in Ireland. Third, I reiterate that we have the testing and tracing regimen that we need. It is a question of sustaining it. One must be very careful about asserting that test, trace and isolate is a substitute for other things. For example, one can test too soon. If I were unfortunate enough to infect the Deputy today, there would be no point in testing her today, tomorrow or the day after. It takes three or four days before one begins shedding the virus. We need to be very careful about how we use test, trace and isolate. It is very important as a supplement to all the other control measures we are using.

I thank Professor Nolan and Dr. De Gascun for appearing before the committee and for their work to date. The expert opinion and analysis of the Irish epidemiological modelling advisory group chaired by Professor Nolan informs NPHET and plays a major role in the implementation of modelling on the ground. The strategy of prioritising acute hospital settings was made at a very early stage. At what stage was that strategy applied to nursing and residential care homes?

Professor Philip Nolan

That was not the case. The initial strategy was threefold. First, it was to ensure that the health system was not overwhelmed. At the same time, we were very focused on reducing community transmission. From the outset, there was specific reference to sheltering the elderly and specific needs in long-term residential care, as people will see if they goes back to the announcements made on 11 March. I acknowledge that because everybody was worried about ICU beds and acute hospitals, it seemed that the focus was on acute hospitals. In fairness to NPHET, its focus was on the need to suppress the virus in the community and protect acute hospitals and the vulnerable. It will always come back to that. One can take specific measures to protect people in congregated settings if the virus is wild in the community, but the only way to fully protect them is to have the virus at incredibly low levels in the community. If it is at high levels in the community, there will be some transmission into congregated settings despite of everybody's best efforts. When it gets in there, as the Deputy is aware, it is, tragically, very difficult to control and very lethal. In fairness to NPHET, it was a tripartite strategy from a very early stage.

I welcome the witnesses and thank them for their service in recent months and for the work they have done. I will put distinct questions and ask that they provide distinct responses because each Deputy only has five minutes.

We have a plan to reopen the economy. It involved five phases but this has been reduced to four. I have seen the fruits of that. I drove up from County Waterford today and it took a bit longer to get to Dublin city centre than it did last week. It is obvious that people are moving around and are out and about more.

I wish to come back to something Professor Nolan stated a couple of times.

He used the phrase "the possibility of a significant resurgence" as opposed to a second wave. I accept that and think it is the correct terminology. He also said in response to Deputy Carthy earlier that there may be the possibility of what he described as manageable outbreaks or a manageable resurgence. What we need to know and what I am sure the Government needs to know in regard to a manageable outbreak is what the reproduction number is. I am sorry but I am pressed for time. At what point does it switch from being a manageable resurgence to an unmanageable resurgence? What is the reproduction number that would tip the balance from manageable to unmanageable?

Professor Philip Nolan

The strategy is to keep the reproduction number as low as possible, so that is number one. Second, when case numbers are very low, it is very hard to estimate what the reproduction number is. As soon as it is above 1, we are encountering difficulty and the further it is above 1, the bigger the problem. I am not stretching out the time here. What really matters is the product of the number of cases and the reproduction number.

I understand that and I also understand all the other parts, in particular the holistic approach and the individual responsibilities that come into it, and that the control measures and all those factors are important. However, there has to be a number. Is Professor Nolan saying the number is above 1 and that if it went above 1, that creates a difficulty and that is where the risk becomes unmanageable?

Professor Philip Nolan

We have to remember that this is a virus and it does not accept human desire or control.

I understand that.

Professor Philip Nolan

We cannot play with it that way. Again, I am not evading the question. I am saying we need to keep the reproduction number as low as possible and case numbers as low as possible, commensurate with the need to get-----

Professor Nolan's job is to provide that data and that modelling. We know it is a virus and we know it is a virus that spreads. If it spreads more quickly, we may have more community transmission as a consequence of more people moving about. I am asking what is the number. There has to be a number when Professor Nolan is doing the modelling and when he is providing the Government with advice. All I am asking is if that magic number or key number for the reproduction rate is above 1?

Professor Philip Nolan

If the reproduction rate is approaching 1, I would be sounding an alarm. If it is above 1, I would be sounding a louder alarm. If that is accompanied by a large number of cases or outbreaks that we would not have expected, I would be sounding an even louder one. We have to look at the risks as an amalgam of three or four different measures.

I will move to Dr. De Gascun. With regard to the control measures, obviously, to keep that below 1 involves many different things. The witnesses are both right in saying that testing, tracing and isolating is one part of the component. We also have to make sure that we have capacity in our hospitals. Dr. De Gascun knows that the contract with the private hospitals will come to an end and we are being told by the Minister for Health that, because of infection control, we may see fewer beds in the system. Again, what modelling is being done in terms of the potential capacity that might be needed in our hospitals? Second, in regard to those control measures, there seems to be mixed opinion and even mixed signals in regard to the wearing of masks and the 1 m versus 2 m distance. From the perspective of Dr. De Gascun’s advisory group, what advice is being given to the Government? I want to ask a very direct question. We have a plan to open the economy and everybody wants to see it happen as quickly as possible. Is Dr. De Gascun satisfied that we have a plan to manage the virus that will co-exist with the now accelerated plan to reopen the economy?

Dr. Cillian De Gascun

In the context of the reopening, we have learned a lot more from the first roadmap of five phases that was put in place. We have learned from other countries, we have seen have how they have reopened and we have seen, thankfully, that there have not been significant resurgences across the vast majority of those. That has given us more confidence, in conjunction with what we have achieved locally, that we can move through the last two phases and that they can be can combined from three into two at this point.

I am sorry, I have forgotten the middle part of the Deputy's question.

The middle part was in regard to the wearing of masks. Specifically, what I am asking is whether Dr. De Gascun is satisfied across all those holistic measures, whether it is wearing a mask or any of the other issues, that there is a plan to deal with Covid as well as a plan to reopen the economy? Are both in sync, in his view?

Dr. Cillian De Gascun

Yes, they are. In the context of healthcare service and private hospital capacity, in essence, our healthcare system has been operating at a greater capacity than it should have been.

The recommended best practice is about 80% occupancy. Obviously we have been over that for a number of years, so that is key that we need to get back to.

I call Deputy O'Dowd.

How much time do I have?

It is ten minutes if Deputy Carroll MacNeill is not speaking.

I welcome the witnesses and reflect the view of the public that they are doing a fantastic job. People really appreciate their professionalism, calmness, knowledge and the way they impart information on the activities which are proportionate to what we need to do to beat this virus.

I understand that the witnesses are here to explain their understanding of the behaviour of the virus and how we minimise future appearances of it. My view is that the largest number of people at risk are those with underlying health conditions, people who are over a certain age and people who live in nursing homes or congregated settings. If the evidence is very clear that 67% of nursing homes are non-compliant with all of the regulations, and if the percentage has dropped, in terms of the last figures on compliance that we have, from 27% compliant in 2017 to 23% in 2018, our biggest problem if this virus reappears and we have an influenza outbreak - the latter is extremely likely - is how we deal with that. Understanding all of the information we have and the knowledge that the witnesses have, what additional steps do we need to take to protect those vulnerable people?

Dr. Cillian De Gascun

I can speak from a virology perspective. I am not necessarily up to speed with the measures in all of the individual nursing homes. However, at this point in time we know that the majority of virus transmission occurs through either direct contact or droplet spread or, in certain circumstances, and perhaps more so in hospitalised setting, where aerosols are generated in the course of an aerosol generating procedure.

In the context of trying to prevent transmission, it comes down to good infection prevention and control measures, which obviously includes the use of appropriate PPE and ensuring that we have sufficient supplies of PPE for all settings in the healthcare system, whether that be nursing homes, residential care facilities or acute hospitals. One of the challenges that we have seen in recent months in residential care facilities is that these are not straightforward healthcare settings. They are peoples' homes and that makes it more challenging than an acute hospital setting from the point of view of deep cleaning, disinfection, sterilising, physical distancing and all of those things. These are social settings and that is one of the benefits of them from the point of view of managing individuals after they go into residential care.

From a virus perspective, ultimately it can be controlled with physical distancing, good hand hygiene, good respiratory etiquette, and it will need, as I said, adequate supplies of PPE, increased cleaning and maybe a review of some of the soft furnishings and that type of thing where the virus is difficult to eradicate. We have to learn from the experience that we have had during this first iteration of the virus so that we are in a better position and more prepared should we see a resurgence.

What is interesting, as an aside to highlight, is that Australia is in its influenza season at the moment and, from memory, they have had their mildest May in terms of an influenza season for over a decade. It is significantly down on last year, and presumably because of the indirect benefits of physical distancing, good respiratory etiquette and good hand hygiene. All of these things that we are recommending for SARS-CoV-2 should actually benefit us for influenza as well when the time comes.

While I respect Dr. De Gascun's contribution, the fact is that the staffing levels, the skills mix and the competencies in these congregated settings are not adequate, and that is the view of HIQA. They are not commensurate with what is actually required to deal effectively with the escalating care needs during a Covid-19 outbreak. That is the benchmark we now have. Thankfully, we are alerted to this now and I know that there is a lot more co-operation between the HSE and the private and public nursing homes sector, but we need to do more. I am not happy that we are doing enough.

My next question is because of Dr. De Gascun's professional knowledge. I presume the flu vaccine should be administered to all people who work in congregated settings.

There is the question of face masks for people in older age groups. Yesterday, the WHO recommended that people aged over 60 should wear medical standard face masks. That is the recommendation and I appreciate we are speaking about it today. If people go to buy a face mask on Amazon, they know the colour is blue but they do not know whether it is medical or not. The point raised by the member of the Labour Party is that we should have an adequate and available supply of medical standard face masks for those the WHO recommends wear them. I do not know whether Dr. De Gascun has a view on this.

Dr. Cillian De Gascun

I will take any opportunity to advocate the influenza vaccination for all groups because it is a vital component of controlling influenza. It is the most effective measure we have.

In the context of healthcare workers, whatever the setting, if they are engaged in near patient care, face masks are recommended and it is important that we prioritise medical grade masks for that setting. The area of masks in the community is one we have touched on and it is more challenging, certainly from an evidence base. We recommend them for people who are symptomatic and those who cannot maintain adequate physical distancing in public, such as on public transport or in retail settings. That is the advice at present and we really want people to take it on board.

The point is the WHO has stated that those aged over 60 should wear one. What is the view of Dr. De Gascun on this? Does he not think that is where we should be?

Dr. Cillian De Gascun

That guidance came out earlier this week-----

Dr. Cillian De Gascun

-----and certainly as a group we have not had an opportunity to review it and see on what evidence it is basing this decision. It seems like a practical approach but in essence it depends on the setting, such as if people are outdoors and physically distanced. People do not necessarily need to wear masks universally all of the time. As I said, as new guidance comes out from the WHO, it is fairly standard practice for us to keep it under review and see how it impacts our existing guidance.

It may not be Dr. De Gascun's responsibility but the point I am making is if that is the recommendation-----

Is the recommendation that they are worn at all times or only in areas of high incidence?

The recommendation is for those aged over 60.

Is it in areas of high incidence?

It is everybody aged over 60. That is the reality. There is a group of people who are older, and I happen to be one of them and thankfully healthy at present. I speak to a lot of people and they are worried about their health. I am not criticising anybody here and I want to state this exceptionally clearly. We need to make sure that if this is what the WHO is saying, we must make sure it happens and make sure people who need masks can get the appropriate and proper ones. If somebody is more vulnerable by virtue of their age or a medical condition, we have to make sure they get medical masks.

We will have a representative of the WHO before us on Thursday.

People going on Amazon do not know what the hell they are buying. It is important that appropriate and proper sources be identified.

My next point is based on what I have read and the witnesses should contradict me if I am wrong. Apparently Hong Kong has had no fatalities or deaths in nursing homes for older people. Are there lessons we can learn from this if it is the case?

Dr. Cillian De Gascun

It is very important that we try to learn lessons from other countries that have had different experiences to ourselves. In the setting of an emergency it is difficult to take those lessons but the importance of the committee's work is try to identify lessons that can be taken from other jurisdictions and things we can do better when this happens again because, as I said earlier, we have had SARS, MERS and now SARS-CoV-2, and this will be an element of our new normal in the coming decades.

We will see it again. In the context of the WHO guidance, however, as I said earlier, I do not pre-empt any decisions on any new guidance that comes out but we would certainly review it, either at NPHET level or through the expert advisory group and we would then make advice.

What about my question on Hong Kong?

Dr. Cillian De Gascun

I am not familiar with that. My understanding is that Hong Kong locked down early on and a suite of measures was taken. I do not know what measures they implemented in their nursing homes.

I am sorry. We have to move on.

I will be quick.

If there is time at the end then you can come in again.

In Hong Kong they prioritised older people by placing them in acute hospitals rather than in nursing homes. That is the difference.

I thank the Deputy for that contribution. I call Deputy Foley.

I welcome the witnesses and I acknowledge their sterling work and leadership as we journey through the Covid-19 pandemic. There has been much discussion this morning and elsewhere on face masks and on testing and tracing but as Professor Nolan rightly said, there is much more involved, whether it is social distancing, handwashing or a variety of measures. In that respect, I want to raise an issue that has been raised with me by a number of my constituents in Kerry, namely, the matter of virus transmission on surfaces. To be specific, how long can the virus survive on surfaces, whether they are plastic, metal, wood or packaging? I ask either or both of the witnesses to answer that question first and then I have a second question depending on their answers.

Dr. Cillian De Gascun

In experimental situations or circumstances, the virus can survive on plastic and steel for up to three days but because that is in experimental conditions in a laboratory that does not necessarily translate directly into the real world. However, that is the evidence we have at this point in time.

This query has been raised with me by teachers, for example, as we have been preparing for the opening of schools. Businesses, homemakers and bus operators have also raised this matter with me. In that respect, frequent reference is made to cleaning and deep cleansing, etc. What specifically do the witnesses envisage for classroom settings or bus operators when we speak of deep cleansing? What does that involve?

Dr. Cillian De Gascun

The specific decisions on that and the job of putting plans in place will be up to the relevant Departments. The advice on cleaning is that it depends on the footfall of a workplace. Notwithstanding the conversation we are having, this virus will not jump off a surface and infect somebody. One will need to touch it, contact it and then touch one's face, nose or mouth. People need to take responsibility themselves when it comes to practising good hand hygiene, avoiding touching their faces and avoiding their masks if they are wearing one. In the context of cleaning, this virus is not necessarily particularly robust. I imagine that the standard detergents that are used for cleaning will be successful in killing it. We should look at instituting a more regular cleaning regimen. If that is in a school, one would imagine that could involve a clean at the end of the day, just before the students come in the following day. It is important for me to qualify this by pointing out that this is not my area of expertise but if one wants to ensure the virus is not on a surface the following day in a school setting, then the surfaces that are commonly touched should be cleaned down at the end of the day and in advance of the students presenting the following morning. On public transport, I imagine it comes down to individual responsibility at passenger level but I imagine that a routine clean on a daily basis for the commonly touched surfaces would be beneficial. I do not know if we will ever be able to eliminate risk completely, which is why individuals have to take a certain amount of responsibility in practising good hand hygiene and in ensuring they do not touch their faces or masks if they are using one.

For example, I know some operators are looking at vacating a classroom for a day for a deep clean so that 24 hours pass without any children being in that room. Does Dr. De Gascun envisage a need for such measures going forward?

Dr. Cillian De Gascun

Again, cleansing is not my area of expertise but in the context of what we are trying to achieve, if we believe there is a risk of the virus being present on a surface at the end of a school day and we want to ensure it is gone before the start of the next school day, we cannot just rely on the presumption that it will desiccate or become inactive overnight from a virology perspective.

Reference has been made to the fact that there may be another outbreak later this year. That will also be the influenza season. Is Dr. De Gascun confident that we are prepared to tackle or live with both at the one time? What measures will be needed?

Dr. Cillian De Gascun

We see every year that our influenza season poses challenges for the health service, but I alluded to Australia earlier and we may get indirect benefits from this. The measures we have talked about in the context of this pandemic are hand hygiene, physical distancing and good respiratory etiquette. Setting aside physical distancing, we probably should have been practising good hand hygiene and respiratory etiquette already. It should not necessarily be terribly remarkable. As I said, in Australia, although it is early days, they seem to have seen a benefit of such measures on their influenza season. If we can carry those behaviours with us, we may be able to have an impact on the influenza season. If the two viruses strike in tandem, it will certainly be very challenging, but I think what we have demonstrated over the past three months is that, as a society, we can control the virus. It was really important to be able to demonstrate that and learn that lesson.

Cuirim fáilte roimh ár n-aíonna chuig an choiste. Professor Nolan said in response to a question from my colleague, Deputy Cullinane, that he would be sounding warnings to the Government if the reproduction rate approached or exceeded 1. What does Professor Nolan believe would be the appropriate public health responses if that circumstance were to materialise? Does he believe further restrictions would be required in that event?

Professor Philip Nolan

The appropriate public health response would depend upon the reason the reproduction number was doing that. In other words, is there a region where there is viral transmission? Is it a set of circumstances? Perhaps it is a set of workplaces in which the virus has been transmitted or, worse still, it is in the general community. The response would depend upon the setting. Perhaps there is a particular type-----

Let us look at if the virus is in the general community as opposed to a localised setting.

Professor Philip Nolan

If it is in the general community, we need to begin to re-escalate those measures that keep people apart from one another and, therefore, keep them from transmitting the virus. I imagine that if there is a resurgence of the disease, it will be clearer to us. Is it because we have restarted this kind of activity? I will not mention any specific activity because then it will become the one that-----

It is possibly a matter of going one step back as opposed to returning to the starting line.

Professor Philip Nolan

I ask the committee to remember how bad things were at the end of March and how urgent it was to stop the virus. Everything had to be thrown at it. A resurgence would be different.

I appreciate that. It is clear.

I wish to ask Dr. De Gascun about risk. I refer to the difference in the level of risk between 1 m and 2 m social distancing. Is the risk of transmission 1% for 2 m and 30% for 1 m? Is that Dr. De Gascun's understanding? Can he explain that to us?

Dr. Cillian De Gascun

That is what the WHO is quoted as stating, which is a nice communicable message for members of the public. It is important to realise that this comes down in essence to droplets, which may or may not contain virus particles. If people cough, sneeze, laugh or even speak or breathe, we know that the large respiratory particles, or droplets, coming out of their mouths drop very quickly - it is gravity - typically within 1 m to 2 m. We also know, however, that there are smaller particles that take a longer time to drop. They can stay in the air for a number of hours, and that is really the concern. They can also be moved around by wind currents. We know, therefore, when it comes to 1 m versus 2 m versus 3 m, the farther away one is, the better. However, we obviously need to get the balance right in the context of what risk we are willing to accept and what we can tolerate as a society. When we looked at this from a starting point of 1 m versus 2 m, we found there is not a huge evidence base that compares 1 m versus 2 m and tells us which is better.

Do the witnesses agree that it is 99% versus 70% or do they have a different level of risk for each-----

Dr. Cillian De Gascun

No, I think we would accept that, but it will be very difficult to quantify-----

Dr. Cillian De Gascun

-----because, obviously, things do not stop at 1 m-----

I understand that.

Dr. Cillian De Gascun

Everything is a gradient.

It depends on how somebody coughs or sneezes and so on.

Dr. Cillian De Gascun

Yes, exactly.

Is it riskier for me to be in 1 m contact with someone with Covid-19 who is wearing a face mask rather than 2 m away from someone with Covid who is not wearing a face mask? Which is riskier?

Dr. Cillian De Gascun

That is a great question. I am not aware that data exists in that context. We know that masks are not 100% perfect. There are different types of mask so it depends which mask a person is wearing. In essence, if a person has a medical-grade face mask, it is not sealed to the face but tied around the ears. There will be air escaping, typically over the bridge of the nose, around the side and perhaps under the chin. If a person is wearing one of the higher-grade medical masks with a filter, then it should be completely sealed. It depends on the mask the person is wearing. Broadly speaking, a mask is better and being farther away is better, but I cannot try to give Deputy Doherty an absolute number on that.

Let us suppose a person who had covid was wearing a mask and I was 1 m from the person. Is it fair to say it would be safer for me than the person who is not wearing a mask who was 2 m away from that person?

Dr. Cillian De Gascun

The farther away someone is from a person who has the infection, the better. In essence, what the infected person is doing by wearing a mask is reducing the amount of particles being emitted, but the number is not reduced to zero. It is a matter of reduced risk. I am afraid I cannot give Deputy Doherty an exact answer on it.

I want to discuss where many people are at this point. There is a belief that the restrictions may change in September. As Dr. De Gascun said earlier, we get more knowledge on the virus as time progresses. Will we have social distancing in our classrooms in December, January and February next year? Will that mean only eight children in the classrooms that used to have 24, 25 or 26 children? What does that mean for the education of our young people?

Thank you, Deputy.

Does Dr. De Gascun believe that as we gain more experience or evidence of the virus this could possibly change and those social distancing measures for that cohort could change?

You may answer, but briefly, please, Dr. De Gascun.

Dr. Cillian De Gascun

I think it will be very difficult. Obviously, we keep under review the guidance we issue. If anything comes out around the context of 1 m versus 2 m that we can look at to inform or provide better advice, then we will do that. However, based on the decision made, and given the evidence we had to hand at the time, we took the view that 2 m was the better option.

I wish to ask a couple of questions. Is there a difference between sustained human transmission and limited human transmission? Are those definitions readily used?

Dr. Cillian De Gascun

Professor Nolan may wish to come in here. Sustained community transmission basically means that there is ongoing transmission of the virus in the community. Limited transmission means, in essence, that it will taper out over time. That may be in a particular setting or may be confined to a particular geographical area, an area of employment or clusters. Sustained transmission typically means it is self-sufficient, as it were.

The Department of Health re-categorised retrospectively several cases from community to local transmission at one stage. Can you tell us a little about that? It was in response to World Health Organization definitions. On 5 May, the Department retrospectively re-categorised several cases.

Dr. Cillian De Gascun

I do not have that information to hand.

A journalist put that in the public domain. In any event, you do not have the information.

Dr. Cillian De Gascun

It is not to hand - I am sorry about that.

I want to ask about the types of testing. Both witnesses have pointed out the inadequacies of testing, at least for the initial period after being infected. Is there an alternative type of testing that is more effective like blood testing?

Dr. Cillian De Gascun

I would not use the word "inadequate", if that is all right. There are limitations, clearly. There will be a latent period between the time that a person becomes infected and the time we can detect the virus in the person's nasal pharynx or throat. A blood testing option is available. It does not have a role in acute diagnostics at this point. This is because although tests have been developed, when they were evaluated we concluded they lacked sensitivity. In essence, if we are doing a blood test what we are looking for is antibody, which is the host response to the infection rather than the infection itself. From the time the person becomes symptomatic we know it takes between seven and 14 days to develop. That would mean an even longer delay. However, antibody testing can play a role. This is work we will be doing in the second half of this month. At a population level it can give us an indication of how many people or what proportion of the population may have been exposed to the virus.

How much does the testing carried out in the national virus reference laboratory cost per test?

Dr. Cillian De Gascun

It depends. Our test costs have evolved over time because it depends on the platform and the number of tests being done. It also depends on the yield, the staff input and so forth. I do not know that I can give the Chairman a figure off the top of my head but broadly speaking, molecular tests or PCR tests would cost in the region of €40 to €60 in the laboratory setting. As I said, it will depend on the platform being used and on volumes.

We heard at the very start that the virus has largely been driven from the community and is limited to clusters now. Is that pretty much where we are at? The witnesses said we have driven the virus out of the community to a large extent.

Dr. Cillian De Gascun

That is what we have seen. It is important to remember that although the numbers have been very positive and encouraging over the last few days, the case numbers we are reporting this week refer to infections that would have occurred seven to ten days ago. As our colleagues in public health and the HSE do more investigation into cases on a daily basis, we will get more information about those. Obviously we saw surges around places of employment but my understanding from the data this week is that more of the cases seem to be related to household contacts which is why we want people, as soon as they develop symptoms, to isolate themselves, contact their GP and get tested so that they are not infecting other people in the household.

Is it fair to say there are areas of the State in which it is not believed there is community transmission at the moment?

Dr. Cillian De Gascun

That is a really good question. I do not know that I can say for definite but we know there are areas that have not had reported cases for a number of days, if not weeks. Is it possible to say that there is no virus circulating in those communities at all-----

It is not to say that there is no virus but rather that we do not believe the virus is being transmitted in the community in those areas, as opposed to in clusters.

Dr. Cillian De Gascun

Certainly the geographic data we have would suggest that there are certain regions of the country that do not have an awful lot of circulating virus in the community but one must bear in mind what we said earlier. Thankfully through the first phase of reopening we did not see a huge increase in the number of cases but obviously as we move into the next phase, based on the incubation period, we are still seven to ten days behind the real-life picture.

Is that something Professor Nolan wants to come in on?

Professor Philip Nolan

There is a very uneven distribution of prevalence across the country right now because essentially we froze the epidemic at a point in time. We need to be very careful now as people start moving around again that we do not transfer it from one part of the country to the other.

At the moment it is limited to certain areas of the country.

Professor Philip Nolan

Yes. I wish to make a point relating to the discussion about face masks, distance and surfaces. All of that work is based on understanding how droplets transmit. We know that the virus lives here for a while and can be transmitted over a certain distance. What we do not know is how likely that is then to lead to infection. Simply because the virus is there does not mean it is going to infect a person. Part of the reason for the uncertainty around 1 m versus 2 m, or face masks versus no face masks, is that even though we have evidence about what they do to droplets, we have very limited evidence about what they do to a person's actual chances of catching the virus. That is why there is a constant erring on the side of caution; it is not necessarily erring but if one is going to make a mistake, one needs to make it on the side of caution and not on the side of liberty.

Deputy Boyd Barrett assures me that his question is very short. Deputy Shortall also has a question but then we need to get out of here to stay within the two-hour limit. I thank the witnesses for their illuminating answers throughout.

Is that a reference to minimum infectious dose? My question is whether the witnesses think the lack of PPE and staff shortages in our public health system, which seemed to preoccupy a lot of the debates in the minutes-----

A short question, Deputy.

-----contributed to the high infection rate among health workers in the hospitals?

Professor Philip Nolan

We do not have time to go through this right now, but I do not necessarily believe that we have a high infection rate among healthcare workers. The peak infection rate among healthcare workers here was approximately 1%, and that is despite very high levels of testing. Many people who are very close to me are healthcare workers and I am anxious that they are protected, but I am also anxious that we work with the facts. What we are looking at is the proportion of cases that are among healthcare workers, which is not a good measure. Perhaps in other circumstances we could work through this question. While healthcare workers are at risk, it is not clear as yet that there was a greater incidence of disease among them in this country in comparison with others.

Are there additional measures the witnesses believe we should be taking in order to minimise the risk of an upsurge?

Professor Philip Nolan

There are none, but I am really worried that we will become forgetful about the basics of washing hands and keeping a little distance between each other. That is not so much an additional measure as a reinforcement of those basic things that are so easy to forget.

Dr. Cillian De Gascun

There is also the fact that Irish people tend to be very good about going to work when they are sick. We have that complex whereby we feel we cannot call in sick or stay at home. That is really important as well. If people have respiratory symptoms for whatever reason, they need to stay at home in the coming flu seasons because if they are going to work while coughing and sneezing, they are transmitting something.

The witnesses do not think there is a need for any stricter quarantining for people coming into the country. Is that the case?

Dr. Cillian De Gascun

It is my understanding that that advice has already gone forward. If we want to suppress infection here, we absolutely need to control the virus coming into the country as well.

Professor Nolan has signalled his agreement to that statement, so we will conclude this session. I thank the witnesses.

Sitting suspended at 1.07 p.m. and resumed at 2 p.m.